Sitaram Bhartia Maternity Program

Ask your gynaecologist for her c section rate

Many of us do extensive research before buying a mobile phone or car, booking a hotel, or even selecting a new restaurant.  But when it comes to choosing a doctor, most of us do little more than get a word-of-mouth reference.  Unfortunately, what often drives patient satisfaction and thus recommendation of a doctor is “bedside manners” – without regard to other aspects of good medical practice.

As chief executive of a nonprofit hospital in Delhi, I have observed this in the context of maternity care.  Gynaecologists are picked on reputation, and yet some of the most popular gynaecologists have undesirable outcomes such as high c section rates!

Risks of c section

A C Section is a major surgery and like all surgeries carries risk.  A little while ago, the American College of Obstetricians and Gynecologists (ACOG) issued a statement that “pregnant women plan for vaginal birth unless there is a medical reason for a cesarean.”  They pointed out that a caesarean delivery can increase the risk for infections, bladder and bowel injuries, and serious complications in future pregnancies.  They noted that babies born vaginally have fewer respiratory problems.

Challenges in finding out the cesarean rate 

A few months ago I met a man whose wife was pregnant with their first child.  This man was concerned about overuse of investigations and interventions in private obstetric practice.  He had visited multiple hospitals to enquire about their caesarean rate.  When I met him in a childbirth education class at our hospital, I congratulated him for being so proactive. But knowing about the performance of a gynaecologist or a hospital should not require such extraordinary effort.  And yet there are many challenges to making such information available.

Most hospitals don’t collect data on clinical outcomes – they may not have electronic health records or lack the manpower to manually collect the data.  Gynaecologists and hospital administrators may also be hesitant to disclose quality-related data because of concerns about misuse by competitors or patients.   But these concerns should not hold back efforts at promoting transparency if we want healthcare to become better and safer.

Moreover, women and their families are also asking for accountability from their healthcare providers. Recently, a petition on Change.org gained well over 100,000 signatures asking doctors and hospitals to make mandatory disclosures of their c section rate.

C section rate at Sitaram Bhartia

In 2014 we publicly disclosed the c section rate of our staff obstetrics and gynecology unit – becoming perhaps the first private hospital in India to do so.  In the previous year – 2013 – our staff unit had delivered 561 babies with a caesarean rate of 40%.  This rate was much above the 10-15% rate recommended by the World Health Organisation and the average rate in countries like Sweden (17%), UK (26%) or USA (33%).  However, it was significantly lower than the 65% caesarean rate reported by a leading health insurance company in India for their claims.

Because the risk of a c section is different for different groups of women – based on whether it is a first or subsequent delivery, whether prior deliveries were vaginal or by caesarean, whether the baby is in the breech or abnormal position, whether pregnancy has reached term (>37 weeks) and whether there are twins – it is more useful to look at caesarean rates for each of these groups separately.

It is particularly insightful to look at the c section rate for low-risk first-birth women.  This is the rate for first-time mothers who have crossed 37 weeks of gestation and have a single foetus in the correct head down position.  Our rate for this subgroup in 2013 was 30%; again this was high compared with exemplary hospitals such as the National Maternity Hospital in Ireland which has a rate of about 18% for the same group.

88% Normal delivery rate*

While our c section rates in 2013 were lower than in prior years, we were unhappy that they were still high. But I am pleased to report that these rates have substantially declined – our total caesarean rate in 2016 was 18% and our low-risk first-birth caesarean rate was 12%. This compares very favourably to most private hospitals in Delhi where rates are typically in the 40-80% range!

C section rate for 2016
88% normal delivery rate for first-birth low-risk mothers

We believe that couples who want a positive birth experience should learn about criteria for selecting a top gynaecologist.

The caesarean rate is a good starting point for evaluating your gynaecologist and letting her know about your preference for a normal delivery.

*The term “normal delivery” is being used to indicate vaginal deliveries as is commonly understood by lay public.

Authors note: This post was originally published in May 2014 and has been revised and updated.

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  • Krishnan Chatterjee

    Its fantastic to see this level of transparency being brought in. It is most reassuring for to be parents to be able to demystify the black box of childbirth. Keep it coming sir !

  • This shows the commitment to the cause. It is a great and bold step. Congratulations.

