Caesarean Section Births in Ho Chi Minh City

(Caveat lector: This post is very long.)

Many of you know someone who has given birth via caesarean section--probably all of you. Unlike its portrayal in Robin Hood: Prince of Thieves (where a Moor Morgan Freeman performs the surgery on Little John's wife), it is not just an emergency procedure anymore. For various personal reasons that can be debated another time, some women opt for caesarean section rather than vaginal birth (i.e. drug free) or epidurals.

Why? Some of the leading doctors in America asked this question, along with, "Should we advise or patients to opt for not-medically necessary c-sections?"

Evidence comparing vaginal births to c-sections is scarce, they say. So,

"Based on indirect evidence," the report continued, "there appear to be relatively similar degrees of risk from both pathways in women intending to limit their childbearing to one or two children."

The report than summarizes the pros and cons to caesarean sections.

"Potential benefits of a requested Caesarean delivery, compared with vaginal delivery, include decreased risk of hemorrhage for the mother and a reduced risk of certain complications for the baby ... Possible risks of a requested Caesarean include respiratory problems for the baby [and] hospital stays tend to be longer for the mother with Caesarean deliveries." (Emphasis is my own).

That is pretty straight forward, and ho hum, but the docs did make a few firm recommendations. One of which is,

"Given that the risks of placenta previa and accreta rise with each Caesarean delivery, Caesarean delivery on maternal request is not recommended for women desiring several children."

This alarm over caesarean sections comes because

"One published study found that this type of delivery increased from 3.3% of all live births in 1991 to 5.5% in 2001."

Other reports have also found problems with caesarean sections. An Australian study found that

"women faced a higher risk of hemorrhage and hysterectomy in their next pregnancy, and there was a higher risk of stillbirth and maternal death.

Anecdotal evidence suggested that women who had caesarean sections were at greater risk of infection and illness which impacted on breastfeeding, bonding between mother and baby, and postnatal depression."

This is important information because Australians have more experience in caesareans than Americans--with almost 25% of births now by c-section.

Also, the Australian report, like the American report, highlights the high comparative cost and length of hospital stay that accompanies caesarean sections.

"[Dr Tracy] said a caesarean section cost on average $1000 more than a natural birth, and women were spending twice as long in hospital - an average of five days compared with two to three days for natural births."

Hey, I wouldn't be a microbiologist without at least one scientific study to throw at you. Here's some hard data from the Medical Journal of Australia. (MJA 2005;183(10): 515-519)

The caveat:

"Of the 136 101 women with data on both first and second births, 25 596 (18.8%) had a caesarean section in their first pregnancy. Compared with mothers with primary vaginal birth, mothers who had primary caesarean section tended to be older, more socially advantaged and more likely to have medical and obstetric complications."

Now the results:

"We found primary caesarean section (compared with primary vaginal birth) conferred additional risk of complications in the second pregnancy for both mother (primarily if she underwent labour) and baby, and that a substantial proportion of serious complications were attributable to primary caesarean section. However, the complications we examined were uncommon, regardless of whether the mother had a primary caesarean section.

...Among mothers who underwent labour, we found higher rates of PPH, hysterectomy, and manual removal of placenta in those who had had a primary caesarean section than in those who had not.

...Primary caesarean section conferred a higher risk of postpartum infection, which is not surprising given the substantially higher caesarean section rate in the second pregnancy in these mothers (18% v 4%). Primary caesarean section also conferred a higher risk of admission to ICU for women who undergo labour, consistent with higher rates of complications overall.

...Our results lead us to conclude that, if a mother has had a primary caesarean section, she will only reduce her risks of complications in her second pregnancy to the level commensurate with a mother who had a primary vaginal delivery if she also has a caesarean section in her second pregnancy."

So, experts from the United States of America and Australia have found that caesarean sections produce extra risks on the mother and child in subsequent births, these risks increase more if the subsequent births are vaginal, they increase still if you have more than two children, and the pros are reduced chances of the child suffering already extremely rare complications.

Now, these are results from two industrialized, wealthy countries with good health care programs--one with lots of caesarean sections and one with few. How does Vietnam stack up??

