In the last week of November 2021, Tahira Jan, a resident of Kupwara in North Kashmir in her late thirties, successfully delivered her third baby at one of the premier private hospitals in Srinagar city, which has emerged as a hub of private healthcare and nursing homes in the valley.
This is not an exception. She has delivered her earlier two babies at another private facility of the city, Ramzaan hospital, under the supervision of the same doctor. A constant factor, though, has been the repeated procedure of Cesarean section for three successive deliveries.
Tahira is not alone, over the past few years, hundreds and thousands of mothers in Kashmir have undergone C-section surgeries for delivering their babies at both private as well as government hospitals.
The World Health Organisation threshold of C-sections ideally between 10-15%, stands breached and surpassed by a huge margin. Jammu and Kashmir, as per the recent data, is reporting an alarming rate of C-sections at nearly 42%.
Lower Segment Caesarean Section (LSCS) or simply C-section is a lifesaving surgical procedure for mothers and babies, which as per WHO, should be only performed when certain complications appear during pregnancy or labor. However, in Kashmir, maternity complications aren’t acting as the only driving force behind C-sections. There seems to be a larger trend at play, involving both doctors as well as patients.
Explaining about what forced them to opt for the third C-section delivery in a row, Tahira’s husband says, “The first C-section delivery itself sets a benchmark for all the upcoming deliveries. During the very first pregnancy when my wife was in her second trimester, I vividly remember, the doctor suddenly told her to be prepared for the C-section delivery. I failed to understand on what grounds, since all the antenatal tests and scans showed no indications of any complication. Upon enquiring, I was asked to stop asking questions and raising any doubts on the credibility of a renowned doctor.”
“Go and consult some other doctor. I can’t risk a woman’s life. I receive hundreds of such cases on a daily basis. This is no different,” her husband recalled the exact words of the doctor, while talking to The Quint.
In contrast, however, a young woman who recently opted for the C-section delivery out of her free will and wish has a different viewpoint, as she believes that the normal vaginal deliveries pose a great risk to both the life of a woman as well as the baby.
“To be honest, going for the C-section was my personal wish. I can never think of risking the life of my baby, along with myself. This is such a sensitive affair. Even though undergoing a surgery is painful, nevertheless, a mother can go to any extent when it comes to her children,” 31-years-old Shazia, who hails from Anantnag district of South Kashmir, told The Quint.
She says her two elder sisters also delivered their babies via C-section.
Top Government Hospitals Leading the Way in C-sections
The leading maternity care hospital of the valley, Lalla Ded Hospital in Srinagar, has reported the majority of delivery cases under C-section category since the past three years.
An RTI application, seeking maternity details from the Directorate of Health Services, Kashmir, revealed that almost 60% of the maternal deliveries at the hospital were conducted through C-section.
Between 2018-19, internal data reveals, out of the total 24,951 delivery cases, a major chunk of 14,871 cases falls under the C-section category. For 2019-20, in the total of 23,226 cases, 13,703 were C-section cases while, between 2020 till February this year, 10,249 cases among the total of 17,671 delivery cases were of C-section.
JawaharLal Nehru Memorial (JLNM) Hospital, which lately earned the tag of one of the best district hospitals in India, has the highest rate of C-section surgeries exceeding 90% of the overall delivery cases. As per the official figures, between 2019-20, out of the total 1454 delivery cases, a miniscule number of 171 cases were normal, rest of the 1283 cases were of C-section.
However, due to the COVID-19 pandemic, the hospital recorded a sharp dip in maternal delivery cases this year. Of the total 82 deliveries, figures say, 72 were conducted through the C-section.
The situation is no different at another hospital in Srinagar with Government Gousia Hospital, as per figures, reporting 800 C-section deliveries out of the total 1059 delivery cases, in the span of three years.
“Between 2018-19: 222 C-section/146 normal deliveries. In 2019-20: 240 C-section/57 normal deliveries. And in 2020-21, 337 C-section and 57 normal deliveries,” say figures.
Urban vs Rural Divide
As compared to Srinagar city, the government hospitals in few urban and mostly rural areas of Kashmir have recorded relatively lower C-section rate. Official figures show that the normal deliveries are mostly common in the rural hospitals, however, main district and sub-district hospitals contribute remarkably to the C-section surgeries.
