Ideas of India: Maternal Healthcare and Evidence-Based Decision-Making

In this episode of Ideas of India, Shruti Rajagopalan speaks with Janhavi Nilekani about India’s high rate of C-sections compared with vaginal births, problems with maternal healthcare, the present and future of Indian midwifery and much more. Nilekani is the founder and chair of the Aastrika Foundation, which seeks to promote a future in which every woman is treated with respect and dignity during childbirth, and the right treatment is provided at the right time. She is a development economist by training and now works in the field of maternal health.

https://www.discoursemagazine.com/culture-and-society/2023/01/05/ideas-of-india-maternal-healthcare-and-evidence-based-decision-making/

It’s routine in Bangalore hospitals to have C-section rates of 70%, 80% and 90%.

The public health world calls this the “too little, too late” or “too much, too soon” challenge in maternal health.

What I was looking for was an evidence-based birth. What I wanted was interventions which science and research and meta-analysis show that the benefits outweigh the harm. I did not want interventions where the harms outweighed benefits. It was as straightforward as that, which was nearly very hard to get.

But the whole time, I kept feeling it is nearly impossible to change the incentives of any institution. Systems are geared around all the actors in it having some incentive alignment to what they’re used to doing. That was one of my biggest takeaways from economics, that aligning the incentives of people is very hard, and changing the incentives that they already have for one of exemptions is even harder.

RAJAGOPALAN: I can see what you’re seeing in terms of incentives, but can you also spell it out in the case of maternal health specifically? What are the incentives? Is it that C-sections are easy to schedule? These doctors are super busy, which means they can do six or seven a day. Whereas when it comes to a regular childbirth, we don’t know how many hours the woman’s going to be in labor, we don’t know what kind of staff you need. You might need more trained nurses, you might need someone who’s a trained anesthetist, a doctor who can be there on call the whole time.

Looking at private-sector urban maternity care, one straightforwardly is cost. A lot of places charge substantially more for a cesarean section, and hence it is in the hospitals’ incentive to do more cesarean sections. Of course, they’re making more revenue per procedure. That’s one.
More important than that, I feel a second but ultimately more important factor is that cesareans are much more cost-efficient. They are much more cost-efficient. You do them back to back.
It takes an hour to do a cesarean. A normal childbirth for a first-time mother, 8 to 24 hours is considered normal.
The big challenge that hospitals have is that if you want to safely do vaginal births, you need to have a reasonable amount of ability to do an emergency cesarean all the time, 24/7. That is very cost-ineffective unless you’re in a large-volume center. If you’re going to keep an obstetrician on standby 24/7, a neonatologist on standby 24/7, an anesthetic team on standby 24/7 in case any particular birth becomes an emergency cesarean, your human resource cost and what you’re paying out in an extremely expensive, high-human-capital employee is much higher than if they’re all there on a day shift during which you’re largely finishing off cesarean births.