KERALA SOCIOLOGIST 40 (2), December 2012, pp.

142-155 @ Kerala Sociological Society

A Contribution to Recent Debates on Increasing Caesarean Sections in Kerala

K.S. Hakim
This paper is an attempt to trace the mentality of Keralites towards medical knowledge by critically examining a recent incident in Kerala. The author is particularly interested in this incident because it was a rare situation in Kerala, where despite the gross violation of human rights, nobody questioned the credibility and ethics of the medical profession and the issue was resolved through transfers of doctors and classic Kerala political party fights. The author strongly believes that most educated and politically conscious Keralites are less aware of and usually will not think about the need to problematize the field of medicine and this was a missed opportunity to do so. While the media just saw it as a sensationalist issue and parties as a way to cover up or critique each other, no gendered critique of medicine was offered. This incident shows the need to question this ideology and make the medical profession accountable to women. Keywords: Medicine, Caesarean, Mechanical model of womens bodies, Keralites, Medical Sociology.

On April 19 and 20, 2011, it was reported that a 22 caesareans were executed on a single day at a government hospital in Chertala in Aleppey district in Kerala by one male and three female doctors. This happened just before the holidays of Easter and some news channels alleged that it was the decision of some doctors in the hospital to conduct these caesareans in this manner so that they may go on a mass holiday. When this incident was

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reported in the media, it created a great furore in Kerala. The concerned doctors defended the incident by showing some practical concerns. They claimed that a majority of caesareans conducted on that particular day were on women who had completed 37-38 weeks of pregnancy1 and most of them had come for their second or third delivery having had caesarean sections in their previous deliveries. Apart from media coverage, there was protest from some youth organisations and the government responded by transferring the doctors from Alappuzha to Wayanad and Malappuram. The lack of mass protest and the dubious response from the government shows that the culture of dissent around medical knowledge and intervention is virtually non-existent. One reason for the lack of intervention from the public in medical issues is because they consider this as a field in which the medical fraternity has expert knowledge necessarily not available to everyone. Doctors are believed to have access to superior knowledge and thus their decisions on medical matters gain a sense of legitimacy. This taken-for-granted mentality has created a market for medical and pharmaceutical mafias. They consider it as a field where they can make enormous profit without any questioning or resistance from the public. It is important to generate a discussion on the implications of the relationship between people and medicine. The job of the sociologist, similar to that of a physician, is to diagnose. We are not concerned with an individuals diseases but with societal disorders and imbalances. I believe that the duty of a sociologist is to problematize and criticise things because our criticisms might make people think. Thinking and rethinking of issues would lead to social change. So there should be real reason, evidence and also clarity in every step of diagnosis a social scientist makes. Just as a physician diagnoses a disease, a sociologist also has to take issues and imbalances one by one, and then diagnose it step by step. As a social researcher, it is the same method that I am going to follow in this paper.

The Facts about Caesarean Section

The discovery of caesarean operation and related scientific developments in the field of gynaecology are seen as good things that have contributed to the life and health of women. There are times where caesarean section is the only option to save the mother and her child. Some of the possible cases where doctors insist for caesarean section are noted below: (See Cunningham et al.

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2005; Keith 2007] If the woman had caesarean section in the previous pregnancy or had any major surgeries on her uterus. If the size of the baby is too big to pass through the vagina or baby has a certain type of birth defect. If the babys buttocks or feet enter the birth canal first instead of the head. This condition is called breech position. If the babys shoulder enters the birth canal first, instead of the head. In medical science this condition is called transverse lie or shoulder presentation. If there are some complications related with the placenta at the time of delivery2. If the babys umbilical cord slips into the vagina, where it could be squeezed or flattened during vaginal delivery. This is called umbilical cord prolapse. If the labour process is too slow or stops or the woman has twins or more foetuses. If the doctor has a strong feeling that the baby is undergoing serious problems during labour process like the baby is under stress, such as a slow heart rate etc. This condition is called foetal distress. If the pregnant woman has some serious medical condition that requires intensive or emergency treatments like diabetes or high blood pressure. Medical science also recommends caesarean section operations in the case of women who have cervical cancer or are HIV positive, where vaginal deliveries can cause the spread infection to the child. Doctors also consider caesarean section deliveries as a safer option for women who have had an initial caesarean section delivery because a normal delivery following a caesarean section delivery increases the chances of the earlier operated upon parts of the uterus breaking and resulting in further complications. In medical terms it is referred to as the uncertainty of scar integrity (Mumthas 2012:81-82). Apart from medical complications, obstetricians also record that women who have had the experience of caesarean section in their earlier deliveries would be prepared for caesarean sections in later deliveries as well. The unwillingness or negative mentality of a woman towards normal delivery sometimes forces doctors to recommend caesarean section for some firsttimers as well. In feminist cultures in the West, there has been a critique of