Anantnag district of South Kashmir, having a dedicated maternity and child care hospital along with other four sub-district hospitals(SDH’s) besides a number of Primary Health Care centres(PHC’s), has reported almost 45% of C-section surgeries in the past three years.
Out of the total 41,706 delivery cases, the figures say, 17,623 were C-section deliveries while 24,083 were normal deliveries.
Interestingly, in the main district hospital of its adjacent Kulgam district, nearly 65% of the overall admitted maternal patients have undergone C-section surgeries, leaving a paltry 35% for normal deliveries.
“Out of the total 2520 deliveries between 2018-19, 1220 cases were of C-section. In 2019-20, 1706 C-sections were conducted out of the total 2280 delivery cases. Similarly, between 2020-21, the C-section tally stood at 2242 against the total of 3273 maternity cases,” hospital data revealed.
In Central Kashmir’s Budgam district, at one of its sub-district hospitals in Magam, almost 50% of C-sections have been reported out of the total maternal deliveries.
On the contrary, in the Keller area of district Shopian in South Kashmir, only 108 C-sections were conducted out of the total 642 delivery cases at the local sub-district hospital, say figures, in the past three years.
Similarly, in the sub district hospital at remote Tangdar, Karnah area of Kupwara district in North Kashmir, only 340 C-sections were performed against the total of 2263 delivery cases during the last three years, figures revealed.
J&K Records a Jump of 25% in C-sections, One of the Leading Places in India
According to the latest National Family Health Survey(NFHS) data, Jammu and Kashmir is one of the leading places in India showing an alarming rate of C-section surgeries, after Telangana, Andhra Pradesh and Kerala.
In the past five years, the rate of the C-section in both private as well as government hospitals of J&K has zoomed by almost 25%, standing currently at a high of 41.7% which falls only a little short of two other succeeding states, to take the second spot in the list. Telangana, having the highest C-section rate in India at 60.7%, is followed by Andhra Pradesh and Kerala at an equal rate of 42.4%.
Among the 41.7% of overall rate, the urban areas contribute a major proportion of 54.7%, while 37.8% of such surgeries are reported from rural areas. As per its previous data, between 2010-15, the overall rate of C-section surgeries in Jammu and Kashmir stood at 33.4%. From 2016-20, the overall rate of C-sections has increased by 8.3%, thus showing a relative jump of 24.9% than its previous rate.
In the past one and half decade, the rate of C-sections has increased by over 300% in J&K.
J&K Ranks 2nd in Private Facility Led C-section Deliveries
The rapid rate of C-sections in private hospitals of Jammu and Kashmir has reached to this extent that it’s now the second place in India after West Bengal, with the staggering rate of 82.1% C-section surgeries. This basically means, out of the 10 maternal patients admitted at the private health facility, 8 patients usually undergo C-section to deliver their babies.
Earlier, between 2011 to 2015, the rate of C-section among private healthcare facilities of J&K stood at 75.5%, the survey said.
Srinagar city, which is the hub of private healthcare sector in the valley, has over 10 well-known private hospitals including Khyber Medical Institute, Shifa Medical Centre, Sheikh Ul Alam Hospital, Ramzaan Hospital, Khanams Hospital besides many lesser-known ones. Such hospitals usually receive a huge influx of patients due to their advanced healthcare system, speedy surgical interventions and availability of top-class doctors.
A staff nurse, at the top Shifa Hospital of the city, says that their hospital usually witnesses 5-6 maternity cases on a daily basis. All of them, she adds, are executed through C-section.
“It’s my third year in this hospital, but I’ve hardly seen any normal deliveries occurring here. We have become used to it, this feels so normal now,”28-year-old staff nurse told The Quint
For each C-section delivery, she says, it costs the patient between 40-60 thousand rupees. “However, if there’s a longer hospital stay due to complications, the charges escalate further. More the stay, more are the charges."
Voluntary Demand, Late Marriages and Ulterior Motives
With the C-section rate reaching alarming levels, the medical experts are citing a plethora of reasons behind its upsurge in Kashmir valley, highlighting that a strong and favourable perception for C-section deliveries deeply-rooted in the society is driving more and more people towards them.
