by JAILEEN JIMENO
THE OBSTETRICIAN said the baby was poised to be delivered suhi—feet first—so she would have to perform a caesarian. That meant P25,000, something Aling Nena, a cook, certainly didn't have. But the would-be mother was her only child, the baby her first grandchild. And so Aling Nena arranged for a loan from her employer.

Aling Nena's daughter, however, began having labor pains sooner than expected. The clinic where her doctor worked was full, so she was referred to another facility, where another obstetrician was told to expect a caesarian delivery. But the second doctor was surprised when Aling Nena's daughter arrived almost ready to give birth—the "normal" way. Two hours later, Aling Nena had her grandchild, as well as almost all her P25,000.

No caesarian was performed because it was not necessary. According to the doctor who attended to Aling Nena's daughter, the first obstetrician had written in girl's medical records that the baby was "cephalic," or in the proper delivery position. The second doctor allows the possibility that an honest mistake was made, but she seems more inclined to believe her colleague had simply lied to get a fatter fee.

In many countries worldwide, the number of caesarian deliveries—CS in medical parlance—is in decline as "natural" childbirth gains more popularity. Here in the Philippines, however, more and more CS operations are being performed, with majority of them being done with little or no medical reason, say medical observers. This means these women are not only being forced to spend huge amounts of money unnecessarily, they are also opening themselves up to high physical risk.

Indeed, according to former health secretary turned senator Juan Flavier, the number of unnecessary caesarian and other operations having to do with the women's reproductive system has now reached "racket proportions."

Normal deliveries obviously still outnumber caesarian births. Official figures show, however, that while there was a 13.5 percent increase in the number of claims involving normal deliveries filed with the Social Security System (SSS) from 1995 to 1997, those involving CS operations rose by 26 percent.

Data from the Philippine Obstetrical and Gynecological Society (POGS), a private agency that oversees obstetrics practice in the country, also show that 20 out of 100 women deliver their babies by caesarian in POGS-accredited hospitals. Medical insiders say the number could be higher in private hospitals, where there is no group monitoring such operations.

Declares Flavier: "Sa ilang private hospitals, diyan malaki ang anomalya, kasi diyos-diyosan diyan ang ilang doktor (In some private hospitals, that's where many of the anomalies are because the doctors are like gods), and there is no one who will really check their records."

Worldwide, Brazil is still leader in terms of the number of CS operations performed annually, with some hospitals there having as much as 30 percent of their pregnant patients going under the knife to deliver their babies. In the United Kingdom, 10 to 15 percent of births are by caesarian, and the United States 20 to 30 percent.

But, says Flavier, "for us, a poor country to be having something like 20 percent of all deliveries done by caesarian means there is something wrong somewhere."

To be sure, the doctors responsible for these operations will reason that they were justified interventions meant to ensure the safety of each mother and child involved. Yet various statistics show no real improvement in infant mortality rates or even a slight decline in pregnancy-related deaths in recent years.

Health experts say six infants out of 100 still die annually before they turned a year old, while the World Health Organization (WHO) has estimated that for every 100,000 live births, 280 Filipino women die of pregnancy-related causes each year. The Department of Health says in 1995 alone, 3,600 mothers died of pregnancy-related causes. Among the causes of maternal deaths are high blood pressure, hemorrhage and infections.

Dr. Sylvia de la Paz, consultant at the Fabella General Hospital, explains that any procedure entailing the opening up the abdomen poses risks, some of them immediate, others long-term. This is why, she says, obstetricians should be judicious in ordering CS operations—or any other surgical procedure, for that matter.

"If you open that up," says de la Paz, "you're adding on the risks not only during the surgery itself. You are putting her at risk for another condition which may call for surgery later."

Doctors themselves admit that post-operative infections are serious concerns. Among the most publicized cases involving surgery on women revolves around a piece of suture left inside the womb.

Surgery also means the patient has to be anaesthetized, a procedure that has proved to be the most common cause of problems in the operating room. According to Dr. Ricardo Manalastas, Operations Chief of the Philippine General Hospital (PGH), many malpractice cases stem from anaesthetic accidents.

Doctors are at a loss over why anaesthetic deaths occur. They say some patients are simply allergic to the substance; there have also been cases of "honest mistakes," or just plain bad luck. "Minamalas lang," says Manalastas. "With anaesthesia, sometimes you'd have no problem giving 20 milligrams to a patient. Give the same dose to another, all of a sudden, she's not breathing."