Although Vietnam's economy is growing by around 7.5% a year, it is not industrialized like America or Australia. Doctors are the upper crust in Vietnam--every child wants to be one--but the health system does not have the expertise or equipment that the other two do. The always horribly written and taken-with-a-grain-of-salt newspaper, the Vietnam News, wrote last year that in Vietnam

"In 2001, 36.9 per cent of mothers undertook the operation, whereas in the first six months of this year alone the figure is nearer 40 per cent."

I dropped this by a few of my friends that have had children recently and was immediately laughed at.

"40%?" one lady said. "Whatever. The percentage isn't lower than 80%"

That preceeded a flow of caesarean stories that proved the impetus for this research.

Le Anh Tuan, deputy director of the Central OB hospital in Hanoi, openly admitted reasons why women get c-sections in Hanoi saying,

"Usually caesarean births are only carried out if there are pregnancy complications, or if the mother is ill, either reason posing serious risks to the health of the mother or child.

...that doctors would also decide to operate if the embryo was over grown, or if the mother was too old or too young. The doctor also said mothers who had received embryo transplants resulting from in vitro fertilisation should also undertake the operation.

...many mothers opt for a caesarian as a way of avoiding the average ten hours of labour pain caused by natural child birth.

...[and] some women prefer this unnatural method as they don’t want to lose their beauty after giving birth, while others want their children to be born on a chosen day."

And the kicker is that he finishes it with this:

"it [is] very difficult for the hospital to deny any request for a caesarean. If they were to refuse the request and the mother was to have problems giving birth, the hospital could be sued."

What are the statistics from c-sections in Vietnam? A report in the Journal of Health, Population, and Nutrition gives some clues.

"Results of a longitudinal study showed that the incidence of post-caesarean infection was 9% with 3-4% severe infection ... Yet, these rates are likely underestimates as routine laboratory analysis of post-caesarean patients was not conducted."

(This is interesting because the government found only 0.16% post-partum infections in its own unpublished study.) The estimates of post-partum infections after vaginal births range from 1.7% to about 5%. Even the most conservative estimate of vaginal births gives an infection rate 10 times higher than what the government recorded only one year earlier in a private report.

Now, if women just want a baby on a certain day, why would they opt for c-section over inducing labor?

"Because the doctors want money," a Viet kieu friend told me. "When I went to have my last son, about a year ago, they would not let me have him vaginal. I told a doctor, 'This is my fifth child. I know what it's like. My labors are quick (30 minutes) and I want to be induced now.' My bags were packed and I was ready to go. The doctors flat out refused. They made me have it caesarean."

"It's 'cause they want money," chimed in her expat husband. "With c-sections they can charge more, and schedule the deliveries, so they can just have one right after the other, and make more money in a day. Plus they don't keep you in the hospital as long as they should so they can pump you in and out faster."

Then another friend--native Vietnamese with an expat husband--chimed in and said, "me too! I just had my son only two months ago. I wanted to have it vaginal, but they would not let me. I said, 'induce me!' and they said no. Finally, I packed up my bags, and went to the hospital at 39 weeks. I said, 'I'm not leaving until I have my baby.' Their response was, 'go home and come back in two weeks.' I was forced to wait until 41 weeks and then forced to have a c-section."

People ask me why I don't have any children yet. This is my answer. I don't want to deal with this crap. It's insanity. To force a woman into surgery, in a country with health care like this, because you want more money, and then hide behind the assertion that "the hospital could be sued." My father-in-law's a lawyer in Ho Chi Minh City and I'm telling you, the LAST thing a hospital in the city is worried about is some woman suing them. 99% of people don't have the resources to sue, and the current laws aren't strong enough to ever win a lawsuit against a government hospital, especially in Hanoi.

So, 5.5% of America, 25% of Australia, and probably 80% of Vietnam has babies via caesarean section. Caesarean sections provide some benefits to the baby, but are outweighed by increased complications to the mother in the second and subsequent births. These are multiplied if the mother has her other births vaginally or has more than two births total. Post-partum infections in Vietnam are at 9% of c-sections, almost twice as high as the most liberal % of vaginal births. Doctors force women to wait until late in gestation and to have c-sections so they can schedule in the birth and make more money.

I'm sick of this. I'm sick of the lack of morals. Forget PMU18, get me an investigation into widespread hospital corruption and hypocracy. Vietnamese ob/gyns at hospitals cause increased health problems in women by doing an unnecessary surgical technique with documented risks on at the least 40% of people in Vietnam (double in HCMC). They are everything I never want to be when I am a doctor.

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