Tahira Firdous, 58, sits outside the operating theatre of Lal Ded Hospital, one of Kashmir’s oldest maternal health institutes, prayers streaming silently from her lips. Inside the operating theatre, her daughter Shazia* is in labour with her second child. Tahira hopes and prays for a natural childbirth, just like the first time.

“She recovered in a short span of time when she gave birth to her first child via normal delivery,” Tahira said. “Some complications may rule out the possibility of natural birth this time for her,” she added, voicing her dread that her daughter might have to bear a ‘tough surgery’ this time.

On any given day, scores of women undergo childbirth in this tertiary care hospital, which provides obstetric and gynaecological facilities to the whole of the Kashmir valley. The facility is named after the 14th-century Kashmiri saint and mystic poet Lal Ded (Ded means grand-mother in Kashmiri).

The ‘tough surgery’ that Tahira fears is the caesarean section (C-section), instances of which have been rising in the region of late.

The Caesarean is a surgical technique that involves making horizontal or vertical incisions in the abdomen and uterus to deliver a baby. Doctors resort to this technique when normal delivery faces complications such as placenta previa (central), vaginal obstruction, failed labour induction, advanced cervical cancer, bladder rupture, foetal distress, malposition/malpresentation of the foetus, comorbidities and hypertension.

While the caesarean section is supposed to be a last resort, used only when normal delivery puts the health of the mother and child at risk, there is evidence that increasingly, it is used as the first option. Far more caesarean section are being performed globally than are actually required. Dr Ian Askew, director of the World Health Organization’s Department of Sexual and Reproductive Health and Research, and of the Human Reproduction Programme, said in a press release in June 2021 that, “not all the caesarean sections carried out at the moment are needed for medical reasons.”

Research by the World Health Organization says that “worldwide, caesarean section rates have risen from around 7% in 1990 to 21%” in 2021 and is projected to continue increasing over this current decade, with nearly a third (29%) of all births likely to take place by caesarean section by 2030.

This global surge in Caesarean deliveries is reflected across most states and Union Territories of India, with an increase in these deliveries, as per the most recent National Family Health Survey. The national Caesarean delivery rate is at 21.5%, which is higher than the ideal range of 10%-15% recommended by the World Health Organization. The recommendation is based on findings that a lower caesarean rate could mean unnecessary deaths of mother or child, while a higher percentage would mean no added benefit in terms of reduction in the number of maternal and new-born deaths. In addition, unnecessary Caesarean deliveries put the life of mother and child at risk.

‘Matter of concern’

While the incidence of Caesarean deliveries is spiking across the country, the spread is not even. Jammu and Kashmir, for instance, as per the National Family Health Survey -5, records nearly 41.7 Caesarean deliveries per hundred births, putting the union territory after Telangana (60.7%), Tamil Nadu (44.9%) and Andhra Pradesh (42.4%). The National Family Health Survey-4 had recorded 33.4% Caesarean deliveries in Jammu and Kashmir – thus, the latest survey shows an increase of around 25%.

Lal Ded Hospital reported, in early January, as many as 13,462 cases of Lower Segment Caesarian Sections and 7,723 instances of Normal Deliveries in the year 2021-’2022, thus Caesarean deliveries made up 63.5% of all deliveries. A recent study on patients admitted to the Lal Ded from November 2020 to February 2021 also concluded that the caesarean section rate was 64.2%, which is almost three times the accepted upper limit fixed by the World Health Organization.

Health authorities reportedly held a meeting in May 2022 for maternal and child death surveillance as well as a caesarean section audit in Jammu and Kashmir. The meeting was chaired by Yasin M Choudhary, the then mission director of the Jammu and Kashmir National Health Mission, who had said that the rising rate of caesarean delivery in Kashmir was a ‘matter of concern’, according to a report in Brighter Kashmir in May 2022. Choudhary also said that the increased trend of caesarean sections across all healthcare units of Jammu and Kashmir “led to many risks associated with maternal and prenatal problems”.

Experts such as Dr Usha Bhau, a consultant gynaecologist from Jammu, said they advise patients who are in good health to deliver via the natural method, and inform them about the implications of caesarean delivery on the human body. “There are two different effects of a caesarean delivery on the human body,” Bhau said. “One is short-term, in the form of anaesthesia difficulties. Pain may last for a while, and it takes time for the stitches to heal. The long-term effects include increased maternal morbidity and permanent scars on the body. There is also a chance that a scar hernia will form, but that happens in rare cases.”

Fear of pain

Abha Chauhan, professor of sociology at the University of Jammu, links the rise of Caesarean deliveries with the increase in the marriageable age of women, which in turn results in later pregnancies and increased chances of mishap as well as fear of pain.

“Previously, women were more active physically even close to their deliveries, and therefore the delivery was comparatively easier. Further, modern life has increased stress and pressures due to changing lifestyles, thereby significantly affecting women’s hormones.”

Chauhan, who is also President of the Indian Sociological Society, said that the absence of a consistent support system, knowledge of personal care and improper dietary habits particularly during pregnancy, have adverse impacts on the maternal health of women.

Dr Bhau said Caesarean deliveries are also linked to the fact that women marry later in life than they used to, and this puts pressure on them to become pregnant. This pressure in turn leads to their undergoing various fertility treatments. “And when they do get pregnant, they worry that natural delivery might adversely affect the health of their precious child, and end up asking for a Caesarean delivery.”

