Choice in Childbirth

I am Neelu Paleti, a rising undergraduate senior studying Health and Societies with a concentration in Health Policy. This summer I will be conducting my senior thesis project, tentatively titled Modern Births?: The Construction of Power, Choice, and Safety of Caesarean Deliveries in South India. This research stems from my broader interests in maternal and child health, institutionalization of care, government-led health policy, and the evolving doctor-patient relationship in India. Though originally from Columbus, OH, I have experienced many different facets of India through my parents and extended family, who are all from the South Indian state of Andhra Pradesh. These experiences and stories of their interactions with the country’s medical system have piqued my interest to study the complexities of healthcare in this region.

When considering maternal healthcare and childbirth, one of the biggest patterns seen across many different parts of the world is the rise in C-section deliveries over traditional vaginal births. Over the past several decades, research has shown more and more mothers undergoing surgery to deliver their babies for a host of reasons. While a caesarean delivery has historically served as an emergency option during pregnancy complications, the World Health Organization deems that such “medically necessary” caesarean deliveries are required only for about 10-15% of all births. The problem that South India is facing is the rise of elective “medically unnecessary” caesarean deliveries that use more healthcare resources but do not necessarily contribute to any improvements in maternal mortality indices.

A 2015-16 version of India’s National Family and Health Survey has shown the rates of caesarean deliveries in Telangana and Andhra Pradesh to be 58% and 40.1% of all deliveries, the two highest rates across the nation. Moreover, 41% of all deliveries in private healthcare facilities in India are C-sections, increasing from 28% in the 2005-6 survey. This compares to around 30% C-section rates in the US. The question raised here asks why in particular are the rates in these South Indian states comparatively so high? What differentiates this procedure in this region of India that formulates this number? Such data has drawn the attention of providers, policymakers, and patients across the country who are now beginning to question the medical necessity of this procedure and the social forces shaping such trends of childbirth.

C-section rates across India, 2010-16

For the past several decades, India has been fighting to salvage its poor maternal mortality rates and ensure better patient outcomes. Many of the safe motherhood initiatives taken by the national and local governments aimed to raise the number of institutional births. As seen in the case of the Janani Suraksha Yojana, mothers were oftentimes even paid to deliver in a hospital, thereby equating institutionalization of childbirth with lower maternal deaths and safer outcomes. However, many of the secondary consequences, such as higher C-section rates, that came with this measure were never fully addressed. 

My project will research the underlying themes of the power and agency of mothers and families in the decision-making process of childbirth, as well as the dynamic of the doctor-patient relationship, especially in private healthcare settings. Through remote interviews with providers, I will contextualize the already existing quantitative research on the rates of C-sections within the nuanced circumstances of pain, family intervention, governmental regulation, and provider convenience more qualitatively. Interviews with healthcare providers in the hospital will portray how the formal education of obstetricians, payment incentives, overall attitudes towards patient populations, and awareness of this rate of C-sections influence the methods of delivery they recommend and use. I hope to contextualize these current themes within the historical evolution of maternal healthcare and midwifery in postcolonial India. Ultimately, this research around caesarean deliveries in South India speaks to larger themes of choice, social control, modernity, and gender, amongst many more that draw from the disciplines of history and anthropology to contextualize health in these communities.

One thought on “Choice in Childbirth

  1. This is an excellent blog-post Ms Paleti. Like you I too am a public-health student/researcher and I am interested in developing a deeper understanding what one can do to make change happen in environments like ours. C-Sections present a very interesting opportunity to study the process of change because there are many opposing poles in the issue that may give a “policy entrepreneur” like me an “entrepot”. These include, (a) we have too many C-Sections in the South (and J&K), we have too few C-Sections in the East – in fact there is virtually no place in India where the C-Section Rate is “appropriate”; (b) the private sector does more than the public sector (except in Pathamthitta in Kerala) but the public sector does a lot more than the WHO guidelines in the South and a lot less than the WHO guidelines in the East – in fact so little that without the private sector maternal mortality rates and peri-natal mortality rates could rise quite dramatically in these states; and (c) mothers want it versus doctors are afraid of violence against them if something goes wrong in a vaginal birth. In a working paper I have tried to explore some of the ideas for change further, and am hoping to build a full program of work / policy-research effort around addressing this challenge in the Indian context. Here is the link to it if you’re interested in taking a look at it.

    Nachiket Mor, PhD

    Research Work

    Professional Profile

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About Neelu Paleti

Neelu is a rising senior from Dublin, Ohio, studying Health and Societies at Penn. Her research interests lie in maternal and child health policies, as well as the institutionalization of medicine in India. Her senior thesis research revolves around the construction of power, choice, and safety in caesarean deliveries in South India. This research will explore how broader themes of decision-making and patient-provider dynamics affect the rising rates of C-sections in regions of India.