Dr Farhat Jabeen, a leading gynaecologist in Kashmir, says that a huge number of expectant mothers are voluntarily opting for C-section surgeries due to the fear of labor pains and exaggerated cautiousness towards their babies induced by their families.
“In most of the cases, elders and relatives of the women counsel the expecting women to go for C-section. Normal deliveries, by and large, have been associated with unbearable labor pains and huge risk factors,” she says.
Late marriages, which is a common phenomenon in Kashmir, is acting as another key factor for the upsurge in C-sections. This has a lot, Dr Jabeen says, to do with making the pregnancy an high-risk affair and necessitating the need for C-section deliveries.
“Over the past few years, we are witnessing a huge number of high-risk pregnancies. For which, delayed marriages and higher age at birth factor acts as a catalyst,” she says.
However, the Doctors Association of Kashmir President, Dr Nissar Ul Hassan, believes that much of the hype and discourse around C-section surgeries in Kashmir is just a facade.
“Call it by its name, this is a well oiled nexus between doctors and private hospitals,” he says, while talking to The Quint.
For financial and monetary gains, he says, the doctors are jeopardising the lives of thousands of patients by conducting unnecessary C-sections at many privately owned hospitals and nursing homes of Kashmir after striking a deal with them.
“Unfortunately, the doctors here have succeeded in generating a viable perception in favour of C-section deliveries that go in tandem with their needs and demands. Kashmir is known for two things; perceptions and concessions. So, the former one has worked out well,” Hassan adds.
As per WHO, medical practitioners should not undertake C-sections purely to meet a given target or rate, but rather focus on the needs of patients.
“In many genuine cases, there is a necessary requirement of an immediate medical intervention to save the lives of both women as well as her children. But, the scale at which it’s being done here, certainly amounts to a blatant misuse of C-section surgeries,”Dr Nissar Ul Hassan
Way Out: Mass Awareness Campaigns and Strict Audits
As the inclination towards C-section grows higher, a recent research study suggests, that there is a need of launching mass awareness and sensitisation campaigns among pregnant women.
“This can be done with the help of the frontline workers like the community health workers and primary care physicians who are the first point of contact of the pregnant mothers for ante‐natal care, check‐ups, or any health problems,” a study published in the Journal of Family Medicine and Primary Care, November, this year says.
Strict enforcement of timely audits in healthcare facilities, and the regulation of C-section delivery in private hospitals, Hassan says, is the need of the hour.
Meteoric Rise in C-section: Ladakh Goes Up by 133%, Highest Jump in India
The C-section rate in Ladakh, a newly carved out Union territory, has gone up by almost 133%. As per the recent NFHS data, about 37.6% of births have been delivered through C-section, in the past five years. Earlier, the rate stood at just 16.1%.
At 37.6%, according to the survey, Ladakh has taken over a biggest leap of 21% in the rate of C-section across different states and UT’s of India.
Dr Khatisha Banoo, a consultant gynaecologist at the leading Sonam Nurboo Hospital(SNM) Hospital in Leh, says that there has been a significant increase in high-risk pregnancies and minimal referrals to tertiary care hospitals and medical colleges due to the harsh weather and accessibility barriers was driving the rate of C-section in Ladakh.
“This hospital is a flashpoint and receives patients from all across the region and even beyond. We receive a huge number of high-risk cases from Nepal. The people, over there, usually prefer to avail healthcare services in our hospital. That adds to the tally,” Banoo says, while talking to The Quint.
Nivedita Roy, a research scientist while exploring the changing scenario of C-section in India, says they found an unwarranted doctor’s intervention during delivery and lack of awareness among the pregnant women related to maternal health in Ladakh.
“Almost all women who were interviewed said that the health providers told them to do cesarean delivery because either they are underweight or the baby inside the womb had excreted in the womb itself,” Roy said.
“We don’t have any private hospitals here, and as such, pregnant ladies remain concentrated in government hospitals, especially ours, which is the leading one. I acknowledge that the current trend is worrying but if we look at its positive side, the maternal mortality rate has gone significantly in Ladakh,” Dr Banoo added.
(Kaleem Geelani and Naved Ahmad are freelance journalists based in Srinagar, Kashmir)
(At The Quint, we are answerable only to our audience. Play an active role in shaping our journalism by becoming a member. Because the truth is worth it.)