De la Paz also says doctors are uncertain whether the problem is with the technique or the dosage. "Sometimes, (the effect) goes higher than expected. It not only deadens the nerves around the abdomen, it sometimes reaches the other vital organs."

Anaesthetic death is a risk that is perhaps worth taking when an operation is done to save a life. But indications are would-be mothers are now being made to take this risk for lesser reasons.

De la Paz herself observes that most hospitals had a sharp increase in caesarian deliveries following the introduction of the electronic fetal monitor. The same thing happened in the United States when the machine, which measures the baby's heart rate as well as womb contractions, was first used.

Normally, the baby's heart rate and the mother's contractions increase before birth, when the baby begins going down the vaginal canal. Some obstetricians reading the monitor conclude that what they are seeing are signs of "fetal distress" and proceed to do a caesarian operation in what is supposed to be a normal delivery case.

"You already have tracings from a fetal monitor," comments de la Paz, "so may pinanghahawakan ka na to justify a CS."

What she leaves unsaid is that the situation may not really warrant such an operation. Health experts say, though, that among more common reasons why obstetricians opt for a caesarian even when a normal delivery is possible is because the latter is "labor intensive." A patient can labor for days at a time, tying up a doctor. Experts point out that a CS operation ends the waiting and frees the doctor—who also gets a bigger fee.

Patients, meanwhile, are almost always in no position to disagree with a doctor who suggests a caesarian. Says Purita Sanchez of the Cebu-based Women's Action to Combat Harassment (WATCH), which was set up primarily to ensure that an expectant mother does not go through an unnecessary CS operation: "When the doctor says you're weak, you have to deliver by caesarian, women don't ask questions. The doctor is a god at that time, and they can dictate the option the women takes."

Many women are also unaware of the options they have. In truth, most women still assume that a previous CS automatically means that the next baby will have to be delivered the same way.

Yet as early as 20 years ago, noted obstetrician Dr. Julita Jalbuena and two other colleagues had already debunked this myth in a paper that advocated the use of what is called a low transverse cut instead of the "classical cut." Jalbuena now says a growing number of obstetricians had taken heed of this, which should mean fewer cases of "second-time CSs."

A classical cut, being vertical, is prone to rupture during labor, as contractions tend to spread, hitting the area where the incision was made. A low transverse cut is horizontal, away from the rupture-prone part of the body where labor pains are concentrated.

If the women themselves know what kind of CS had been done of them before, reason some experts, they would be able to argue for "trial labor" before another caesarian is performed on them.

But in government hospitals, doctors are usually at their wit's end trying to get a grasp a woman's past medical history, especially those who have had CS. Experts say many women—even those in Metro Manila—also show up in hospitals for the first time only when labor pains start.

Still, even those who should know better also fall under the spell of physicians insisting on a CS. WATCH's Sanchez, for instance, is a nurse and her husband is a doctor. But all their combined medical training and knowledge got shunted aside by parental worries when told by an obstetrician that their daughter needed a caesarian. They were still haggling over the doctor's fee when their daughter gave birth, the normal way, in the labor room.

Then there are the women who, unable or unwilling to bear the pain, insist on delivering by caesarian. But observers say the attending physicians are responsible for pointing out the risks involved to such patients, and should still think twice before proceeding if the operation is really uncalled for.

Experts have pointed out that the rise in caesarian deliveries has economic implications as well. In the last three years, each caesarian claim at the SSS has meant, on average, an extra P4,000 compared to a member filing for "normal" maternal benefits, or a total of P227 million more from the state agency's coffers. Caesarian deliveries also cost the labor market more because women who have them need longer rest. An SSS member who delivers normally is allowed 60 days of paid maternity leave. Those who have a CS operation get 78 days.

Unfortunately, say some observers, there are doctors who are more concerned with their own bottom line. Sanchez says her group has noted that an expectant mother who has a husband working abroad is more likely to end up having a caesarian. "When they learn your husband is an overseas contract worker, you're through," she says. "They'll say you'll have to have a caesarian."

De la Paz, meanwhile, echoes other obstetricians that a "good conscience" is one of the operative words in medical field. But she adds, "There are times that an obstetrician-gynecologist is building a house. So…instead of fetal distress (leading to a CS), you have 'pocket distress.'"