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28 January 2008

A Racket In Caesar's Name

Illicit trafficking in human organs is shocking news. But there's a much older racket that is thriving - unnecessary Caesarean section for childbirth. I expose a nine-month long conspiracy to create a medical situation that leaves women with no choice
Not only to medical practitioners, but also to the huge population of lay people who must see a doctor for the treatment of apparently routine to dangerous diseases, the recent arrest of five kingpins, including a doctor, in a kidney trade racket should come as no surprise. This is not because many tend to presume that organ trade must be thriving "somewhere out there", but because when it comes to manipulation of patients, including those who are highly educated -- education serves no purpose when at the eleventh hour your doctor turns livid and says, "You may go to any other doctor if you don't trust me!" -- it has perhaps become fait accompli. Never mind if you are a PhD in cryogenic technology; anybody who does not hold at least an MBBS degree is a gullible customer.

Perhaps the most common of all medical practice-related rackets is that of Caesarean section for childbirth. From the second month of pregnancy - or as early as it is detected - your wife's weekly reports may show she is in the pink of her health right up to a couple of weeks before the expected date of birth. That is when, if no other ploy works, some hospital staff may misbehave with your wife, her blood pressure is then obviously likely to rise, and presto! They have an excuse to cut her lower abdomen to dig the child out. Psychologists point to a social phenomenon that adds to the stress of the expecting woman -- being accompanied by her mother to the maternity ward.

It has been found that in the first two trimesters a pregnant woman appears emotionally quite stable, barring some aberrations. It's in the third trimester that the tradition of the woman being sent to her parents' house comes into the picture. Relieved of an 'ignorant' (insensitive?) husband after a long time, she is likely to love the idea of being pampered by her mother and hence may feign vulnerability. Thereafter, it's the mother taking her to the gynaecologist for regular check-ups till childbirth.

Gauging the concern in the eyes of the mother of the pregnant woman, the gynaecologist may say anything that scares her all the more -- a precursor to making her ready for the Caesarean section so that she may, in turn, persuade her son-in-law to sign the consent letter for the surgery.

Why is this elaborate dramatic plot being explained here? For, the scene is all too familiar to most people who have parented children but rarely is there any movement to sensitise the people on this impending, planned drama that unfolds in almost all hospitals day in and day out.

Study the Caesarean cases in your family and among friends. Did the placenta of the pregnant woman lie so low in the uterus that it covered the exit to the birth cervix (placenta praevia)? No. Did the umbilical cord fall forward and the baby could not be delivered easily (cord prolapse)? No. Was the baby lying with its head upwards (breech baby)? No. Was the mother affected by hypertension? A ploy to disturb her has already been elucidated. Was the unborn baby too small or weak to survive a natural birth? No. Did the mother have had a Caesarean section before (although it is possible for such a mother to have a vaginal delivery in a later pregnancy, this theory is floated as a hard-and-fast rule)? Maybe yes, maybe no. Was the mother so anxious about the delivery that a Caesarean section was considered? Need this be answered after the passages above?

One notes that though most of the questions above are likely to be answered in the negative by mothers in the neighbourhood who have delivered their babies the Caesarean way, surgery is forced on them. The gynaecologist can of course argue that he/she found that the baby's health was threatened due to lack of oxygen. Now, what caused that? The intervention to induce pain when the expected time of delivery had lapsed: electronic foetal monitoring, intravenous drip, epidural or spinal analgesia, one or more vaginal exams, urinary catheter, membranes broken after labour began, and/or synthetic Oxytocin (Pitocin) to speed up labour.

If the labour inductor is Syntocinon, it can cause strong contractions and put the baby under stress. You are more likely to need a forceps (or ventouse) delivery or a Caesarean following an induction. There is also a small risk that if the Syntocinon drip is used to induce or augment labour, the uterus may be over-stimulated. This would seriously reduce the oxygen supply to the baby and could, in the worst-case scenario, cause the uterus to rupture (tear). The medical condition necessary to rip your abdomen apart is ready!

But before that, how does the expected date of delivery lapse? You will be surprised to know that in this age of sophisticated technologies, when a woman tests positive for pregnancy in her urine test, a typical gynaecologist in India still asks the date of her last menstruation though it is next to impossible to conceive at that time. Yet, the doctor calculates 40 weeks from that date to estimate the date of childbirth. They do so knowing fully well that the period during which the patient is most likely to have conceived is that between the seventh and 21st day after she has had her 'periods'. This follows that the 'expected' date of delivery of the child is brought ahead at least by a week to as much as three weeks. The expecting parents should right then be able to read the plot. Up to three weeks before your child is supposed to emerge in this world, your doctor may say it's time and make you go under the knife. Putting it bluntly, women should beware that the conspiracy for the Caesarean section is hatched right on the day when pregnancy is confirmed.