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the rise of caesareans among women and the dubious reasons for this. For example, Naomi Wolf in her book Misconceptions speaks of the sudden rise of caesarean sections in the early twentieth century (Wolf 2003). In the Chertala incident in Kerala, what incensed the public was the allegation that the doctors had recommended caesarean sections where normal deliveries would have been adequate, so that they could finish the operations at their convenience and then go on leave. Here comes the importance of separating emergency caesareans and planned caesareans. Emergency caesareans are conducted only when the situation demands it and no other option is left. But nowadays more and more caesareans are being pre-planned for various reasons. We also have to examine why the pregnant woman and her family sometimes prefer caesarean deliveries to normal deliveries. There are first-time mothers who prefer caesareans for various reasons; an important psychological factor being fear of the pain of vaginal delivery. The false belief that caesarean deliveries are painless as compared to normal delivery also prompts many women to opt for it. On the other hand, some families believe that there is a good time for giving birth and select auspicious timings for the birth of their child which can be achieved through the caesarean operation. Women who have undergone a caesarean section in their first delivery usually prefer to have caesarean sections in later deliveries as well. It has been noticed that such women are usually reluctant to face normal labour pain. Many women have memories of the pain that they experienced during their labour before they were referred for caesarean sections, and believing caesarean sections to be less painful than normal deliveries, they force the doctor to recommend for caesarean sections again as an easy way out from the normal pain of labour. A professor of gynaecology at the Calicut Medical College the hospital which has the highest number of deliveries in Asia3 says that even if doctors advise a normal delivery, some women who have had a prior caesarean section are mentally prepared for another caesarean section and would create such a drama at the delivery table even for normal labour pain, crying out to the doctor to perform a caesarean as if their uterus was breaking apart. Such conditions create a situation in which the doctor is helpless and forced by the immediate circumstances to follow what s/he knows to be a less-than-perfect solution to reduce the pain and terror of the patient (Mumthas 2012 : 81). It is a common belief that caesarean sections are painless and harmless

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but this is not true. The chance of internal bleeding in a womans body and death of both woman and child because of lack of oxygen during caesareans is a common cause of maternal and infant mortality in many parts of the world (Edmonds 2007:224).Though the chances of uterus rupturing is found to be decreasing because of new developments in the field of medicine and proper observation by the doctors, the maternal mortality rate of women undergoing caesarean sections is still four times higher than the death rate associated with normal deliveries (Cunningham et al.2005 : 592). In a survey conducted in England between 1994 and 1996, the maternal mortality rate was found to be higher at the time of emergency caesarean sections (ibid: 592). In addition to the higher maternal mortality rate, some of the other possible after-effects of caesarean sections are infections and damage to the womans internal organs. There are greater chances of risk to the health of women who became pregnant after once undergoing a caesarean section. In such cases the chances of internal damage to the uterus and other organs situated near it such as the ureter, urinary bladder, small intestine, large intestine, etc. are much higher (Mumthas 2012: 77). Records from Calicut Medical College point to the fact that the surgical risk factor is much higher for middle aged women referred for uterus removal or other surgeries related to the malfunctioning of the reproductive organs, because of their history of one or more caesarean sections in early pregnancy stages (Mumthas 2012: 77).This makes it clear that if one wants a complete picture of the effects of caesarean sections one should keep in mind the after-effects of caesarean sections on the womans body even five or ten years after it. This shows us that caesareans are not as safe and harmless as they seem. It has many consequences in the long run.

