Ten days before Christmas in 2012, Sheetal*, 29, a Mumbai housewife pregnant with her second child, received a rather upsetting call from her gynecologist’s office. She was told her gynecologist – the one she’d consulted for all nine months of her pregnancy – wouldn’t be able to attend to her during childbirth the following week. Sheetal was given a choice: Either another qualified gynecologist would attend to her when she eventually went into labour, or her original gynecologist could perform an elective Cesarean delivery, also known as a C-section delivery, one week ahead of schedule.

Rather than shift doctors, Sheetal chose to be operated on.

“I was very uncomfortable with the idea of a doctor I didn’t know delivering my baby,” she says. “I thought it would be easier this way because now, I was better prepared for birth.”

A Cesarean delivery is a procedure that involves surgically removing a baby from the womb. Originally developed to save the baby or mother from rare life-threatening complications, the procedure has become more and more common for normal pregnancies. The pros include the convenience and sense of control it can give women and families; the cons are that it’s a serious operation with a long recovery time that ultimately weakens the uterus for future births. Despite this, the pros are currently getting more attention.

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Today, if one can afford it and is so inclined, it is entirely possible – and not uncommon – for families to pre-order such a procedure in the many private hospitals across the country, as easily as ordering any other convenience or luxury service. Greater disposable income among the Indian middle class is driving this trend toward operations, which result in hospital bills roughly double those for vaginal births. The misconception that a C-section delivery is a worry-free – because less painful – method of delivery has also contributed to its popularity—even as epidurals, or numbing injections that ease the pain of vaginal deliveries, become commonly available in cities and towns across India.

Still, C-sections are becoming commonplace surgeries outside of India, too. An unprecedented rise in the global rates for Cesarean surgeries recently prompted the World Health Organization to appeal to the international medical community, urging them to perform a Cesarean delivery only when emergency circumstances make it a medical necessity.

GROWING TREND

“Rising numbers of women in India are beginning to shun vaginal deliveries, opting for surgical procedures instead,” says Dr Parang Mehta, a pediatrician based in Surat.

A recent study by Health Reform Asia found that government and private hospitals in Tamil Nadu and Kerala had the highest rates of C-section deliveries in the country. Of babies born in Kerala, 41%, and 58% of those born in Tamil Nadu, were delivered by C-section. The rest of India records 18.6% of births as Cesarean deliveries, a figure that has been steadily rising since 2008—and is now much higher than the 10% WHO correlates with complications that require life-saving measures.

Harini* Prakash, 26, an architect in Chennai, is one of the 58% in Tamil Nadu. She, too, chose to have her baby delivered through an elective C-section delivery early last year.

“I wanted a Cesarean delivery all along, so there was no question of waiting for labour to begin,” she says. “I’ve heard stories of how painful the natural birthing process is and I was determined to avoid it if I could.”

Family pressure also played a role; the date, time and hour of birth were decided well in advance, not by her medical team, but by the family astrologer.

“My in-laws deeply believe in astrology,” she explains. “Planning an auspicious time for our baby’s birth was very important to them. A Caesarean delivery seemed to be the ideal choice for all of us.”

This trend is not just linked to increased wealth, options and medical misconception. A paranoia that experts are beginning to identify as ‘precious baby syndrome’ also plays a role. Dr. Mehta describes parents – who conceived after years of effort or miscarriages, at an advanced age, or after expensive fertility treatment – petrified by the idea of anything happening to their child. While vaginal childbirth isn’t inherently dangerous to babies, it certainly isn’t gentle. And so these parents insist on C-sections out of fear; many doctors – concerned a lawsuit may be in the offing if complications arise during vaginal birth – have taken to performing, and even advising, Cesareans on these pregnancies.

But is this the best course?

“Without a doubt, natural [vaginal] birth is the best option for any mother,” says Dr. Sudha Dheep, a gynecologist based in Madurai.

Women’s bodies were designed for childbrith, Dr. Sudha explains; age doesn’t change this.

“Though younger mothers are believed to go through the birthing process more easily, an older mother can deliver normally, too,” she says. “A 40-year-old patient of mine had a natural [vaginal] birth recently.”

Of course, some conditions can threaten the natural order. The mother’s pelvis size, ability to physically withstand pain, the length of the labour, and complications around the fetus position, placenta and umbilical cord are all factors that would lead Dr. Sudha to consider performing a C-section.

But for most women, she says, a vaginal birth should be Plan A—not Plan B.

“Patients often urge us to perform an elective Cesarean for frivolous reasons,” Dr Sudha says. “We counsel them that natural [vaginal] delivery is best.”

OVERLOOKED RISKS

When Cesareans are performed for non-medical reasons like convenience or date of birth, not only do healthcare costs skyrocket, but serious health risks to the mother are often ignored.

“Though, theoretically, any number of C-sections can be performed, the uterine scar grows weaker every time,” says Dr. Sudha.

What this means is that, with each progressive surgery, the scar takes longer to heal and is more prone to infection. Uterine rupture – where the uterus bursts under the pressure of active labour – is a dreaded, life-threatening complication that occurs when a scar from a previous C-section failed to heal. This drives up the number of Caesarean deliveries further; once a woman has delivered by C-section, she’s discouraged from ever trying a vaginal birth.

C-sections are a major operation with all of the risks of other such procedures, such as infection and blood clots. Far from being the pain-free alternative to vaginal birth, the pain of which can be dulled by an epidural, the initial pain of a C-section is so intense that it warrants the same or heavier medication. While methods have recently improved – surgeons now use a horizontal, rather than a vertical incision, which reduces post-operative difficulties, Dr. Sudha says – recovery time still takes up to four weeks. That’s much longer than the few days of recuperation required after a normal delivery. Women recuperating from a C-section also may have trouble lifting anything heavier than their baby or even climbing steps.

SOFT COERCION

Health care is an industry like any other—driven by the bottom line. Higher revenues from Cesarean deliveries can tempt some medical facilities to encourage and maximise these unnecessary operative procedures. And both doctors and patients can be seduced by the convenience of scheduling birth for a known date, time, and location. But for a normal pregnancy, Dr. Sudha says, it’s best to proceed with a vaginal birth.

“A Cesarean section should be performed only when complications arise and there is a medical emergency that warrants it, especially if the lives of the mother and baby are at risk,” she says, echoing the WHO’s conclusion in its global appeal.

In order to avoid pressure to have a birth that’s more convenient to your medical team than to you, pick your gynecologist with care. Have a preliminary discussion at the beginning of your pregnancy to ensure he or she believes in the ideals of vaginal birth and has a reputation for patience to see the process through. Be wary if every service offered is overpriced. And if a C-section delivery is recommended in advance, don’t hesitate to get a second opinion.

*Names have been changed to protect privacy.