The Cesarean in Contemporary Taiwan

According to one survey, up to half of the mothers who chose to give birth by Cesarean section at the National Taiwan University (NTU) Medical Center did so in order to make sure their child was born at a propitious moment. But some scholars adopt a completely different explanation. They believe the reason why pregnant women choose Cesarean delivery is that the medical system and its authority are so overwhelming that they lose the right to decide for themselves.

Whatever the case may be, the fact remains: Taiwan's Cesarean birth rate is already one of the highest in the world, well beyond Europe, the United States and Japan.

In the early hours of the morning, in the operating room of a Hsinchu area hospital's obstetrics and gynecology (OBG) department, the birthing mother on the operating table has already been administered anaesthesia. The doctor stands ready to one side, watching the clock on the wall, waiting until five o'clock to begin surgery.

The birthing mother's husband and mother-in-law stand in wait outside the operating room. Beforehand, they made sacrifices and gave notice to their ancestors. Then with the help of a fortune-teller, they determined the child should be brought into the world by Cesarean at this very hour and minute. The child would have a good fortune and would be born under the star Kui in the Big Dipper, legendary home of Wen Chang the God of Literature. If these were ancient times, he would rise to be a prime minister assisting the emperor.

In less than an hour, the nurse comes out, holding a baby boy. When he sees his son's square face and big ears and hears him crying loudly and clearly, the first-time father says with satisfaction, "He does have the bearing of a high official after all. Maybe someday he'll be appointed to the presidential cabinet!"

According to her experience, nurse Lin Li-yun estimates that about three out of every ten pregnant women will have their child's fortune calculated to select the perfect time for a Cesarean.

According to a survey conducted by the Executive Yuan's Department of Health, the rate of Cesarean operations in the Taiwan area in 1991 was 36.6%, one of the highest in the world.

In the last five years, this high number has not decreased. Estimates up to March of this year indicate that the rate remains above 30%. In other words, one out of every three children in Taiwan is brought into the world through Cesarean delivery.

In fact, the report "Impact of Cesarean Operations on the Health of New Mothers," presented by NTU public health department teaching assistant Huang Chun-yuan and based on a survey of 500 births from December 1994 through February 1995, estimates that half of the Cesarean births were performed because of traditional Chinese fortune-telling beliefs, in order to give the child "good luck."

Fate is rooted in the bones

This is a small reflection of the great aspirations Chinese parents have for their children, "hoping their sons will be dragons and their daughters phoenixes." The Taiwanese have a popular saying: "Fate is rooted in the bones and can't be cut away." The meaning is that everything in a person's life, failure or success, good luck or bad, is predetermined. It is rooted in one's bones and cannot be avoided. And this fate is generally decided at the very moment of birth. Therefore, in telling someone's fortune, Chinese people first and foremost stress the "eight characters" that specify the year, month, day and minute of birth. This can be said to be the foundation of destiny.

In the past, the art of Cesarean delivery was not highly advanced, and the time of natural birth was completely dependent upon chance. Even under these circumstances, it is said that there were still some strong-willed mothers who did their best to bend the situation, using sheer perseverance, for example, to hold back until the perfect moment, then using all their energies to bring the child into the world. Others, seeing that a propitious day was approaching and noting that their womb had not started to contract, would exercise with all their might to precipitate labor.

Today Cesarean surgery is commonplace and can save a great deal of effort. One need only determine the minute of birth, make an appointment with the doctor, and when the moment arrives, go lie down on the operating table. As if placing an order with Old Man Heaven, this method is favored by mothers and fathers who are unwilling to have their children lose at the starting line.

The problem is that when the ancients calculated fate, they laid emphasis upon the process of nature, and fate was determined by natural circumstances. Since Cesarean births are determined by human beings, are the "eight characters" derived from this kind of birth legitimate?

There is one such example from the past: One couple were overseas students living in the USA. When the wife became pregnant, they decided to return to Taiwan to have a Cesarean. They asked a fortune teller to select a time of birth that would give their child "an emperor's fate, with great luck, great wealth, wherein someone will always be there to provide, both in dining and dressing." Ironically, their wishes were granted: the child had a congenital disease, and for the rest of his life would always require someone to look after him.