The Context of Kerala

The World Health Organisation has recommended that only 15% of all deliveries should be through caesarean section as an international standard. In Kerala, the rate is much higher. Most of these caesareans are conducted on women not because of any emergency or necessity but only because of the option to plan according to convenience. It is assumed that this scenario is peculiar to Kerala because women in Kerala are generally educated and have enough knowledge about their bodies, although as Sharmila Sreekumar has shown, women in Kerala are also

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formed by contradictory and predetermined hegemonic scripts (Sreekumar 2009). Popular womens magazines and healthcare shows telecasted on television also disseminate bits of medical information. Thus, in Kerala we see a situation where some women actually request the doctor to perform caesarean sections because they have knowledge about it and have calculated its pros and cons. Their logic is often utility-oriented and some even go to the extent of requesting a caesarean because they want a tubal sterilisation procedure to be carried out along with it (Mumthas 2012: 81) two birds with one stone! Tubal sterilisation is a simple procedure compared to caesarean sections but educated middle woman in Kerala might be less aware of this fact and indeed studies of the politics of the information that these women access need to be conducted. Some socially committed medical professionals say that higher rates of institutionalised (hospitalised) childbirth, greater dependence on private hospitals and positive attitude of the people are the reasons for the high rate of caesarean sections in Kerala. Advertisements promoting caesareans and overdependence on private hospitals which have tie-ups with the medicare business mafias contribute a lot to the positive attitude of the people towards caesareans.

Problem with Peoples Mentality and Influence of Advertisements

Planned caesareans are becoming more common in Kerala because of the influence of the profit motive that has come to view these operations as a major business opportunity. Through advertisements of various kinds caesareans as a desirable form of delivery has entered the popular psyche, including that of the educated woman. Some of the points that are used to advertise planned caesareans are noted below: It avoids some of the possible complications and risks to the foetus. It avoids the possibility of post-term pregnancy (the infant being born after its due date). It helps ensure that a pregnant womans obstetrician and anaesthetist will be available for the delivery. It may offer a more controlled and relaxed atmosphere, with fewer unknowns such as how long labour and delivery will last. It allows parents to know exactly when the baby will be born, which makes issues related to work, childcare, and help at home easier to

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address. It may minimise injury to the muscles and tissues covering genitalia which may occur during vaginal delivery leading to the risk of prolapsed uterus and vagina, sexual dysfunction, urinary or anal incontinence. There is no doubt that there are situations which necessitate caesarean deliveries. On the other hand, it is alleged there are also instances of doctors and families planning caesareans for reasons of their own. The fact left untouched is that caesareans are an option to be exercised only in cases of emergency. This factual aspect is hidden in many of the advertisements which promote caesareans. Thus, the time-consuming and painless idea of caesareans enter into the common sense of the people of Kerala as something that is good and proper. This actually points to the power of advertisements and other ideological measures like media, television and internet in spreading the dominant medical model backed by the capitalist motive of profit and fed by a consumerist mentality. We can use Gramscis idea of hegemony4 to understand how caesarean sections come to be accepted without any question but through consensus how the ideas of the hegemonic capitalist market are spread through various channels. The Kerala experience tells us that the perception about safe delivery occurring through caesarean sections has been internalised by people. The popular notion of painless and safe delivery has effectively penetrated public consciousness. Different channels are involved in this process. The advertisements of caesarean section among medical practitioners as well as in the public sphere have contributed much to its popularity. The representation of advertisements as truths coming with the label of scientific knowledge, combined with the authoritative knowledge of doctors (Jordan 1997) makes people accept the doctors prescription of caesarean without question, even when normal delivery is possible. Even educated women in Kerala have started to think that there is no harm in undergoing caesareans and imagine that it is prescribed as a safety measure, not only for them but also for their children. Emily Martin (2001) in her research shows how the educated middle classes in Western Europe subscribe to the medical-mechanical model and therefore succumb to the hegemonic influence of the capitalist business mentality. In a similar fashion we can see how the educated middle classes of Kerala have been influenced in such a manner as to be responsible for the huge percentage of caesarean section deliveries which are not of an emergency character. We have to deconstruct the taken-for-granted character of caesarean sec

