In India, C-sections are in the stars

NEW DELHI, India — It's the night before the Hindu festival Dussehra and Dr. Rishma Dhillon Pai is preparing for a long day come morning. One patient has already scheduled a cesarean section for the auspicious occasion, and another just checked in for the same, even though the hospital is officially closed for the holiday.

Dr. Pai, who is a consultant gynecologist at the Jaslok and Lilavati hospitals in Mumbai, and the first Vice President (Elect) of the Federation of Obstetricians & Gynaecologists of India, says the requests for elective C-sections shoot up during the festival seasons or on "auspicious" dates, such as the recent 09/09/09.

"Muhurat C-sections," as they're quickly becoming known ("muhurat" in Hindi means an auspicious time period), are part of a wider trend across Asia, in which tens of thousands of women are opting for surgical cesarean sections in the hopes of having babies on a date and time deemed lucky by their astrologers. Middle and upper class Indians, with access to some of the best health care in the world, are now increasingly opting for this highly controversial practice.

"A patient told me that if her child was delivered on the time dictated by her astrologer, it would be a boy, his skin would be fair and he would look after his parents in their old age," says Dr. Pai. She says people can be very finicky about having doctors deliver at exactly the right time. "If they say that the baby should come out at 11:15 a.m., you're literally making the incision and waiting for three minutes until it's 11:15 to get the baby out."

"Historically, it was the conception time that was important, but now people are asking about birth times as well," says astrologer Ajai Bhambi. He advises women and their families on auspicious times and dates depending on the position of the moon, on one condition: the woman's doctor must already have determined that there is no other safe option but to have a C-section.

In a survey conducted by Delhi's leading private hospitals, led by Sitaram Bhartia hospital, in 2007, it was revealed that the cesarean section rate is almost as high as 65 percent in some of these facilities. It is up from 40 percent in 1997, despite a World Health Organization directive that such deliveries should not exceed 15 percent of any society.

However, the numbers, while indicative of a trend, don't tell the entire story. In India, most deliveries take place in neighborhood nursing homes, whereas the more complicated cases are referred to private hospitals. These high-risk deliveries are more likely to be performed through cesarean sections and hence skew the percentages.

Smita Choudhuri, a 34-year-old management consultant from New Delhi, who had a planned cesarean section after her doctor said she had no other option, said she found it helpful to consult Bhambi on the birth date of her baby.

"In our culture, we believe in astrology, and as long as it's in our benefit, there shouldn't be a problem," says Choudhuri. She has been visiting Bhambi for almost a decade and credits him for various improvements in her life.

With her husband, Choudhuri regularly attended Lamaze classes, rested well and prepared herself for the big day. A few weeks prior to the event, however, her doctor told her that it was unlikely that she would be able to deliver naturally.

"I kept trying for a natural childbirth until the very end, but when it became clear there was no other option, [Bhambi's] given date came in handy," she says. "Women who've never given birth have this idea that a C-section is a painfree procedure. But that's a myth. It may be quick, but the recovery can take months."

Dr. Monir Islam, director of the World Health Organization's Making Pregnancy Safer program, says the rising number of C-sections in Asia is a cause for concern, because in the absence of an emergency, the surgery is not only unnecessary, but can cause complications for both the mother and the baby, including infections and bleeding.

Islam says he's also concerned that doctors are not giving their patients full and proper advice regarding the positives and negatives of both natural childbirth and C-sections, because of the convenience factor for them.

Dr. Debasis Dutta, a consultant gynecologist at the Max Hospital, New Delhi, who has performed over 15,000 cesarean sections over the course of his career, says a woman can spend between 12 and 18 hours in natural labor, during which time a doctor could be looking after several patients.

Furthermore, the procedure which was once reserved for emergencies and high-risk pregnancies is becoming a common alternative for women who don't want to go through the pain, want to get back to work quicker or, of course, are planning it according to the stars.

Experts are divided on the ethicality of the practice. Dr. Islam says this is a difficult question to answer, because it concerns two aspects: a personal choice and a public health choice.

"If a woman has been given all the options, the pros and cons, and she still wants a cesarean section, for whatever reason, can we deny her right to choose?" he asks. "How good the [astrology] science is, I can't judge. But people believe in it."

Dr. Dutta doesn't think there's anything wrong with the practice. "It can be unethical if you have to do it at a fixed time, but given a two-hour window, for instance, there is minimal risk," he says.

Critics say doctors have a financial incentive to perform cesarean sections, especially at private hospitals, where on average, the surgery will cost Rs 20,000 ($400) more than a normal delivery, and astrologers are taking advantage by playing on people's belief systems.

"When money becomes the motive," says Dr. Islam, "that's when it's certainly crossed the line into the unethical."