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    Thursday, April 20, 2006

    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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    MGO said...

    The law student in me is curious now, since you mentioned lawsuits were cited as a potential (but realistically unlikely) cause for the situation.

    Is there tort law in Vietnam? Can you really sue someone for damages for an injury done to you?

    The reason that interests me is that it's a form of private, rather than administrative law. Suing someone doesn't require government officials to act on your behalf - you act on your own behalf. The government just adjudicates.

    Lack of a developed tort law system was cited to me as a danger of doing business in China, so hearing it might be found in Vietnam is very interesting to me. And as far as corruption goes, especially if the law somehow gives a pass to doctors arguably inflicting injury on their patients.

    By the way - re the post on the people fighting but being advised not to get the police involved. Reminds me of something they mentioned about ancient Chinese law in my study abroad course. Apparently, the state didn't like to have to step into private disputes, so as an incentive to make people work things out on their own, the court (supposedly) meted out corporal punishment to BOTH parties before resolving the dispute in court. So maybe there's some sort of connection. Who knows? China and Vietnam do share a lot of history and culture.

    VietPundit said...

    Wow, 40% (80% ??!!) are c-section? I haven't seen this problem mentioned much in the VN press.

    Re the money factor: I knew that money dictates everything in health care in VN, but this is too much.

    I know of friends and relatives in VN who had to give cash to hospital employees (nurses, technicians) to get the medical care they need (even things like clean towels). Medical ethics aside, that's a sad commentary on people's humanity.

    Triet said...


    I'm going to be a crappy blogger and say--yes, but I can't answer it.

    "Tort Law" exists in Vietnam, but like most law in Vietnam (and I assume China) is severly dictated by the communist party. In English speak, that means they enforce what they want to enforce and make everything else far too hard to do.

    Suing someone doesn't involve the government in the USA, but in Vietnam, everything is the government. Even "private" companies are only partially private. The government holds a stake in everything. In my post, I am talking about births in Ho Chi Minh City, we almost exclusively happen at hospitals. Hospitals are government funded and ran, the doctors at hospitals are known to be members of the party--not necessarily the best doctors around.

    So, to the best of my knowledge, it is possible to sue in Vietnam (I will find out more). However, in this case, you will be suing, even indirectly, the government. Therefore, the government makes it very expensive, impractical, and scary to try that tactic. Much easier to just get a c-section. You must remember that many Viets (most?) in HCMC make between 600k VND and 1.5 mil VND a month ($40 USD to $93 USD) and suing a doctor/hospital would cost FAR more than that. Normal people just can't do it.

    Also, interesting observation about China. I don't know if that's the reason for reticence in the actions of Vietnamese police, but it makes some sense.

    I was shocked too. I didn't believe the numbers until I asked other people. I'm not talking about all of Vietnam here. The 40% number is a government figure for all of Vietnam, but the 80% is my straw poll about only HCMC. I expect that most women outside HCMC have vaginal births.

    That said, even 40% is sickeningly high.

    I have, unfortunately, also heard about giving money to get adequate care. When I heard (and read) about the prevalence of c-sections in Vietnam, I couldn't understand why. I thought that maybe it's part of the Vietnamese obsession to be western, modern, like giving children formula instead of breastmilk. The theory about making money stemmed from the comments I heard people make (it kept popping up) and I included it. It's the only reason I can think of that explains why so many totally healthy women/babies were denied vaginal births/inducement AND adequate hospital time. However, I would like to get my hands on something more and explore this further...maybe someone can help??

    Finally, one of the small points I made in my post which I think is worth highlighting is the % of post-partum problems. Reasons why aside, and going with the # published in the pro-government state-run english-language paper, 40% of Viet women are having c-sections and 9% of them are having serious complications afterwards. Two things jump out at me: the government study claimed only 0.16% and the independent study found 9%. That's a huge difference. It would make the government look bad. It makes me wonder if the 40% number is doctored too.

    Second, 9% of 40% is still almost 4%. 4% of all births in Vietnam have serious complications DUE TO c-sections. Vietnam has some brave mothers.

    Triet said...
    This comment has been removed by a blog administrator.