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tions in order to see through its facade to the other motives that guide caesarean sections as a business. This is not to say there is blind acceptance of the practice everywhere. We can also see resistance to caesarean sections. Diametrically opposed to the biased psyche of middle class women in Kerala is the negative response of working class women in different parts of Europe to caesarean sections (Martin 2001). In her field work Martin found many women eagerly awaiting the experience of a normal delivery, and who felt cheated when the doctors made them undergo caesarean which meant that they could not experience the birth of their child. Martin (2001) criticises so-called ethically neutral, objective medical knowledge which she says is partial and patriarchal in nature. According to her, women lose their agency when medical knowledge in the capitalist system treats their body similar to a machine which needs to be maintained and repaired. Doctors consider womens bodies as machines which produce a product i.e. the child. Here the role of woman is just like a labourer and the doctor is supposed to supervise and mediate the labour process. Throughout all the practices associated pregnancy and child birth including caesarean sections, more importance is given to the product: the child. In such a derivation of equations, the woman as the object of all these acts loses her agency in many senses. Her body and self become objectified and less attention is given to her own choice and will. Even within the event of childbirth women are attributed a passive role because the dominant medical model sees the uterus as an involuntary muscle over which the woman has very little control. Apart from caesareans, other practices associated with deliveries also accord more importance to the convenience of the doctor who deals with the pregnant womans body rather than the so-called sacred act of delivery (ONeil and Kaufert 1990). At the delivery table, women are usually required to deliver lying down for the comfort of the doctor whereas squatting or other postures are understood to be more comfortable for the woman herself. In an important work edited by Kalpana Ram and Margret Jolly (1998) some contributors projected the pain of native women when the colonial modernising mission forced them to adopt modern medical practices that provided safer options for childbirth. Some of the accounts of their fieldworks in South India reveal to us the real experience of fisherwomen at the modern hospital delivery table they were not even allowed to scream out in the pain of delivery and were actually rebuked by the attending nurses for disturbing

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others. This shows us that hospital deliveries are not always a comfortable experience for women, especially for underprivileged castes and classes who are often singled out for such abuse. A more comprehensive account of the social structuring of human bodies is put forward by Michel Foucault (1977). For him, institutions like hospitals and medical knowledge are important especially in terms of effective governmentality. The concept of governmentality points to the way in which the dominant system and ideas try to produce people in the way best suited to fulfil the requirements of the (capitalist) system. Here the organised practices (mentalities, rationalities, and techniques) through which subjects are governed and controlled are very important. Marx in his critique of capitalist political economy talked about commodity fetishism, i.e. the mystification and commodification of human relations and emotions under the capitalist system. Marx saw human relations becoming commodity-centric which is the result of the peculiar social market trade of capitalism where social relationships between people are expressed, mediated and transformed into objectified relationships between commodities and money. The Marxian theory of commodity fetishism is very important for us because it tells us how and why economic relationships and interactions in capitalism mask and transform the real human social relations and motives in order to justify their power and authority. Capitalism has always avoided and masked the subjective aspect of economic value in order to universalize and naturalize the objective aspect of economic motives. This is a matter of attaining power or domination.

Conclusion
Lessons from Kerala shows us how a useful scientific discovery prescribed only in situations of emergency because of its side effects on womens bodies in the long run, comes to be popularised and established due to commercial interests. The inherent nature of capitalism i.e. the urge for more and more profit has gained dominance through the privatisation and commercialisation of the medical field devaluing womens rights over their own bodies and bodily experiences. With the large-scale privatisation of the medical field after the 1990s, every activity related to medicine, from the admission of students to various medical courses to consultations, diagnoses, scanning and caesareans be-