Sadly for the patients, hospitals that have to defend their diagnosis keep the alibi of vaginal bleeding, if nothing else, ready. And it is virtually improbable that no abnormality in a pregnant woman would be observed at all. So, you can't take legal actions. Subjective reading of a patient's condition, too, cannot be denied as a 'right' of the doctor except in extreme conditions. Therefore, how will we bust this racket which all indicators -- like poor women being far less operated than affluent women, as the former cannot afford six to 10 times the hospital expenditure of Caesarean section as compared to normal delivery -- suggest surely exist?

What can India consisting of teeming millions of illiterate people do when in the sensitised as well as hypochondriac US, an estimated 920,000 Caesarean births are performed each year (The Medical Racket by Martin L Gross), most of which are unnecessary. There seems only one solution to this problem: An international consumer forum that demands explanation of every Caesarean section vociferously and a national law that obliges.
I applied my faith in this article on myself. My wife had had her last menstrual period (LMP) beginning 7 January this year. When she was found pregnant, we told the doctor it was 22 January (a fortnight post-LMP, the most fertile period for a woman). So the doctor calculated 280 days thereon and said that the expected date of delivery (EDD) was 28 October. On 10 October, however, as per the calculation that only my wife and I knew, my wife delivered a baby normally.

None of the ultrasonography reports could catch our lie because different ratios of the foetal biometry components predicted different EDDs!

I had presumed with reason that if we had revealed the real LMP date, the doctors would have calculated the EDD as 1 October and would have forced us to go in for a CS on 2 October.

The doctor's fees for normal delivery and Caesarean section have been equalled across all private hospitals and nursing homes in Delhi. This is to prevent gynaecologists/obstetricians pushing for a CS unethically, eyeing a much inflated bill. (Our first meeting with the gynaecologist predated this fee equalisation move by hospitals)


Chaitali said...

Interesting article. To think of it, medical students (at least the ones I know of) abhor one subject: Biochemistry. Ironically, it is the knowledge of this very subject, which enables them to tinker with a hormone here and some time there, and rake in the moolah.

The task of the doctors is made easier by the alarmingly skewed ratio of doctors to patients (~1:2,300). This means that one HAS to rely on the "few good men/ women".

However, the gullibility of the patients is also at fault. Half-baked knowledge about childbirth, compounded with an inherent need to be diagnosed with some major problem often invites such exploitation. However, if the mother was aware of her rights and the doctor sensed that, he/ she would probably play it safe and spare her the ordeal.

Surajit Dasgupta said...

True. There are two more related problems for which the obstetrician/surgeon cannot be blamed:
(1) Often the pregnant woman is too scared of the pain involved in vaginal delivery; so she asks for a Caesarean section, unmindful of the fact that normal delivery would mean experiencing pain for a few hours, which peaks at the time of delivery, while surgery would mean a lot of inconvenience/restrictions in movement for a couple of months after the childbirth
(2) Much before I became a journalist, my friends from the medical fraternity had confided in me that owners of maternity wards (both in hospitals and nursing homes) demand a heavy revenue collection every month, much of which comes from Caesarean sections; so if, say, they randomly calculate that in a given month there will be 70 normal and 30 Caesarean deliveries and you happen to be unfortunate enough to fall among the latter 30%, you will be operated upon, whether or not your medical condition demands it. On an average the cases necessitating Caesarean section never exceeds 5% of all pregnant women admitted.

Chaitali said...

So, I guess the whole picture is rather grey!

It has been my general observation that the properly-educated and the absolute illiterates are the only ones who manage to get a normal delivery done in normal circumstances. It is rather amusing to watch the "discussions" on medical problems in the rest of the population. You can actually predict the outcome of (even the future) pregnancies from such discussions. :D

Surajit Dasgupta said...

"It has been my general observation that the properly-educated and the absolute illiterates are the only ones who manage to get a normal delivery done in normal circumstances."

The fact is that from the point of view of a sincere doctor and the reputed medical institution he/she works for, not to be able to make a woman deliver her baby normally puts a question mark on the medical practitioner's education and the institution's credentials as a state-of-the-art R&D centre.

parijata said...

Thanks for this article! I was one of those people who requested for a c-section because I was scared of traumas that happen during normal deliveries. Thankfully, my doctor said that she will first try the God-given way and do a C-section only if it is absolutely necessary.

It is with my father-in-law's hospitalization that I have had some of the worst experiences. He had an angiogram, and happened to have about 73% blockage in one of the arteries. So we got an angioplasty done for him. During the hospitalization, they first goofed up by giving diuretics and making his sodium levels so low that he was unconscious for two days and was put in the ICU. Then, because of the angioplasty, he was given 80 mg of Storvas. We thought that the dosage would be reduced after some days, but it wasn't. I went with him for follow-up after two months, but still the dosage was not reduced. My father-in-law was complaining of gas all the time, so this reputed doctor gave another medicine for gas. For many months my father-in-law took this high dosage of Storvas, until I decided to take a second opinion from another doctor, a cardiologist, about his gas. That person brought down the storvas dosage from 80mg to 20mg, and eventually to 5mg. My father in law is doing fine!

I am sorry for using this space to rant about my bad experiences, but I feel that the greed of doctors and hospitals is something everyone should know about.

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Surajit Dasgupta treats no individual, organisation or institution as a holy cow.