Dr Akeela Bashir, resident medical officer, Fortis Hospital, Delhi said that patients’ preference is a major cause for the spike in Caesarean deliveries. “Some patients, mostly with a history, believe that the vaginal deliveries could pose a threat to their lives and that of their babies, and opt for a Caesarean delivery instead.”

Dr Qazi Haroon, state project manager of the National Rural Health Mission, Jammu and Kashmir said that one reason women shy away from natural delivery is that their capacity to bear pain has decreased significantly. “Some women may prefer to avoid experiencing labour pains and in some ways, modern technology has aided them.”

Sana Masud, a 38-year-old mother of two, agrees. She regrets that due to lack of awareness of the consequences, she opted for caesarean delivery rather than bearing normal labour pains. “Although my body was prescribed as healthy for a natural childbirth during my first delivery, yet I could not persuade myself to go for it.”

Haroon said the government has been trying to raise awareness of the issue. “Jammu and Kashmir has started early sensitisation and behavioural change communication for pregnant females to motivate them towards natural deliveries,” he said. “It is necessary for making the pregnant women and families understand the merits of normal delivery, since in many cases patients themselves opt for caesarean delivery, instead of a normal delivery.”

“I was motivated from the very beginning to go for natural method as I was aware of the long term benefits,” said Sadaf Manzoor from Baramulla, who delivered a healthy baby in November. “I had some complications at the beginning but those subsided soon and luckily, my consultant doctor also didn’t press for a caesarean delivery,.”

Rising indiscriminately

“Ideally, when a delivery situation becomes urgent, Caesarean surgery is the only life-saving option. However, in urban areas, this has become common procedure as a result of two factors: financial, as gynaecologists charge extra for the surgery and often counsel patients to go for it, and the social aspect, as a majority of the women, who are from the higher socio-economic status, prefer surgery over natural births,” said Arbind Sinha, a leading anthropologist and development communication expert who teaches at Mudra Institute of Communications, an Ahmedabad-based university. “This then triggers emulation among peers; women opt for surgery because someone from their peer group had opted for it, and thus a cascading effect kicks in.”

This cascading effect is visible in the numbers. Caesarean deliveries, earlier believed to be mostly prevalent in private hospitals, are now rising in public hospitals as well – which, in effect, means that women across social strata are increasingly opting for such surgeries. Across Jammu and Kashmir, the National Family Health Survey-5 survey records almost 43% deliveries as caesarean section in public hospitals, and 82% of deliveries in private hospitals.

Caesarean section are no longer resorted to by city women alone. Thus, while urban areas of Jammu and Kashmir report 54.7% Caesarean deliveries, rural areas–where such procedures used to be less common – report 37.8%, in the latest National Family Health Survey.

The district-wise data of Jammu and Kashmir as per National Family Health Survey-5 reveals that most of the districts with high rate of Caesarean deliveries fall in the Kashmir division. Pulwama district in south Kashmir tops the list with around 61% of Caesarean surgery, followed by Srinagar.

This trend, if it continues, will lead to a spike in maternal mortality and maternal morbidity. To counter the possibility, Dr Haroon said, the government has initiated a programme called “High Risk Pregnancy Identification” to identify those requiring more care during early-stage pregnancies, thereby ensuring against later complications. This, Dr Haroon said, will help arrest the trend of Caesarean deliveries.

One of the ways in which the government hopes to address health needs of rural areas and vulnerable sections of society, including maternal health, is through the band of community-based functionaries, Accredited Social Health Activists, under the National Rural Health Mission.

Over 12,000 Accredited Social Health Activists workers are present in Jammu and Kashmir, and they counsel women and families, preparing them for normal deliveries, educating them about breastfeeding and complementary feeding, teaching them about family planning, immunisation, contraception and prevention of common infections, including Reproductive Tract Infection/Sexually Transmitted Infection, as also teaching expecting mothers how to care for their newborn babies.

To further aid in these efforts, the Ministry of Health and Family Welfare in 2018 laid down some guidelines on midwifery services, focusing on addressing existing issues by promoting “quality, continuity of care through provision of women-centric care and promoting natural birth”.

In November, during a capacity-building workshop organised at Sher-i-Kashmir Institute of Medical Sciences in Soura, Srinagar, Dr Haroon talked about acceptance and smooth integration of midwifery services and cadres into the health delivery system. He said midwives trained to International Confederation of Midwives standards would be “an asset to the health system.”

“This is by far the most structured approach for checking the ever-growing Caesarean delivery rate in the hospitals across India,” he had said at the workshop.

Dr Suhail Iqbal, a gynaecologist from Baramulla, points out that the ratio of cases to doctors needs to be more equitable in order to reduce the burden on doctors. “The expectations of people at the time of delivery places undue burden on the attending doctors,” said Iqbal. “In case of any unpleasant result (during normal delivery), people are anyway ready to blame the doctor for negligence, and this pressure leads to doctors opting for Caesarean delivery.”

Given the seriousness of the issue, said Dr Haroon, “We have started doing Caesarean delivery audits on a daily, weekly and monthly basis in the public sector across Jammu and Kashmir.” Doctors are expected to fill in a form providing details of the patient every day, before conducting Caesarean delivery, clearly indicating the reasons for the procedure in each case.”

Dr Haroon said that thanks to this initiative, the number of Caesarean deliveries has reduced by 5%-7% in district hospitals across Jammu and Kashmir – and this, he said, is a hopeful augury which suggests that the problem can be reversed. Similar audits are now being planned for the private sector as well, he added.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.