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came profit-oriented. All the issues raised here are beyond the scope of this paper. But among those there is one which I have pointed out for further discussion the question of the commercial interests hidden in the popularity of caesarean practice. There has to be a critical thinking against the disciplining of womens bodies through caesareans: here women lose their agency and doctors and medical knowledge become the ultimate authorities (See and Jordan 1997, Trevathan 1997) that decide and convey the apt time and procedure by which a woman can deliver her child. The woman is understood under this dispensation as a machine which has no control over the process of childbirth. Vaginal birth is projected as a difficult task and labour pain as the most painful experience in this world. The caesarean is advertised as a technique which is the safer option which gives relief and painless delivery to the woman and also ensures that the product emerges without any problems. Here the contested subject is a pregnant womans body on the delivery table which awaits expert opinion as to whether or not to follow natural birth or undergo caesarean. Foucault tells us that no history of the body can be written without considering the bodys location in a political field (Quoted in Oakley 1986:252). So if the dominant medical authority projects and promotes an invention like the caesarean as ultimate and useful irrespective of the fact that there is no emergency or real situational necessity, one has first to look at the dominant socio-political economic arrangement or system through which this knowledge comes in, the way in which knowledge about the pregnant womans body is constituted and the role that power relations play in constituting that knowledge and the motives behind such a formulation of knowledge. One can identify the role of the system of capitalism and its interests in economic profit and its involvement in creating authoritative knowledge about the pregnant womans body. This is not to say that there is a conscious, organised effort to gain domination over people by doctors who are proponents of a capitalist system. Hegemony works in unconscious ways, and though it would not be possible to go into its working in detail we will try to delineate a few points: The field of medicine has never been problematize as it has the aura of being de-politicised or above politics and therefore being beyond reproach. We also have to remember that we have focused on the situation in Kerala, where left organisations and trade unions question everything that is not seen

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as being democratic. In a situation where we claim that capitalism is spreading its interests even through the acts of medical practitioners, it is worth wondering why this issue has not been taken up by the Left and peoples movements5. One reason for the lack of intervention on their part in medical issues is because this is a field in which the medical fraternity claims to have expert knowledge not available to everyone. Doctors are believed to have access to superior knowledge and thus their decisions on medical matters gain a sense of legitimacy. In these ways, the expertise of the medical fraternity is reified and its practitioners who can demand unquestioning obedience (Oakley 1980) can actually use their expertise to promoting the interests of capitalism as their conscious collaboration reaps benefits for them too. This shows us how hegemony operates in a manner that can take medical professionals away from the fundamentally ethical nature of their profession. New developments and discoveries including advancements in the field of caesareans are good for humankind if we use them rationally and with discretion. But the system of capitalism ruins even positive aspects of scientific discoveries only because of its inherent nature of business and profit motive which came true for the so-called sacred medical field also. The basic issue emerging from this paper is that if anybody wants to fight against capitalism/commodification/profit-centric mentality in contemporary Kerala then their struggle should also include the medical field, increasing private hospital and medicare business associated with it. These are some of the unnoticed places where capitalists and pharmaceutical business mafias working in conjunction with each other are making more and more profit in contemporary Kerala without any questioning. The voice against labour exploitation has already been raised by the nursing community in Kerala. But it is just a spark pointing to a particular form of exploitation prevailing in the private medical hospital business in Kerala. These struggles have to be taken into public platforms and widely discussed. Medicine and hospitals are part of the everyday life of a majority of Keralites. Most of us access medicine and hospitals in some way or another. It is this researchers opinion that one should not give any sacredness to the medical field, doctors or related technicalities of medicine because then one cannot question them or criticise their authority. It is better to create a situation where doctors and other authorities are responsible for answering patients questions for instance if a doctor insists that a patient buy a particular brand of expensive medicine from a particular medical shop when lower

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priced, better quality medicines are available; or prescribes medicines, Xray, scanning or caesareans in cases where it is not necessary at all. For this to be possible, the field of medicine has to become a part of Keralas vibrant political culture of criticising everything which is seen as being undemocratic and exploitative.

Acknowledgement
I would like to thank Professor Tulsi Patel for providing me complete freedom to write this paper as part of my research course work at the Department of Sociology, Delhi University. I am grateful to Dr. Khadeeja Mumthas, Professor Obstetrics and Gynaecology, of the Calicut Medical College, Kerala for clarifying my doubts, providing books and articles and giving access to medical knowledge whenever I was in need of it. The friendly encouragement and support of Linda, my colleague at the Department of Sociology, Delhi University has also been of immense help. I owe her particular thanks for correcting mistakes, providing suggestions and insisting that I clarify some of the abstract ideas in this paper. I am pleased to thank Mr. Sunil Kumar my mentor and supporter always, for making me sharp and capable. He dedicated his free days for me and travelled with me to collect materials for this paper. Special thanks to Dr. Ashly Tellis, Department of English, Miranda House, University of Delhi, for his critical engagement with, and suggestions to improve upon, the paper. Finally my deepest gratitude to Dr. Antony Palackal of the Department of Sociology, Loyola College of Social Sciences, Trivandrum for providing me help and support at some critical points in my life and for encouraging me to write this paper.

