Shova Karki, 29 of Sanghu gave birth to a baby¬-girl on October 31, 2006 through Caesarean Section at Om Hospital and Research Centre at Chabahil. She was diagnose with a normal baby position during her antenatal care (ANC) visits where the doctors told her that she could have a normal delivery. However, two days before the delivery, attending doctor referred her for a surgery.
INDiRA ARYAL: CIJ
One of her relatives, who works as a staff nurse in the same hospital convinced the attending doctor to wait for a couple of days, hoping that Shova would go into labor. On the second day, however, the doctor told Karki that the baby was not in a normal position and cautioned her about complications if she waited for too long long.
She was shocked to hear this, especially because the doctor had not informed her about the baby's condition until the day before she was admitted to the hospital, “ I suspected a foul play but couldn’t have done anything. I had to agree for an operation," she says.
Karki does not want to have another baby because she know she may never be able to deliver normally again. “Even if I plan for a second baby, I will not go to a private hospital," she says.
Doctors claim that if the first delivery is through a caesarean method, the chances of second caesarean delivery is high. Besides, women who have delivered babies through C-section suffer from long term health complications than those who deliver baby normally.
Bhawana Nemwang 27, of Morang was admitted to Patan hospital for normal delivery on September 10, 2012 but the next day attending doctor suggested her to be prepared for a surgery citing that her baby was about to defecate inside the womb.
Obstetric/Gynecologist Dr. Sheelu Aryal explains that defecation inside the womb can threaten baby’s life. But often hospitals create such panic to persuade patients and family members for unnecessary operation.
Nemwang is not alone. Laxmi Lama, 27 from Nuwakot was also cajoled into a caesarean section at Kathmandu Medical College in Sinamangal citing that her baby was about to defecate inside the womb on October 19, 2012. Lama said she was admitted to the hospital for normal delivery.
"Attending doctors had convinced me that I could have a normal delivery but at the last hour, they decided to operate on me, " Lama told me. She feels she could have had a normal delivery had they waited for few. “I was beginning to go into labour pain when I was rushed into OT."
She also complains that she had to pay exorbitant fees of Rs. 42,000 for five days stay in the hospital where she heard delivery charges were free at KMC under Ama Surekshya Programme.
Woman, who have undergone operation in private hospitals complain that they were not sufficiently informed by their doctors during regular visits and were forced into surgery at the last moment.
Surgery is gradually replacing normal delivery in the hospitals of urban cities. Deliveries through caesarean have increased up to 84 percent in Kathmandu Valley which puts women’s health at high risks.
Various hospital records and sources inside Health Ministry confirm that private hospitals are involved in an unethical practice of forcing pregnant women into unnecessary operation for profit making.
Medi Care National Hospital provided delivery services to 19 women from July 2011 to June 2012, out of which more than 15 were cessarean deliveries. Om Hospital and Research Centre received received 1252 delivery cases from July 2011 to June 2012, out of which 80.68 percent were C-Section. Similarly, 667 women received delivery services from Valley Maternity Nursing Home, among them 77.36 percent are CS. Civil Service Hospital received 175 cases during that period of which 70.28 percent were CS and 170 women received delivery service from Vinayak Hospital of which 64.7 percent were CS.
Likewise, B & B Hospital provided delivery services to 144 women during last fiscal year, of which 67 percent were CS cases, 596 women received the services from Kathmandu Model Hospital with 60 percent CS cases, 265 women received delivery services from Kritipur Hospital during that period, of which 49.43 percent were CS, and Kathmandu Medical College provided delivery services to 1856 women, 44.7 per cent with C-section.
Similarly, TU Teaching Hospital provided delivery services to 4071 women during that period, among which 37.88 percent are CS. Norvic International Hospital provided delivery services to 813 women with less than 24 percent CS and Shankarapur Hospital at Jorpati provided delivery services to 121 women, among them 34.7 percent are CS.
Box 1
S.N. Name of Hospital Total Delivery (July 2011- June, 2012) C- Section (%)
1 Medi Care National Hospital 19 84.2
2. Om and Research Centre 1252 80.68
3. Valley Maternity Nursing Home 667 77.36
4. Civil Service Hospital 175 70.28
5. B & B Hospital 144 67
6. Vinayak Hospital 170 64.7
7. Kathmandu Model Hospital 596 60
8. Kritipur Hospital 265 49.43
9. TU Teaching Hospital 4071 37.88
10. Shankarapur Hospital of Jorpati 121 34.7
11. Norvic International Hospital 813 23.12
Sources: Hospitals and Family Health Division, Ministry of Health and Population.
The data collected from private hospitals in Kathmandu valley proves that C- Section is in their major business lists.
The government of Nepal follows World Health Organization (WHO) standard of C-Section which recommends that C- Section rate should not exceed 15 percent of the total cases. It calls to set an international standard, pointing about 10 to 15 per cent of pregnancy cases may require emergency obstetric care if a woman is to survive without lifelong disabilities and only five percent of such cases have life-threatening complications.
