THE UNKINDEST CUT 0F ALL Caesarians Endanger Women's Health

U.S. OBSTETRICIAN-gynecologist John Smith has this to say to women about to seek medical advice regarding their reproductive system: "When it comes to your body, in the absence of a compelling reason to do so otherwise, it is better left alone."

The admonition appears in his book, Women and Doctors, where he also warns, "any intrusion into your abdomen or pelvic cavity will cause harm." Indeed, says Smith, even simply opening the abdomen, touching its contents, and closing it again will result in adhesions that can make bowel movements, urination and intercourse painful. They can also lead to bowel obstruction as well as infertility.

"If something is actually cut, traumatized or removed," writes Smith, "the likelihood of these complications increases, and consequences related to specific organs involved will also occur."

To be sure, Smith's Filipino counterparts also know of these risks. But observers of the health sector say many of them today are subjecting women patients to unnecessary operations anyway, leaving the latter several thousand pesos poorer—and most probably in worse physical shape.

Even some doctors say they have colleagues who are too quick to wield the scalpel and perform not only caesarians that are uncalled for, but also other surgical procedures that women patients can well do without.

Available data from the Philippine Obstetrical and Gynecological Society (POGS), for example, show that in 1994 alone, the rate of delivery by caesarian in the then 110 POGS-accredited hospitals stood at a high 20 percent.

The number of hysterectomies or the removal of the uterus—whether partial or full—in the same hospitals also took a sizable 16 percent of all operations done on gynecological patients in 1994. This represents a four-percentage point rise from 1991 figures.

POGS is a private organization that monitors the practice of obstetrics and gynecology in the Philippines. While Dr. Mario Festin, head of the POGS statistics board, admits the figures for caesarians and hysterectomies done in the group's accredited hospitals are high, he says this is partly because these institutions are usually chosen precisely for their expertise in gynecological operations.

POGS President Delfin Tan also proclaims proudly that obstetrics-gynecology is "one of the most disciplined and progressive field in the medical profession."

But health sector observers say too many of these specialists seem too blasé about the removal of parts from a woman's reproductive system and treat a woman's womb as if it were a veritable garden of ready-to-harvest goods.

Purita Sanchez, a Cebu government nurse who is among the founders of the Women's Action to Combat Harassment (WATCH), says some doctors pushing for a hysterectomy could even be abrasive, telling patients "na wala nang gamit yan, alisin na lang natin tutal menopausal ka (that has no use anymore, let's remove it since you're menopausal anyway)."

For most women, however, the removal of the uterus could be psychologically traumatic since it is part of what makes them female. A hysterectomy also ends any woman's hopes—however slim—of ever having a child.

WATCH was actually set up to guard against women having to undergo unnecessary caesarian operations. But the group now also seeks to limit the "violence" women are subjected to when they submit to a check-up, the abuse coming often in the form of questions that demean women and disregard their emotions.

Until now, for example, 'Teresa' refuses to go into any detail with what she had to go through during a check-up with an obstetrician-gynecologist. But she does say that the number of internal examinations she was made to endure caused her so much trauma that it affected her sexual relations with her husband.

Since 1990, she and her husband had been trying for a baby and were undergoing fertility exercises. These were under the guidance of an obstetrician-gynecologist, but when Teresa was diagnosed as having a non-malignant ovarian cyst in 1994, financial considerations drove her into the offices of another doctor who accepted Medicare patients.

The doctor, connected with a well-known Quezon City hospital, removed her left ovary—and her left fallopian tube as well. According to Teresa, she was later told that "problems" had cropped up during the operation: that was why one of her fallopian tubes had to go.

Teresa says she signed no document regarding the removal of her ovary. While she was unconscious on the operating table, no one thought of asking permission for the removal of her fallopian tube from her next of kin keeping vigil at the hospital.

Their talk while she was still fighting the effects of the anesthesia was the last Teresa ever saw of the obstetrician-gynecologist who performed the surgery. She later learned that he specialized in vaginal repair.

Teresa was also stunned when the doctor who was guiding her and her husband in the fertility exercises told her she had undergone an unnecessary operation, which had also diminished her chances of getting pregnant. Chocolate cysts, she was told, can now be removed through laparoscopy, a process calling for two small incisions on the abdomen through which tubes are inserted. The cyst would then be taken out slowly, sparing the ovary.

"My fertility doctor said, 'When was that doctor born? There's laparoscopy now, it's not like before where you kept on taking things out,'" recounts Teresa.

