Public discussions over unnecessary C-sections are not a recent phenomenon in India. In 1991 the author of a scholarly article lamented that while poor women in India suffer due to a lack of even simple and basic services, rich women suffer from needless surgeries, “such as unnecessary cesarean sections and hysterectomies.” In 1996, the Times of India carried a report titled ‘Caesareans at the drop of a hat,’ which claimed that private hospitals in Mumbai had C-section rates between 20% and 40%; a consulting obstetrician was quoted as saying there were too many “knife-happy” doctors in private nursing homes. Today, of course, few in India would be shocked at C-section rates of 40%, since we are now seeing some private hospitals performing the surgery on more than 90% of their pregnant patients.

(Unnecessary C-sections, which fuel most of these high rates, are an individual and public health hazard, though delving into the reasons why is outside the scope of this piece. To understand why we need to be worried about too many C-sections, read this elegant explanation by Dr. Neel Shah, one of America’s most passionate obstetricians. The current piece focuses more on approaches to solve the problem in an Indian context.)

The popular explanation of the C-section ‘epidemic’ — that doctors and hospitals are greedy and unethical — while valid to a considerable extent, is neither comprehensive nor helpful in terms of getting at sustainable solutions. If, for example, doctors received equal fees for C-sections and vaginal birth (more commonly understood as ‘normal delivery’), cesareans still would not lose their appeal: time and convenience are two crucial elements that the medical system dearly desires and the C-section plentifully provides. A normal delivery typically requires the investment of several more hours than does a C-section. Of course one might ask why an obstetrician is unwilling to devote those 10 to 16 (or more) hours: Is it not their professional duty?

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A good way to explain this is to take an example of the typical Indian ‘nursing home.’ Suppose it is owned and operated by an obstetrician, Dr. A, and that you, a full-term pregnant woman, are a patient of hers. You start feeling active labor contractions around 10 pm and reach the nursing home soon after. Unfortunately, Dr. A left the clinic just 15 minutes back, after overseeing the birth of another baby (and a full day of seeing patients before that). As you wait for her to arrive, you start getting more and more anxious. The nurse tries to calm you down. What you want, though, is not the nurse (however skilled she may be) but ‘my doctor.’ Dr. A finally arrives around midnight, and you and your family feel relieved that now you are ‘in safe hands.’ Your baby is born in the early morning hours, after which Dr A leaves for home. Later that afternoon, you receive a call from a friend. You miss it, but the friend leaves a message: “It was so annoying, Dr. A was more than two hours late to my appointment!”

While this scenario describes two normal deliveries in a private nursing home within 24 hours, it is not difficult to see how obstetricians feel pressured to go for the more convenient and less time-consuming C-sections. Dr. A could easily have scheduled both both women for C-sections at times that suited her — what generally, and unfortunately, happens in most Indian nursing homes — instead of enduring personal and professional stress, not to mention making clients/patients wait interminably.

Would it have been unethical of her to do so? In some cases, it is a straightforward answer of yes; for example if the doctor cites a fake reason for an emergency C-section, even though the patient would prefer a natural birth, then it is unethical. But in many cases, the situation is less black and white, and it’s this grey area that causes most current ‘solutions’ for the C-section epidemic – like the ‘naming and shaming’ of doctors, suggested by one government minister – to hit a wall. Such punishment-based approaches assume that obstetric decisions are simple and easy, and that if doctors perform a cesarean without a medical reason, they are always and simply wrong and unethical. But that’s just not the case.

Let’s go back to Dr. A. To prevent the pressures of normal deliveries taking up most of her time and energy, let’s assume she employs two confident nurse-midwives with impeccable skills. She will soon realize, however, that many women and families, especially in urban India, do not think highly of nurses and insist on a doctor being present during childbirth. (This of course is not helped by the fact that the majority of nursing colleges in India  are privately owned — for profit — and are more like degree-churning factories than strong training institutes.) Another ‘solution’ Dr. A might try is group practice. Ideally, if two or more obstetricians have a common practice and clinic, they can divide the work among themselves and make sure that one of them will always be available for patients. Such group practice, however, is easier said than done, especially in a field like obstetrics where the personal relationship a woman develops with her doctor is crucial. It is also unfair to expect every doctor to be comfortable and open to the prospect of something as financially and organizationally complex and stressful as group practice.

With midwifery and group practice impractical, Dr. A could (if she is still motivated not to succumb to the pressure of doing more C-sections than medically necessary) limit the number of patients she sees and radically hike her fees. This might even work for her personally (though on a large scale, it won’t, as only a few wealthy families would both need and be able to afford such pricey obstetric services). If it does, however, her surplus of patients will be diverted to other obstetricians – who will then experience additional workload and, thus, additional pressure to take the ‘easier’ option of C-sections. (India anyway has very few specialists with respect to its population.)

These are a few of the hindrances to making a purely rational, medical decision that an obstetrician has to contend with. There are others, too: families demanding precise birth dates and times for astrological reasons, genuine medical uncertainty about the health of the fetus, the risk-aversive attitude of both families and their consulting doctors, etc.

I note these difficulties of obstetric practice primarily to suggest we not spend our time devising innovative punishments for doctors grappling with the inherent, often competing and ethically ambiguous demands of their profession, but rather channel efforts toward helping doctors genuinely interested in reducing their C-section rates. This is an approach that navigates the grey area of ethics and also ensures better care for women. Besides, it will help create an enabling, rather than punitive, environment for the newer generation of doctors — who are already apprehensive about the largely counterproductive web of legal injunctions around medical practice.

With that in mind, the government, having already displayed interest in addressing this issue, must arrive at an evolving strategy through a general consensus of patient advocates, doctors, nurses and midwives, public health experts, and social workers. It could begin such a process by picking the brains of those doctors and hospitals which have already made great strides in reducing their C-section rates. It might be more tempting for politicians to be seen ‘doing something’ by making sure the ‘bad guys’ are punished — but leaders must rise above that. The general public, for its part, can help by ensuring that public opinion focuses on constructive and sustainable solutions instead of divisive and polarizing claims and blames. The objective of improved and enriched maternal and child health can be best achieved if activists and politicians abandon their default attitude of suspicion, and acknowledge doctors as equal partners; and if doctors abandon their default stance of superiority, and value the participation of non-medical groups in medical decision-making.

This is obviously an approach that will be neither easy nor immediately effective. ​It is pertinent to remember, however, that C-section rates have skyrocketed not due to any purposeful efforts exclusively directed in that direction, but due to the arbitrary coming together, since the 1980s, of several social, cultural and political factors which then enmeshed with an imperfect healthcare system. Only by thinking ‘out of the docs’ will be able to take up the gargantuan task of addressing this daunting medley of issues. Otherwise, if we continue our current focus on punishing doctors, we will simply end up reducing (and alienating) obstetricians… but not reducing the number of C-sections.