Dr. Akhilesh G. Kirane is currently a Senior Resident in Obstetrics and Gynaecology at Government Medical College, Miraj, Maharashtra. He has done his undergraduate and postgraduate from the same institute. His areas of interest are Operative Obstetrics and Gynaecologic oncology.
Introduction Better diagnosis and early referral due to increased health care coverage have increased the cesarean deliveries at tertiary-care hospitals of India. Improvements in the health care system raise many concerns and need of cross-checking system in place to counter the problems pertaining to patient education and participation of patient. While most of the cesarean sections are done in good faith for the patient, it does not escape the purview of consumer awareness and protection.
Materials and methods This cross-sectional study was undertaken at a tertiary level government institution to understand the level of awareness of 220 patients regarding the various aspects of cesarean delivery which are essential for women to know before giving an informed consent.
Results 71 % of the women had knowledge about the indication and need to do cesarean delivery. Of these, only one-third (25 % of total women) were properly explained about procedure and complications. Other demographic and social characteristics were also evaluated.
Discussion While the health care schemes have had their improved results, the onus lies upon the caregivers to improve and maintain the quality of health care in these tertiary-care government hospitals in proportion to the increase in patient load. The results of this study highlight the need for proper counseling of patients regarding complications of cesarean section. The fact that only 25 % of total cases were explained proper procedure and complication as opposed to 71 % of patients having proper knowledge about the indication of cesarean section points out the lack of information in seemingly ‘‘informed’’ consent.
The way forward To bring about awareness about the risks and complications of cesarean section, there is a need that patients be counseled during the antenatal visits, specifically when patients visit near term for antenatal check up.
Keywords : Cesarean section, Informed consent, Patient education
Cesarean delivery is one of the most frequently performed operations in women. With improving basic healthcare facilities at the ground level and greater percentage of institutional deliveries as envisioned by most of the national health programs, a proportionate increase in diagnosis of complicated cases has occurred. Better diagnosis and early referral due to increased health care coverage have simultaneously increased the rate of cesarean deliveries at tertiary- care hospitals of India. While this paints an improved picture of our health care system, it does raise many concerns and need of cross-checking system in place to counter the problems like patient education and active participation of patient in decisions pertaining to the indication, procedure and choice of operative intervention. Very important and central is the question—how ‘‘informed’’ is the actual informed consent? Time and again, it has been proven in many studies that cesarean delivery has greater morbidity and mortality than normal vaginal delivery which makes proper counseling very essential before an informed consent. While most of the cesarean sections are done in good faith of the patient, it does not escape the purview of consumer awareness and protection. This study was therefore undertaken at a tertiary level government institution largely catering to semi-urban and rural population to understand the level of awareness of the patients undergoing cesarean delivery regarding the indication, procedure, and various other aspects which are very essential for women to know before giving an informed consent. Such periodic studies at every tertiary hospital in government setup as well as private setup will definitely help in better counseling of patients undergoing cesarean section, and thus improve doctor–patient relationship, lead to better overall management of these patients, and will also reduce the number of litigations and medico-legal problems, if any complications occur.
Patients were selected irrespective of the indication of cesarean section or its nature, elective or emergency. Women were interviewed with a questionnaire which was prepared in local language and information regarding social characteristics, previous pregnancies, their knowledge, and attitudes toward cesarean section was sought.
Total 220 women participated in this study.
The healthcare facilities and coverage have received a boost with proper and strict implementation of various schemes like JSSK (Janani Shishu Suraksha Karyakram), National Ambulance services, and Mother–Child tracking system under the National Rural Health Mission. Evidently, the result of the government schemes is a significant rise in institutional deliveries due to increased awareness about the health facilities as well as strengthening of primary health centers with ease of referral and better transport facilities. Institutional deliveries increased on an average by 7 % points between NFHS 2 and NFHS 3 with 20 states having increase in institutional deliveries by more than 7 % points to more than 15 % points [1]. Schemes have had their improved results, the onus lies upon the caregivers to improve and maintain the quality of health care in these tertiary-care government hospitals in proportion to the increase in patient load.
Pre-operative and post-operative counseling of the patient undergoing cesarean section constitutes an integral part in the maternal care. Patient education and active participation of patients in decision-making process after understanding all the risk are very important in management of these patients. Increase in medical legal problems has occurred mostly due to misinformation of inadequate information provided to the patients and relatives. In his paper, explaining the causes of increase in medical litigation in the UK, David Chacko observes, ‘‘As a consumer of medical care, the patient has a right to assert his interest in self determination and participate in determining the course of treatment….. In this sense, consumerism creates a standard to which the doctor must be held and provides a means for the patients to enforce the standard.’’ [2]
The results of our study point to the fact that there is still much ground to cover in regards to counseling regarding pre-operative and post-operative complications. These patients were selected irrespective of elective or emergency nature of cesarean section because irrespective of the indication, importance of informed consent and proper explanation of procedure to patient or relatives cannot be undermined. The fact that only 25 % of total cases with explained proper procedure and complication as opposed to 71 % of patients having proper knowledge about the indication of cesarean section points out the lack of information in seemingly ‘‘informed’’ consent. Many times patients are only explained about the indication, while procedure and complications of cesarean section and other facts are not communicated. This short coming is magnified into a problem when the patient has any complication intraoperatively or postoperatively. An overwhelming majority of women in our study, 81 %, preferred vaginal delivery, while 13 % of the patients wanted cesarean delivery. Combined with the fact that 85 % of all patients were literate, it demonstrates majority of patients with willing for vaginal delivery and if subjected to cesarean section without proper explanation and counseling, they may represent a subset of patients who would then question the very need and justification of carrying out the procedure. These findings are concurrent with findings of Saoji et al. [3] and Sharma et al. [4].
About 85 % of total patients were of opinion that there was more risk to mother in cesarean delivery, and the point made earlier remains vindicated and stresses upon proper patient counseling before cesarean section so that patient understands the risks and benefits of the cesarean section is essential. In the findings of Saoji et al. [3], 91 % indicated the preference for vaginal delivery. Thus, patient education and proper counseling regarding pre-operative and postoperative risk and complications have become an in dispensable part of cesarean section.
The problem of proper patient education and information center cannot be tackled only in labor room or antenatal wards. Many times emergent indications warrant immediate action which might not give enough time for proper counseling of patients or her relatives. So, to bring about awareness about the risks and complications of cesarean section, there is a need that patients be counseled during the antenatal visits, specifically when patients visit near term for antenatal check up. This will help patients actively participate in the medical decisions even during emergency and understand the nature of complication, should it occur. Tertiary-care hospitals should conduct similar studies at regular intervals to evaluate if patients are given proper information before cesarean section, thus maintaining good doctor–patient relationship and reducing potential medicolegal litigation.
Acknowledgment Ms. Prachi V. Jog.
This cross-sectional study was undertaken in our institution from December 2013 to June 2014 after getting the Institutional Ethical committee approval. Data were collected from 220 women who underwent cesarean section in this institute, after their due written informed consent and the authors declare that they have no conflict of interest.