One magazine editor also recalls that when she was working as a private tutor, one of her students had been born via Cesarean by her mother's choice, yet in every respect the results were not agreeable-"She was very hard to teach." Nevertheless, her little sister, also delivered by Cesarean, turned out to be an exemplary child, much in line with her predicted fate.

The right to control their own bodies

Actually, don't modern people know that cultivation after the fact is more important than the initial conditions? In fact, Chinese people simply like to make sure every matter of life is auspicious. When people reopen their businesses after New Years, begin a construction project, move to a new home or arrange for a medical operation-even when political candidates plan a time to register-they will all choose a propitious day. Having a Cesarean to give one's child a good fate fits well within this general logic of seeking peace of mind.

Even if some mothers-to-be choose Cesareans for other reasons, they often also select the exact time of surgery. "Except under emergency conditions, almost all mothers who choose Cesareans arrange the time of birth. Sometimes two or three mothers choose the same time, which makes the doctors and nurses terribly busy," explains Lin Li-yun.

Chen Shu-ying, who required a Cesarean because of diabetes contracted during pregnancy, is an example of the minority of unbelievers. Planning to give birth at the NTU Medical Center, she went two weeks in advance of her anticipated time of birth to schedule surgery, discovering that the "good days" were already booked solid. She had no choice but to choose a day that no one wanted because "it was a little unlucky." Although both mother and child went through delivery untroubled, later on her child turned out to be weak and frequently ill. Both physically and mentally exhausted, she frankly confesses that she regrets that she was so careless at the outset and did not choose a more auspicious day for her surgery.

"Many reasons are hidden underneath traditional thinking," avers OBG physician Chan Yi-hung, who has been engaged in medicine for more than 20 years and has watched the rate of Cesareans steadily increase. He believes the reason is that Cesareans give modern women the power of choice to reduce the danger and pain of giving birth.

According to his analysis, modern women do fewer arduous tasks, and their muscles are less flexible. Because of such factors as marrying older and giving birth later in life, difficulties and impediments in giving birth are increased. In addition, there are a number of psychological factors, for instance emotional fear or anxiety over the danger and pain of birth.

"Natural birth is very taxing in terms of time and energy. During the process, either mother or child could have an accident at any time. So during the days before Cesareans, giving birth was a gamble, like walking a line between life and death." He says that long ago the Taiwanese had the saying: "Winning at birth is the fragrance of chicken wine, losing at birth is four planks." The meaning is that if the birth goes smoothly, the mother will smell the aroma of her family stewing chicken soup with sesame oil, the traditional tonic for new mothers. If there are problems during birth, they must prepare a casket.

Today the situation has gotten better because of pre-birth examinations and improvements in medical treatment. Nevertheless, natural birth for a first-time mother takes an average of 12 hours, far more than a Cesarean operation, which usually takes one hour. In this modern day when people increasingly treasure the lives of mothers and their unborn babies, considering the dangers involved, the motivations to choose a Cesarean have increased.

Furthermore, Chan Yi-hung notes, "Modern women's capacity to endure pain is getting lower and lower. In order to avoid experiencing such tremendous pain, quite a number of women, as soon as they get pregnant, tell the doctor to give them a Cesarean or some other painless delivery. They simply won't accept a doctor's advice to 'first try natural birth, and only use medical surgery if it doesn't work out smoothly.'"

Changes in doctor-patient relations

Chang Sheng-ping, chief of obstetrics and gynecology at Taipei Veterans General Hospital, views this problem from the perspective of the evolution that has occurred in doctor-patient relations. As patients' consciousness of their own independence increases, doctors' authority diminishes proportionately, giving rise to greater elasticity in the decision-making process.

"In the past, patients completely relied upon the doctors' diagnoses and accepted our opinions. Nowadays, before patients come to the hospital, they already have something planned in their minds. If they want a Cesarean, a Cesarean it is. 'If you don't help me, I'll go to a different hospital.'" He notes, "Before the 1980s, the rate of Cesareans at Veterans' General remained below 15%. In the last ten or more years, it has rapidly grown." This period coincides with an era of dramatic change in Taiwan's society, in which the public has become far more aware of personal rights and women more conscious that they have power over their own bodies.

