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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)

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