  • Abhishek Bhartia

    Thanks to Dr. Kedar Mate of IHI for sharing the link to an excellent article published recently by the New York Times – “In Delivery Rooms, Reducing Births of Convenience.” I think there are learnings here for private obstetric practice in India too!
    http://goo.gl/wWtm1A

  • Rakesh Taneja

    It is commendable that you have initiated a discussion on cesarean rates in obstetric practice. As a practising Gynecologist and Obstetrician, I feel the debate is very timely. The quality of decision making is extremely important. I am confident that medical audit will be adapted in all spheres of medical practice. Your categorisation of ‘low risk first birth women’ is the category which will have the maximum impact in the long run. May I suggest standardisation of the indications for cesarean so that effective statistical comparisons can be undertaken for medical audit.

    • Abhishek Bhartia

      Excellent suggestion. We use Robson’s Ten Groups and National Maternity Hospital (Dublin’s) indications for cesarean section. A recent systematic review concluded the following –
      “Results suggest that women-based classifications in general, and Robson’s classification, in particular, would be in the best position to fulfill current international and local needs and that efforts to develop an internationally applicable CS classification would be most appropriately placed in building upon this classification.”
      http://goo.gl/XxwV1j

  • Prof Dr V Gautam

    I applaud this landmark event. I hope it will set the trend for all to follow.
    As the next step it may be worth considering the ways to achieve standardisation of such reports for comparison between service providers. It may also be desirable to gain external validation of internal audit. Sincere Best Wishes for what should be seen as a transforming contribution to the Indian health care.

  • Hospital Guide

    This is a very important step you have taken towards transparency in healthcare! Congratulations! Yes standardization of reports and external validation would be important as already mentioned below. Wish you all the very best.

  • Debashis Dhar

    Quality control is a never ending mission and a journey of commitment and truthfulness. Unfortunately majority of private health care systems are more akin to’quantity’ rather than ‘quality’. In this era of evidence based medicine I really appreciate your bold effort of audit and surveillance of LSCS in your institute. A multi centred database in cooperation with other like minded Indian institutes or parent bodies can be utilised to formulate guidelines and evidences pertaining to our population.

  • Sanjay Bansal

    I commend you for being forthright and honest about your c-section rates. I think transparency in medicine is very important. We struggle with this issue in the US as well. Im concerned about the transparency of payments, which I’m convinced is vastly in the favor of the favored few (insurance companies, drug companies, etc).

    I had a few comments while reading the blog:
    1) 1st paragraph: you mention evidence based medicine. Im afraid that concept might fall on deaf ears. My hunch is that the Indian mind set is that any doctor who reads and reviews the medical literature for their illness is not well educated enough. I think deep seated is the idea that the “good” doctor should know the answer right away.
    2) 5th paragraph: i don’t think its a matter of initiative or courage. Rather, I think its a matter of high expectations and demand for accountability, and being persistent for answers to ones questions.
    3) 8th paragraph: nice point that the interpretation of the data depends on the individual risk groups.
    4) 9th paragraph: you give comparison with Ireland’s rate, but what about with a leading indian hospital’s.
    5) 10th paragraph: i recommend also discussing post op care, morbidity and mortality.

    • Abhishek Bhartia

      Thank you for your comments. Cesarean rates of Indian hospitals are typically not available – and if so are rarely segmented by risk groups – we thus chose to quote NMH Dublin. We hope to become more transparent over time and address other issues related to patient safety such as peri-operative care.

  • Mukesh Jindal

    I am totally convinced about what has been written in the article.

    We had our normal baby delivery in this hospital 2 years back. It was a fantastic experience. I could really feel from very beginning the commitment of doctors in trying to ensure that the baby was born through normal delivery.

    Before selecting this hospital, I had done my homework by visiting Max, Fortis and Gangaram hospital. I found those hospitals to be overcrowded and with very little personal attention. The doctors were too busy and didn’t value the patient as much. And when I asked them about the rate of Cesarean delivery in hosiptal, they gave me bad looks and were not ready to talk about it. At Sitaram Bhartia, I was given full personal attention and all my queries were answered.

    If we decide to have our second baby, it will definitely be in this particular hospital. I recommend everyone to select this hospital if they are planning to have baby.

    All the best

    Mukesh

  • Sonali

    Reminds me of the quote – a small step for man, a giant leap for mankind. This truly is revolutionary. Thanks to you and your team for great leadership, courage and vision. Hopefully this will herald an era of transparency in healthcare and India – making it safer and better for all of us.