There are two agencies that are supposed to oversee the practice of obstetrics (which is focused on pregnancy, labor and childbirth) and gynecology (specializing in matters concerning the woman's reproductive system) in the country. The first is a government body, the Professional Regulations Commission (PRC). The second is POGS, which is under the umbrella of the Philippine Medical Association.

POGS was set up in 1952, with the aim of ensuring a high standard of professionalism and the continued improvement of skills of those in this field. Aspiring members must have performed 100 gynecological surgeries before they apply. Then they have to undergo rigid written and oral examinations. Today, there are 1,337 POGS doctors. The organization also accredits hospitals that pass its standard on equipment and facility.

According to POGS president Tan, the organization has seldom had to revoke a member's accreditation due to malpractice or unethical activities. The courts and the PRC are actually the ones that dispense punitive sanctions against erring obstetrician-gynecologists. And whatever the outcome of a case before the PRC or the courts, the POGS does not act moto propio on complaints involving its members. Complainants have to file a case before POGS itself before a member is investigated by its ethics committee.

Tan is tightlipped regarding how many members have already been disciplined by the committee. He merely says, "Definitely, there were complaints. There were varied cases, usually brought to us by the patients or their lawyers. We have a committee on ethics and if we feel he should be removed, we remove him."

Senator Juan Flavier, however, observes: "The most abusive doctors get from POGS is a slap on the wrist, and they are allowed to continue their practice."

The former health secretary adds that even a hospital's review committee can sometimes whitewash its probe to protect a colleague. "They will try to cover up the abuse," he says, "since no one can access their records anyway." Confirms an obstetrician-gynecologist: "We're like a mafia. We protect our own."

Dr. Julita Jalbuena, who sits at the PRC medical board, meanwhile says malpractice suits against obstetrician-gynecologists are rare, and can only recall a handful of cases in the last few years. She also says, "If there is malpractice, these usually happen in non-training hospitals or in hospitals where there is no review committee."

But like POGS, the PRC does not act on its own. Patients have to file a case, and very few do. Jalbuena recalls that some malpractice cases that managed to get media attention in the past—no matter how controversial or exaggerated they became—did not even reach the PRC. Those that managed to do so were eventually withdrawn, she says, following a settlement with the doctors involved.

Most doctors interviewed for this story, however, do not deny they have abusive colleagues who put patients on the operating table out of sheer greed. These doctors get away with it not only because there are little sanctions awaiting them, but also because most of the patients do not know any better.

Dr. Sylvia de la Paz, an obstetrician-gynecologist who is a consultant of the Health Alliance for Democracy, says women should first find out what their doctor's specialization is, as well as his or her training credentials. She advises women not to shirk from doing research on the doctor's reputation. After all, this is someone to whom they are about to entrust their body—and perhaps their lives. A second opinion, especially when the doctor is recommending surgery, can also help a patient come to an informed decision.

At the same time, de la Paz acknowledges that some general practitioners (GPs) in rural areas are often forced to do operations they are not qualified to perform simply because there are no obstetrician-gynecologists around. She recalls that when she served in a community hospital in Samar from 1978 to 1982, the GP there was performing caesarian operations. He was even able to do vaginal hysterectomies, she says, difficult procedures even for obstetrician-gynecologists.

A vaginal hysterectomy involves the removal of the uterus through the vagina, a process that is susceptible to "honest mistakes" or "bad luck."

De la Paz recounts how the GP in Samar did them: "May libro dito, pasyente nakahiga diyan. Hala, ano ang sabi sa libro (The book's here, the patient's lying over there. Okay, so what does the book say)?"

"What is wrong with this picture is that those who are trained are not here," she says. "They are either abroad or in the cities."

But as Teresa's story shows, even those who have enough background may not be worthy of a patient's trust, and fail to heed one of the most basic things they learned in medical school: Primum non lascere—Above all, do no damage.

Dr. Sylvia de la Paz, a consultant of the Health Alliance for Democracy, and other obstetrician-gynecologists offer the following to women in need of medical advice:

  1. Find Dr. Right. This involves knowing your would-be doctor's credentials, training records, complication rates. Know why a surgery is called for, and what the risks are.
  2. Know the specialization of the doctor who will do the operation. Only an obstetrician-gynecologist who has received formal training can operate on a woman's reproductive system.
  3. When in doubt, get a second opinion.
  4. After the operation, get a copy of your operative technique record. This should contain the name of the surgeon, the anesthesiologist, date, time and type of surgery performed, and the findings after the surgery. It is your right to know the details.
  5. Present these to another doctor and get his/her opinion.
  6. If your previous delivery was through a c-section, know why it was necessary and what kind of cut was used. Inform your doctor if you prefer the next delivery to be normal.

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