Hail Caesarean: Such births rising in East Asia

This is scary! - AmyMc

BANGKOK: When the time came, the doctor stood over Suthasinee Santikanavin's bulging belly and said: "It's almost 9:19. We are going to pull the baby out."

The birth of Suthasinee's daughter was written in the stars, at least according to a Thai astrologer who helped pick the precise day, hour and minute that the infant should be extracted from her mother's womb by Caesarean section.

Suthasinee's husband, Mahakanasnan, an intelligence officer for the Thai Navy, stood anxiously beside the operating table and made sure the auspicious timing was respected. He programmed the alarms in both of his cellphones, one in each pocket, to vibrate silently at 9:19 a.m.

"The alarms went off," Mahakanasnan said, a tone of satisfaction in his voice. "And I heard the baby crying."

That baby's birth at a private hospital here on March 22 was part of a wider trend of what medical researchers are calling an epidemic of Caesareans across East Asia.

Once considered a procedure reserved for emergencies or high-risk pregnancies, Caesareans are now commonly planned for a variety of non-medical reasons, including fear of labor pain, convenience for the doctor and the patient, and astrology.

In a region that lives by time-is-money production schedules at footwear and computer chip factories, the elective Caesarean brings clockwork and clinical tidiness to one of humankind's most stubbornly unpredictable processes.

Meanwhile, medical advances that have made the procedure safer and more routine have also, paradoxically, helped reinforce age-old superstitions. Couples in Chinese-influenced cultures have long tried to time births for auspicious years. Now, many can refine their choice to the day and minute.

The World Health Organization estimates that under normal circumstances a country should not have a rate of Caesareans higher than 10 to 15 percent. That widely quoted benchmark was established two decades ago and was loosely based on the experiences of developed countries with the lowest infant and maternal mortality rates.

But while Caesareans have become increasingly commonplace in almost all countries outside Africa - they make up around 30 percent of all births in the United States, a quarter of births in Germany but less than 2 percent in Mali, Niger and Nigeria - rates have skyrocketed over the past 15 years in East Asia as the region has prospered.

In Bangkok's private hospitals, which typically cater to wealthier patients, Caesareans now make up about 65 percent of births, up from 40 percent in 1990, hospital administrators said. In Hong Kong, where the notion of scheduling a birth dovetails with the city's palpable ethos of efficiency, 59 percent of all babies born in private hospitals came into the world under the knife in 2005, compared with 31 percent two decades ago, according to the Department of Health.

Cesareans involve slicing through layers of skin and fat and stretching apart abdominal muscles to reach in and pull out the baby. They take about an hour to perform and are safer than ever; in the West, the rate of maternal or infant mortality from the procedure is well below one percent for both mother and child.

Yet the growing use of elective Caesareans is controversial. Because it entails major surgery, there is always the potential for complications, even as the technology improves.

Still, the procedure's popularity is growing and is having a sociological impact. Increasingly, birthdays occur by appointment.

Whether astrologers or doctors decide, there is often haggling over the appropriate day and time.

Bumrungrad Hospital in Bangkok, a large private facility that caters to wealthy Thais and foreigners, bars parents from scheduling Caesareans during the inconvenient hours of 9 p.m. to 7 a.m. The hospital delivers about 180 babies a month, 65 percent by Caesarean.

At St. Paul's hospital in Hong Kong, where the Caesarean rate is about 70 percent, couples are charged extra if they select a time of birth between midnight and 7:30 a.m.

Noppadol Saropala, an obstetrician at Bumrungrad, says about one third to half of all his Thai patients who choose Caesareans want to set their own date and time. But there are limits: A patient must be close to the average gestation period of 40 weeks.

"I will not do a Caesarean if they're less than 38 weeks," Noppadol said.

If labor drags into a Friday evening, doctors may be tempted to speed things along, said Monir Islam, director of the WHO's Making Pregnancy Safer program. "They will go for a Caesarean section so that they don't have to be called over the weekend," Islam said.

Caesarean rates have been known to spike on the eve of major holidays. One recent example was April 12, the day before the start of Thailand's Songkran festival, a time of family gatherings, which this year amounted to five days off. At Phayathai 3, a private hospital in Bangkok, the number of Caesareans rose to eight, compared with the usual rate of three or four a day, said Supakorn Phawanna, a hospital spokesman. Supakorn said patients chose Caesareans because they wanted to "have relatives and friends visit their baby during the long holiday."

Doctors and hospitals alike have a financial incentive to perform Caesareans, especially at private hospitals. At Phayathai 3, a "Caesarean package" - four days and three nights in a private hospital room - costs 41,900 baht, or about $1,200. That is 40 percent more expensive than the typical vaginal birth.

Elective Caesareans are not covered by Thailand's universal health care system, reinforcing the notion that this is a procedure for the rich. In Thailand's government-run hospitals, which serve the country's have-nots, only 20 percent of births are Caesarean.

One of the women who chose April 12 to give birth was influenced less by the holiday schedule than astrology.

Apinya Jirupansawat, a 34-year-old employee of a stock brokerage, was told by a Chinese astrologer that she had three choices: April 12, 18 or 24.

After cross-checking with Thai and Western astrology books, Apinya settled on the first day. As she explained, according to Chinese astrology, a child born then "would support his parents and be easy to raise."

Some days of the week are luckier than others, said Pinyo Pongcharoen, the astrologer who helped time Suthasinee's daughter's birth.

This year, according to Thai beliefs, Sunday and Monday are generally auspicious, he said, while Saturday and Wednesday are not.

Doctors sometimes have trouble timing Caesarean operations so that the baby is extracted at the astrologically correct hour, Pinyo said, but ideally the birth should take place within 10 or 20 minutes of the time he selects as most compatible with stellar and planetary alignments.

"Sometimes we give them many dates," Pinyo said in the classroom at a Buddhist temple where he lectures fellow astrologers. "It's up to the doctors and the parents to choose which one is most convenient."

Pinyo's colleague, Sompong Winworanat, says the lucky time should be planned for the baby's first cry.

"It's not the time when the woman's stomach is cut," Sompong said. "It's when the baby first screams: Waaaaaa!"

While there is little public debate about soaring Caesarean rates in East Asia, there are early signs of a backlash.

Concerned by a national Caesarean rate of 40.5 percent in 2001, doctors in South Korea managed to bring it down by three percentage points by 2005, according to Joo Hyun Nam, the chairman of the Korean Society of Obstetrics and Gynecology.

In Japan, the overall Caesarean rate has risen sharply, but was well below its neighbors at 21.4 percent in 2005, up from 11.2 percent in 1990. The rate in Taiwan is 35.4 percent, according to a study published last year in the medical journal Birth.

If some see the burgeoning resort to Caesareans in Asia as a problem, it is overshadowed by more pressing issues related to the application of medical technology to engineer a culturally desirable outcome in childbirth, such as the growing use of ultrasound and abortion to determine a child's sex, said one international health official who asked not to be named because she is not authorized to speak for her institution.

When compared to such practices, she said, "I don't see such a big, big tragedy in terms of all babies being born on a Saturday."

Pornnapa Wongakanit contributed from Bangkok.