C-Section

source: Le Monde August 21, 2014

Pierre Barthélémy

translation: doxa-louise

WHY ONE CHINESE BABY OUT OF TWO IS BORN BY CAESARIAN SECTION

We are dealing with dizzying large numbers: in 2010, 8 million Chinese babies were

born by caesarian section. That is one out of two.  A rate one might want to compare to that of 21% in France, already seen as relatively high and suspected of being abusive.To better understand the importance of the phenomenon, let us look at other numbers published Wednesday August 20 in the British Journal of Obstetrics and Gynaecology (BJOG). Very low in the 1980s, the rate of c-sections has exploded along with the economic development of the country, going from 3% in 1988 to 39% in 2008 and 52% two years later! To the point where researchers with the World Health Organization (WHO) have talked of, in 2010, an epidemic of caesarian sections in certain parts of the world, including China. Back in 1985, the WHO had explained that nothing, from a medical point of view, could justify a rate of c-sections larger than 10-15%.

To conclude on Chinese numbers, let us note a striking difference between city and rural area but still that, even in a rural context, one third of entrances to this world are made consequent to this operation ( a comparable rate to that in the United States). In an urban setting in 2010 that was 57% (after a peek of 64% in 2008). Considering the city of Shanghai alone, one sees, still in 2010, a registered 107 330 birts by c-section, thus precicely the number of births by c-section for the whole of France in that same year...

Beyond the numbers, the BJOG study tries to identify the causes for this widespread phenomenon. The first explanation offered is also the simplest, almost a truism. If Chinais seeing an explosion of this surgical act, it is foremost because women are giving birth more in the hospital than was the case a few decades back. The article goes on notably to indicate that the proportion of births in a hospital environment has gone from 54% in 1993 to 82% in 2002 and that today, one rarely sees a home birth. This has been re-inforced by the galoping rate of urbanization in the country, which had in 2010 50% city dwellers as opposed to only 20% thirty years earlier. 

Another series of causes, less evident, has to do with the fonctioning of the health system. Even if, as a function of the one child policy, China has seen its birth rate go down enormouly to reach 1,6 children per woman today, nonetheless  the gigantic population of the country (almost 1,4 billion inhabitants) results in a total annual volume of births to ‘manage’ that is quite high : 16 million babies per year with represents some 44 000 births per day. thus the system has some difficulty in keeping up because, per1 000 inhabitants, the number of doctors, nurses and midwives  is three times less in China than in countries such as France, Britain or the United States. Furthermore, the one-child policy means that, in the Empire of the Middle, we are dealing primarily with first-time births, which on average require many more hours of care much higher than for women who have already given birth... The hospitals are thus ovefull and a management-focus  is to look for quick and efficacious solutions, thus opting for a programmable operation that lasts one-half hour.

Another ‘perverse’ system effect has to do with money. The revenues that doctors and hospitals get form c-sections are higher than those from a normal birth. The BJOG study also notes that medical personnel, often taken to court when things go wrong - which then results in financial compensation - might thus be tempted to go for the ultra-prudent, the security of lesser risk and thus to choose an operation to avoid a complicated pregnancy. Finally, still for reasons tied to money, one finds that  social support is better for a caesarian section in the country.

Lastly, in the list of causes explaining how China has reached such a gigantic rate of c-sections, one finds a psychological and social effect  concomitant with the one-child policy. Pressure form family (and in-laws) being high, this unique birth must be perfect. From this perspective , the c-section has become the norm: it is perceived as more efficient, les painful for women and also less dangerous even if, on this issue, statistics show the contrary and that, for the mother, risks are at least three times higher than for a normal birth.

But there are long-term risks as well and, according ot the BJOG study, that is where the extravagant rate of caesarian sections could hurt women and the health system. A caesarian is not a banal act, without consequence. It is a true surgical act, whose principal consequence is a scar in the uterine wall. This can become  a  weakness

in the future, especially should there be a further pregnancy. The scar can open during birthing (a risk that might well justify a further c-section), make it difficult for the embryoto adhere to the placenta, lead to hemorrage or unplanned hysterectomies. So long as one has but one baby, this is not so serious. But as the BJOG article argues, with the

repeal of the one-child policy, all these risks could suddenly come to the fore... The study concludes laconically that ‘given repreated c-sections, the current risk-benefit ratio will change’. A euphemism to point out that after an epidemic of c-sections, China couldbe in a store for an epidemic of gynecological problems.