BORN C: The number of Caesarean births in China are on the rise (GONG BO)

After watching a live online broadcast of natural delivery two years ago, expectant mother Gao Yun decided then and there that when her time came she was opting for a caesarean section (C-section) birth.

"It was so scary. I thought it must be very painful to have a natural delivery, so I chose the C-section," Gao told ChinAfrica.

Gao is just one of an increasing number of Chinese women having caesarean births for non-medical reasons. According to a global survey on maternal and perinatal health by the World Health Organization (WHO) issued this year, China has the highest rate of C-sections in the world, at 46.2 percent. The number is triple the WHO's recommended maximum level of 15 percent. The number of C-sections without medical reasons is 11.7 percent, also the highest in world. More alarmingly, the percentage is on the rise.

C-section is usually performed only in a life threatening situation, when a vaginal delivery is risky to the infant or the mother. However, in China it seems to have become a fashionable trend. The WHO's figures of China's high caesarean rate have fueled mounting public controversy.

According to a 2006 report of Beijing Public Health Information Center published on its website, in the 30 years from the 1950s-70s, only 5 percent of expectant mothers had C-sections. However, in the 1980s, the percentage rose dramatically to 30-40 percent and further to 40-60 percent in the 1990s. According to a survey by China Economic Weekly in May this year, in hospitals of most big cities in China, the current percentage of C-section is between 40-60 percent; in a few hospitals, the percentage even reached 90 percent.

The right to choose?

Facing the high caesarean rate, obstetricians complain that they also found themselves in a dilemma. "Nowadays, young mothers are more fearful. They think they cannot endure the pains brought by natural delivery," said Deng Yonghua, a retired gynaecologist in Xiangyang People's Hospital in Hubei Province. In an interview with ChinAfrica, Deng noted that it is the main reason for the increasing caesarean rate.

According to Deng, in most cases, hospitals will give C-sections at the requests of expectant mothers. Meanwhile, doctors will also suggest a C-section even if a minimum risk is foreseen. "We do not want to be involved in lawsuits for possible accidents happening in natural delivery. It will damage the hospital's reputation and waste much time and money," added Deng.

Mothers also have their own consideration. Before bearing her baby, Gao heard about one of her friends who had a natural delivery having difficulties when she was in labor. She finally resorted to C-section, but both she and her baby got hurt. "You will never know what would happen during the labor, so caesarean birth will be safer than natural birth," Gao said.

"As a bonus, C-section can help me keep in shape. Nowadays, the incision of C-section is under the bikini line, so the scars won't be seen," she added.

Though there might be some truth to what Gao said, Deng Yonghua suggested that vaginal delivery should be considered first unless an abdominal surgery is necessary. "Many complications may arise during labor, but it is not good to schedule the C-section in advance," she said.

She explained that C-section has many drawbacks and sometimes poses risks to mothers and babies. "For example, C-section can cause adhesion where the scar tissue connects with the organs," Deng said, adding that it may also interfere with a woman's subsequent pregnancy. Though most of China adheres to a one-child policy, many families can opt for another birth if their first children are mentally or physically disabled, or die during childhood. In this case C-section may influence follow-up pregnancies.

According to Deng, C-section could lead to stillbirth in subsequent pregnancies and mothers are advised to wait for three years until their next conception. Deng said a woman can only have a maximum of three C-section births.

Deep-seated cultural beliefs also contribute to the high C-section rate. Some mothers want their babies to be born in a certain astrological sign, which they believe may favor positive characteristics. Some women even elect C-section to schedule the birth on a certain day. For example, on August 8, 2008, many women had their "Olympic babies" through C-sections, according to china.com.cn.

Follow the money

But many mothers have their own opinion of the issue. Some blame the hospitals for persuading them into having abdominal surgeries. Li from Henan Province, who refused to give her full name, is one of them. She originally intended to have a natural delivery, but the obstetrician told her there might be risks in her situation to have a natural birth.

"The doctor said the umbilical cord might bind the infant's neck and suggested me to take the caesarean option instead. But the results of previous pregnancy examinations show everything is OK," said Li. "I think the hospital did this because C-section brings it greater profit; but I dare not ignore the [obstetrician's] suggestion," said Li.

According to the information released by Beijing Women and Children Hospital, the average cost to the individual of a C-section is 6,000 yuan ($880), while that of natural delivery is only 2,500 yuan ($365). Meanwhile, mothers with C-section need to stay in hospital longer, which can also increase hospital profits.

"It is true that gaining profit is one of the factors for public hospitals to persuade expectant mothers to receive C-section," said Gao Ling, Chief Physician in Amcare Women and Children's Hospital, a private hospital in Beijing. "The main reason is that the [natural] delivery fee is very low." Gao worked in a public hospital for nearly 30 years.

However, Deng Yonghua doesn't agree that all the hospitals are motivated by financial incentives to perform C-section. "Situations vary among hospitals. In most cases, hospitals will act according to a patient's will. Though some C-sections are doctor-ordered, most of them are requested by the mothers."

Educate mothers

Many women select C-section as they believe it provides them with higher quality of medical care. However, the reality is starkly different from conventional wisdom. WHO reports caesarean birth without medical need could be much more harmful than natural delivery as it increases the mother's risk of maternal mortality and morbidity.

"Without a good medical reason, pregnant women who choose C-section are exposed to a higher risk, without additional benefits for the baby or themselves," said Dr. Robert Scherpbier, the medical officer for maternal and child health at WHO China. "The risk of maternal death is up to five times higher, and the risk of maternal illness is even 14 times higher than with spontaneous delivery," he said. "Contrary to popular belief, illness in newborns is also more frequent after a C-section which is done on request."

To curb the trend of increasing caesarean births, Scherpbier emphasized that an increased focus on quality of medical care is needed. C-sections should only be performed when there is a good medical reason, he said.

"There is the need to educate pregnant women, their families and doctors on the increased risk of death and illness that result from C-section without medical reason," Scherpbier added.