  • Pankaj Jain

    I am delighted to see the use of numbers to measure the quality of healthcare. I think it is very much needed, esp in India where the patients and their family have no idea what they are paying for, and if they are being taken for a ride. Patients also need to start seeing the healthcare professionals as practitioners of science. Besides if we want to improve the healthcare system it is important to measure – it is very difficult to improve something that you cannot measure.

    As for the alarming rate of c-section in India, there are multiple sides of the story (Note: I am not from the healthcare industry, but these observations are based on my personal experience). Of course as you pointed out perhaps ensuring normal vaginal delivery is not an objective of most healthcare providers in India, either because they don’t care or perhaps the monetary incentives (or the amount of time required for normal delivery) are in favor of c-sec. But if I look from the patient side, there seems to be a lot that needs to be addressed there as well. Our society needs to be educated about the benefits of normal birth (and the downside of c-section). It is also important to communicate that there are a lot of things that can be done during maternity that can maximize the chances of normal delivery. We also need to recognize that normal delivery is painful, and the expecting mother may be tempted to take the easy and “safe” c-section route (esp if the obstetrician also does not discourage that). So we need to figure out a practical way to remove the fear of labor pains.

    These are some of the things that may need to be tackled before we hit the utopian 10% rate you mentioned in your post. But measuring these numbers and the commitment for transparency are great first steps. All the best !

  • Anil Verma

    First of all I apologize for responding late.
    This is an excellent thought and future direction.
    Quality metric is very important to ensure we are following the guidelines to provide the best quality of health care to our patients.
    Like US in cardiology we have APPROPRIATE USE CRITERIA in all aspects of cardiovascular care such as what is considered appropriate to perform angioplasty, this is done to ensure that physicians are following the guidelines, providing appropriate care and containing cost.

    Appropriate use criteria is an attempt by American College of Cardiology to persuade physicians to balance good medial therapy and invasive costly treatments. In my hospitals I am graded upon how many stents I have used and how m
    any heart caths I have done without performing appropriate stress test or trying good medical therapy.

    I believe Sitaram Bhartia has taken right steps towards formulating some level of appropriate use criteria in performing C-Section.

  • Rahul Dutta

    First of all hearty congratulations to you for making this effort and hopefully other’s in the Industry will appreciate the importance of transparency in medicine.
    We had our normal baby delivered almost 2 years back under Dr Rinku and for me it was a definite choice where we’ll be heading to for maternity care. When I talk about our experience with friends, most of them get really surprised b’cos they get the exact opposite elsewhere.
    Making patients aware of medical options and enabling them to take right decisions is the key USP of SBISR.
    Good Luck to the entire team…

    • Thanks Rahul for being such a great supporter of Sitaram Bhartia!

  • martinogk

    Great initiative to reduce the Cesarian delivery rate, and also to be transparent about the numbers at your hospital. As a patient it is hard to say no if the doctor recommends a Cesarian delivery, since it is sometimes critically needed; so knowing that a hospital does not recommend them unnecessarily is the way to go.

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  • Manjul Mayank

    A million dollar question indeed in front of many of aspiring
    parents!!

    Going through childbirth process is a mix of immense pain
    followed by immense happiness – in this journey one can’t just imagine the role
    of a good hospital, doctor and support staff – it’s simply priceless!

    Having blessed with ‘baby blue’ @ SBISR recently on 31st
    Oct, my personal experience has been truly phenomenal. We were really privileged
    to be accommodated by Doctor Rinku at the very last hour, with just few weeks
    left from D-day.

    I must admit that our dream of a normal delivery could not
    at all have been possible, if the world class consultation, personal touch, care
    and professional advice we received from entire SBISR team wasn’t there. Ever
    since we made our first visit to the hospital we were simply asked to have ‘trust
    in institution’ as a whole and not any single individual team/ doctor – I’m
    sure this may sound a bit contrary to our real world where most of us run after
    a particular doctor/ hospital.

    Can’t thank Dr Rinku and entire Gynae team at SBISR team much
    for their passion, commitment & never give-up attitude, but hope my few
    words of gratitude resonate my emotions and does speak volumes of SBISR being
    as seasoned and established institution still following some world class
    ethical practices – Kudos to entire team !!

  • Our current normal delivery charges and cost of caesarean delivery can be found on this page:
    http://www.sitarambhartia.org/maternity-program/delivery-charges-delhi-hospital/
    Sorry for the late response. Hopefully, you’ve already had a great delivery experience!

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