Conversely, Chang Sheng-ping admits that doctors today are not as patient with or confident in natural birth as they were in the past. Consequently, any time some slightly dangerous symptom appears during the slow process of birth, they opt for a Cesarean to ensure safety.

Chang Sheng-ping states that every birth is "like an emergency." If there are too many abrupt changes, or gynecological complications such as hemorrhaging in the mother, damage to the uterus, etc., a dangerous situation may develop. If the patient does not trust the doctor enough, disputes over treatment may easily occur.

Chan Yi-hung points out that in Taiwan, OBG sees the second highest number of disputes over treatment. (The highest of all is internal medicine, where treatment is more complicated, and the number of patients greater.) In order to avoid the consequences of any potential accidents, doctors are less and less willing to reject their patients' demands.

In the USA, OBG has for this reason been listed as a high-risk profession with frequent malpractice suits. This is one reason why the USA ranks number one in Cesareans among all the developed nations. The most common reason that their doctors are sued is for not performing a Cesarean.

The "medicalization" of birth

Many in the medical community believe that women's increased claims of power over their own bodies, the changes in doctor-patient relations, and the resulting decrease in physicians' authority are all causes for the increase in Cesarean sections. Yet according to National Defense Medical Center associate professor of humanitarian and social sciences Liu Chung-tung, herself a woman with a background in nursing, "It demonstrates the problem that the bodies and birth process that belong to us women have been 'medicalized.'"

This so-called "medicalization," she explains, is the result of the excessive expansion of the medical profession and the service sector. More and more functions of everyday life, including the natural phenomenon of birth, become enveloped within the scope of medical care. From birth, to personal health, to the prevention of aging-everything becomes encompassed. People therefore become more and more dependent and controlled by the medical system and lose their personal autonomy.

The most prominent advantage this phenomenon has for the medical establishment is that they can compete for and expand resources. For example, medical fees vary according to the method of birth. Cesarean births are on the average NT$10,000 more expensive than natural births. For the physician this, to a greater or lesser degree, is an incentive.

Moreover, the results of medicalization have an effect on people's choices of medical treatment. When having babies, for example, every country has traditional birthing methods. From ancient times China has had an excellent tradition of delivery, carried out by midwives whose knowledge has been passed down. Nevertheless, after modern obstetrics was developed, women's birthing territory was moved from the home to the hospital. Those who assisted delivery changed from female midwives to OBG physicians, who are predominantly male. The natural process of birth also changed into a high-tech medical procedure.

Thus, the expectant mother is put in a strange, frigid and sterile environment, lies supine on the operating table with both legs stretched out, has her private portions examined, receives an enema, and has her pubic hair shaved. This kind of clinical birthing experience often makes women feel embarrassed, pained or uneasy, and they naturally wish to avoid it at all costs.

"The support and service of medical personnel will definitely influence an expectant mother's psychology and her willingness to have a natural birth," affirms Kaohsiung Min-sheng Hospital psychiatrist Tseng Chi-hua, who has herself tasted the bitterness of giving birth on the operating table. She believes that giving birth feels far worse if there is no family member or tender and compassionate nurse by one's side.

"For example, midwives are a tremendous support when women give birth," she says. Most of them are women, who have shared this experience, and can guide the mother through the entire process and provide an immense amount of psychological support. One major reason Japan's Cesarean rate is so low is that they have preserved the midwife system."

Chiu Ming-hsiung, chairwoman of the Hualien County Midwives' Association notes data that indicate one of the keys to a low Cesarean rate lies in a high-quality delivery with a midwife attending the mother throughout the whole process. "The Cesarean rate in the Netherlands is only five percent, and midwives take part in at least 40% of deliveries, half of which occur at home. Japan also has the low Cesarean rate of 7%. Part of the reason is that Japan has more than 20,000 midwives practicing in hospitals and clinics, or helping OBG physicians to deliver newborns."

Back in 1951, when more than half of the babies in Taiwan were delivered by midwives, only three percent were delivered by doctors. In 1994, 99% were delivered by doctors, pushing down the rate by midwives to 0.4%.