Despite such recommendations, the CS rate has increased all over the world. According to 2010 report by World Health Organisation (WHO), one in every two births in China are delivered by C-section. The rate is around two in five in Thailand and Vietnam, and nearly one in five in India. The Asian survey report of the same year says, China recorded the highest number of C-sections with 46 percent, followed by Vietnam and Thailand with 36 and 34 per cent respectively. The lowest rates were in Cambodia (15 per cent) and India (18 per cent).
Dr. Tirtha Raj Burlakoti, who heads the Curative Division at the Ministry of Health and Population (MoHP), says the inclining rate of CS in private hospitals, which is at alarming 70 to 80 per cent, calls for immediate intervention but admits that the Ministry has so far been ignoring the problem..
Unsafe Motherhood
The Government of Nepal launched Safe Delivery Incentive Programme (SDIP), under which 55 private hospitals and public hospitals across 75 districts in the country were provided with cash incentives for each safe delivery. According to the scheme, the government has been providing Rs. 1000 for every normal delivery to hospitals with 25 bed capacity and Rs. 1500 for the ones with capacity more than 25 beds. Where as, incentive for Cesearean delivery are as high as Rs. 7000 for each. From this amount, patients in Terai hospitals get Rs. 500, those in the hilly areas get Rs, 1,000 and those in the mountains get Rs. 1,500. The hospitals earn more from the C-Section cases than from a normal delivery.
Dr. Sheelu Aryal of Ama Surakshya Programme says, increasing trend of CS in these hospitals despite government's Safe Delivery Incentive Programme proves that the incentive itself has become counterproductive.
According to Family Health Division, during the fiscal year 2068/69 Mechi Zonal Hospital provided delivery services to 2048 women, among them 636 were CS and Janakpur Zonal Hospital provided delivery services to 10,656, among them 1641 were CS.
In the same period, Paropakar Maternity Hospital at Thapathali provided delivery services to 24080, among them 4514 were CS. Bharatpur Hospital provided delivery services to 14211 with 1731 CS cases and Seti Zonal Hospital had 681 CS cases out of 5469 deliveries.
Delivery: A Big Business
Patan Hospital, BP Koirala Institute of Health Science in Dharan and Kathmandu’s TU Teaching Hospital did not accept government’s Safe Delivery Incentive Program, under which the hospitals are not allowed to charge the patients, stating that delivery is the main source of hospital’s income and the incentive provided by government is too little.
The charge for a normal delivery at Patan Hospital is around 16,000 rupees, where as for the CS, it can cost anywhere between 25,000 to 40,000 rupees depending upon the choice of bed and other facilities. The charges for a normal delivery at Om Hospital and Research Centre range between 15,000 to 20,000 rupees, and the cost of CS is up to 45,000 rupees along with 12,000 rupees of extra medical charges. But the cost can differ for each patient and usually it is on the higher side. Karki had to pay 70,000 rupees for her CS at Om Hospital six years ago.
Similarly, the cost of a normal delivery at Valley Maternity Nursing Home in Putalisadak is around 20,000 rupees, while for a Cesarean it can cost double the price. Kathmandu Model Hospital at Pradarshani Marga charges around 7,000 rupees for a normal delivery and it can cost up to Rs. 25,000 for a CS with five days of post operative care at the hospital.
B&B Hospital in Gwarko charges 23,000 for a normal delivery and up to Rs. 40,000 for CS, excluding medical charges. However, Medi Care Hospital at Chabahil does not have a fixed charging rate and lets the doctors decide their own fees.
This is an indication that delivery is a big business, especially in private hospitals of Kathmandu because of which they are reluctant to accept government’s Safe Delivery Incentive Programme.
Laxmi Tamang, staff nurse and doctoral candidate at The University of Sydney says, “Urban women are at higher risks due to unhealthy practices at city hospitals which profit by making unnecessary interventions in women’s normal physiological process.”
She adds that there is a moral erosion among healthcare providers who have become money-minded rather than service-oriented, ignoring basic human sensitivity towards an expectant mother and her child.
Doctors claim that C-section is five times riskier than a normal delivery, but consider it to be a necessary evil. But in private hospitals of Nepal, this unhealthy practice seems to be on the rise due to the fact that it fetches more money than a normal delivery.
Ironically, some health experts argue that the trend of families vandalising hospitals and manhandling doctors in case of patient’s death or developing complications, asking large amount money as a compensation, deter hospitals and doctors from taking the ‘risk’ of a normal delivery.
Senior Obstetric/Gynecologist Dr. Kasturi Malla says that it is normal for the cases of CS to go up when the overall number of delivery cases are high. On the other hand, senior Gynecologist Dr. Aruna Upreaty says that personal and institutional excuses cannot be a rationale for unethical practice. “You cannot just cut open and sew human beings because it makes your life easy,” she concludes.
(Published in Rising Nepal on 18 Jan.2013)
