India has one of the highest rates of cesarean section deliveries in the world, but a new study suggests that following the World Health Organization’s guidelines can help improve women’s care during childbirth and lower the number of unnecessary C-sections.
The Problem of High C-Section Rates in India
Cesarean section, or C-section, is a surgical procedure to deliver a baby through an incision in the mother’s abdomen and uterus. It can be a lifesaving intervention when there are complications or risks during labor or delivery, such as fetal distress, breech position, or placenta previa.
However, C-section can also have negative consequences for the mother and the baby, such as increased bleeding, infection, pain, scarring, and longer recovery time. It can also affect the future pregnancies and births, such as increasing the chances of placenta accreta, uterine rupture, and stillbirth.
According to the latest National Family Health Survey (NFHS-5), India’s C-section rate has increased from 17.2% in 2015-16 to 21.1% in 2019-20, which is higher than the global average of 18.6%. The WHO recommends that the C-section rate should be between 10% and 15%, as there is no evidence of additional benefits beyond this range.
The reasons for the high C-section rate in India are complex and multifactorial, such as the lack of skilled birth attendants, the preference for painless delivery, the fear of litigation, the financial incentives, and the social and cultural factors.
The Solution of WHO Guidelines for Childbirth Care
The WHO has developed and published a set of guidelines to improve the quality of intrapartum care and enhance women’s childbirth experiences. The guidelines are based on the best available scientific evidence and the human rights principles, and they cover various aspects of care, such as labor monitoring, pain relief, labor induction, labor augmentation, and C-section.
One of the key recommendations of the WHO guidelines is to change the definition of active first stage of labor from the widely used 3 centimeter (cm) or 4 cm to starting from 5 cm of cervical dilation. This is because the historical ‘1 cm per hour’ rule for labor progress is unrealistic and inaccurate for most women, and it can lead to unnecessary interventions, such as C-section, when the labor is slower than expected.
Another key recommendation of the WHO guidelines is to remove the ‘alert’ and ‘action’ lines from the partograph, which is a graphical tool to record and monitor the labor progress. The partograph was originally designed to identify and prevent prolonged and obstructed labor, but it has been misused and overused to justify C-sections, especially in low-resource settings.
The WHO has also developed a ‘next generation’ partograph, known as the Labor Care Guide (LCG), which is a simplified and user-friendly tool that focuses on the woman’s well-being and preferences, rather than the numerical measurements and time limits.
The Impact of WHO Guidelines on C-Section Rates in India
A pilot study, conducted by researchers from India, Australia, and Argentina, has evaluated the implementation and effectiveness of the WHO LCG in four hospitals in India. The study, published in the journal Nature Medicine, is the world’s first randomized trial of the WHO LCG, and it involved 1,000 women who were admitted for labor and delivery.
The study found that the use of the WHO LCG reduced the C-section rate by 10.5%, from 30.9% in the control group to 20.4% in the intervention group, without compromising the maternal and neonatal outcomes. The study also found that the use of the WHO LCG improved the women’s satisfaction and empowerment, and the health workers’ confidence and competence.
The study concluded that the WHO LCG is a feasible and effective strategy to improve the quality of care and reduce the unnecessary C-sections in India, and it can be implemented in busy and resource-limited settings. The study also suggested that the WHO LCG can be scaled up and adapted to other contexts and countries, where the C-section rates are high and rising.