"Midwives, who are mostly graduates from nursing schools, have no way to compete with doctors, who are deemed both professional and authoritative," says Yu-mei Y. Chao, deputy general manager of the Bureau of National Health Insurance. However, in order to lower the frequency of Cesareans and to save medical resources by reducing the involvement of the medical establishment in child delivery, the Bureau of National Health Insurance has currently reversed the trend, emphasizing the efficient use of midwives and allowing their service to be covered by insurance.

Insufficient information

Hu Yow-hwey, associate professor at National Yang-Ming University's Graduate Institute of Health and Welfare Policy, holds that insufficient information from the medical community and the prevalence of traditional concepts are also major causes of the excessive use of Cesareans.

She finds that most pregnant women think Cesarean delivery is safer for newborns and as safe for the mothers as natural delivery.

In the research sample, a fourth of the new mothers stated their doctors did not fully notify them of the benefits and drawbacks of the two methods of delivery, as well as potential complications. Also, more than 40% of new mothers felt their hospital did not provide sufficient pre-birth health education about natural delivery.

"A similar situation also prevails in Taiwan when performing hysterectomies, determining the sex of the fetus, and prescribing medication for menopause," says Hu Yow-hwey, who comments that a traditional outlook, lower education levels and an unequal position relative to men make women more vulnerable and easily controlled in a male-dominated medical system.

"What's particularly unusual is that nearly 17% of women express that the reason they would choose a Cesarean section is 'worry that natural delivery will cause the vagina to tear and loosen, and to influence their future sex life,'" she says. Quite a lot of women are willing to take a cut in the belly to please their men.

Making a clean cut?

In fact, although many studies show that under some circumstances Cesarean delivery can indeed ensure the safety of the mother and baby, it also has a degree of potential risk.

One report indicates that after the operation, the estimated death rate of mothers is 2-11% higher than natural delivery. Infection, pulmonary embolism, misapplication of anaesthesia and massive hemorrhaging are the major causes. Moreover, women who undergo Cesareans are also five to ten times more likely to suffer from disease.

Newborns delivered by Cesarean have a 4-8% rate of respiratory distress syndrome, four times higher than naturally delivered babies. During the Cesarean section, the baby may also suffer from surgical injury. Partial anaesthesia can cause the blood pressure of the mother to drop and deprive the baby of oxygen.

Obstetrician Chang Sheng-ping confirms that the risks involved in a Cesarean are indeed higher than in natural birth. This is because in a Cesarean operation, the knife directly cuts into the belly and may hurt internal organs or blood vessels in the abdomen. Furthermore, although recent medical techniques have reduced the dangers from external surgery and anaesthesia, as a whole, "with every new step in the medical process, the possibility of problems is also greater."

"Cesarean delivery is supposed to be a medical operation that saves lives, and it should only be applied in a life-or-death situation, for example, when delivery is difficult because of the baby's position, when there are multiple fetuses or when the uterus is damaged. The occurrence rate of such cases is actually very low," says Hu Yow-hwey. "In addition to this, you could say that having a Cesarean is never obligatory."

Apparently, many mothers-to-be and medical professionals currently hold different views as to whether Cesareans are imperative or not. Perhaps this controversy will only be resolved when this new generation, born by Cesarean, has already grown up.

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Chinese people believe that a child's fortune, good or ill, is determined in part by the heavens, but the parents will try to do what they can, to see if they can bend fate. (photo by Hsueh Chi-kuang, drawing at right from Chinese Popular Prints)

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People like to undertake every major event in life at an auspicious hour, in hopes of making everything successful. This is why Taiwan's divination industry still flourishes. (photo by Pu Hua-chih)

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To keep their figures as slender as a mannequin's, many women deliberately choose Cesareans. (photo by Huang Li-li)

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In the health and medical establishments, women hold unequal positions relative to their male counterparts, and they remain disadvantaged. (Sinorama file photo)

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One out of every three children of the new generation has been delivered by Cesarean. Will they be any different from those delivered naturally? (photo by Pu Hua-chih)

To keep their figures as slender as a mannequin's, many women deliberately choose Cesareans. （photo by Huang Li-li）

In the health and medical establishments, women hold unequal positions relative to their male counterparts, and they remain disadvantaged. （Sinorama file photo）

One out of every three children of the new generation has been delivered by Cesarean. Will they be any different from those delivered naturally? （photo by Pu Hua-chih）