Notes
1. According to medical textbooks, 37-38 weeks is the normal gestation period then the foetus supposed to be mature enough to be taken out of the womb of the mother. 2. Placenta is the tissue that connects the mother and the baby and nourishes the baby in the womb. Placental problems can cause dangerous bleeding during vaginal birth so the doctors prefers caesarean in such conditions. 3. Calicut Medical College, http://www.cmc.edu.in/obg/services.html accessed on November 11, 2012. 4. Antonio Gramsci in his famous prison Notebooks talks about the hegemony of

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A Contribution to Recent Debates the state in the Italian context. He saw that the ruling class ideology got sanction even among the lower classes through hegemony. The creation of hegemony is not a single act but is a long-term process. Gramsci talked about the formation of the nation or national popular through hegemony. It has three stages: a) A condition where a coalition of class interest, or consensus is formed b) In order to rule by hegemony, the ruling class has to give up some of their economic interests in order to retain political power. The working class comes to believe that they have gained some concessions. c) The entire society starts to think that this is the best political arrangement that they can imagine. This actually masks social and economic exploitation under capitalism. 5. However, it is important to note that at the time of this incident, it was the CPI (M) led coalition in power in the state. While the CPM government responded with transferring doctors, the Congress defended certain doctors and attacked the CPM for the transfers and the Indian Medical Association exonerated the doctors on the basis of spurious accounts of the womens cases. All three responses had no critique of the medicalised violence on women and, in any case, we know of these responses through media reports which in Kerala are specious and spurious, to say the least.

References
Cunningham, Gary, F. et al. (eds.) 2005. Williams Obstetrics. USA: McGrawHill Company. Edmonds, D.Keith. 2007. Dewhursts text book of Obstetrics and Gynaecology. Oxford: Blackwell Publishing Foucault, Michel. 1977. Discipline and Punish: The Birth of the Prison. London: Allen Lane. Jordan, Brigitte. 1997. Authoritative Knowledge and Its Construction. In R.E. Davis-Floyd and C.F. Sargent. (eds.) Child Birth and Authoritative Knowledge: Cross Cultural Perspectives. pp. 55-79. London: University California Press. Martin, Emily. 2001 (1987). The Woman in the Body: A Cultural Analysis of Reproduction. Boston: Beacon Press. Mumthas, Khadeeja. 2012. Maathrukam ( Mal.) (Motherhood). Kottayam : DC Books. Oakley, Anne. 1980. Women Confined: Towards a Sociology of Child Birth. Oxford: Martin Robertson. __________. 1986. The Captured Womb: A History of the Medical Care of Pregnant Women. Oxford: Blackwell. ONeil, J. and Kaufert, P.A. 1990. The Politics of Obstetric Care: The Inuit Ex-

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K.S. Hakim perience (53-68). In Handwerker, P.W. (ed.) Births and Power: Social Change and the Politics of Reproduction, USA: Westview Press. Ram, Kalpana and Jolly,Margaret (eds.) 1998. Maternities and Modernities: Colonial and Post-Colonial Experiences in Asia and the Pacific. Cambridge: Cambridge University Press. Sreekumar, Sharmila.2009. Scripting lives, Narratives of Dominant Women in Kerala. Hyderabad: Orient Blackswan. Trevathan, W. R. 1997. An Evolutionary Perspective on Authoritative Knowledge about Birth.In R.E. Davis-Floyd and C.F. Sargent. (eds.) Child Birth and Authoritative Knowledge: Cross Cultural Perspectives. pp. 80-88 London: University California Press. Wolf, Naomi. 2003. Misconceptions: truth, lies, and the unexpected on the journey to motherhood. New York: Anchor Books.

K.S. Hakim is a Research Scholar at the Department of Sociology, Delhi School of Economics, University of Delhi- 110007. Email: kshakim@ymail.com

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