She’s having a baby, but how?

Trust is a word that produces mixed emotions in 29-year-old Lee Min-seon. As the young mother of a 30-month-old daughter who is expecting her second child in less than four months, she battles with the same question that haunted her in the delivery room when she had her first child ― whether she really had to go through a cesarean delivery as her doctor insisted.
About two and a half years ago, Ms. Lee checked in to a small neighborhood clinic in Seosan, South Chungcheong province, where she lives, to give birth. The labor, Ms. Lee recalls, went relatively smoothly for the first few hours. Her blood pressure was stable; the baby was facing the right direction; her cervix was halfway open. But just as she entered the active phase of labor, she was given alarming news from her doctor: her baby’s pulse was dropping, a sign that the fetus might not be getting enough oxygen, and it was releasing too much meconium, a sign of distress. The hospital couldn’t explain why, she says. The doctor quickly called for a cesarean delivery and asked Ms. Lee’s husband to sign an agreement. Within an hour Ms. Lee was taken to an intensive care unit, received a spinal anesthetic and got a 13-centimeter (5-inch) incision in her abdomen.
When she pulled herself together, though, Ms. Lee said she realized more than half of the mothers in her room had cesarean deliveries, too many to be a mere coincidence. In fact, it was probably not a coincidence, as Korea has the highest rate of cesarean deliveries in the world.
Ms. Lee said she wonders whether the situation would have improved if the doctor had waited a little longer. She noted that she paid over 2 million won ($1,700) for the C-section, including the surgical fee and hospital charges for four nights, as opposed to the 150,000 to 200,000 won typically charged for a normal delivery.
“I try to believe in every doctor’s conscience,” she says. “But it still leaves me with some doubts about whether I had to go through the section when I see the number of cases of cesarean births here.”
Ms. Lee said it was “a sense of loss” ― the loss of control, of femininity and a chance to greet her baby the way she wanted ― that left her feeling bitter about the whole process of cesarean delivery and hospitals. The experience, she says, left her with a sense of powerlessness.
Cesarean sections are traditionally performed in emergency situations during a delivery, when the life of a baby or a mother may be at risk. But in Korea, some doctors reportedly perform cesareans when they could be avoided, for what some critics believe is “the sake of the hospital’s own interest.” The sentiment has led to strong distrust of local health authorities among the public.
According to the National Health Insurance Corp., 184,636 C-sections took place in Korea last year out of 470,923 total deliveries, accounting for 39.2 percent of total births. That was down from 43 percent in 1999, but is still four times higher than the acceptable standard recommended by the World Health Organization and about 30 percent higher than in Latin American countries, which have the lowest cesarean rate. The figures indicate that Korea had the world’s highest rate of cesarean births for the period from 1999 to 2003, followed by the United States, at 23 percent, and Japan, at 20 percent. An average of 50 billion won in health insurance fees is spent on C-sections every year, the health agency says.
In towns like Seosan, where medical resources are less advanced than in cities, the number of cesareans is even higher, as clinics try to avoid taking any risks or facing high-danger situations. The health agency’s survey found that C-sections accounted for over 51 percent of deliveries in some cities in Gangwon and Chungcheong provinces and on the island of Jejudo.
Hospitals are even more unwilling to let mothers have vaginal deliveries after having a cesarean, although the risk of rupturing the uterus, the most common serious complication, is less than 2 percent, according to most medical experts.
“A strange look is the common reaction you get in hospitals when you insist on having a vaginal birth after a cesarean,” says Ms. Lee, adding that she is determined to have a vaginal delivery of her second child. “They ask me why I am being so persistent for something that might entail risks. But I believe no labor or delivery is risk free, whether it is a C-section or a vaginal birth.”
Kang Ji-yeong, a resident of Seoul who had her first child through a cesarean and is expecting her second child in a few weeks, got a similar reaction from her doctor when she expressed her wish for a vaginal delivery.
“My doctor told me straight from our first meeting that his clinic is not big enough to afford such risks,” Ms. Kang says. “Even if that chance is one out of 1,000, he said if anything goes wrong the risk could be too great and critical for the reputation of his clinic in the long term.”
One criticism from civic groups is that many doctors here view cesarean deliveries as a defensive measure against any risks, which in some serious cases could create an immense legal and economic burden for doctors, particularly those who run small clinics.
“It appears that the priority of many clinics nowadays is purely focused on pulling in customers,” says Kim Ji-suk, a board member of Beautiful Birth, a local civic group focusing on mothers’ health, and an advocate of natural delivery. Ms. Kim said she was advised to undergo a cesarean delivery after her first endoscopy, for what she now believes were unnecessary reasons.
“I’ve seen clinics that tell mothers with minor problems that they can have a normal delivery and then change their word at the last minute,” she says.
Lee Pil-han, an obstetrician, agrees, saying cesarean deliveries in Korea are still used as a strategy to avoid any possible medical mishaps. And despite the risks involved in a cesarean birth ― such as postpartum infections, blood loss and other side effects resulting from blood transfusions and anesthesia ― some doctors still insist on C-sections, he said, because it allows them to reap extra profit with less time and effort than in normal deliveries. Currently, the cost of a C-section is about 2.5 times higher than that for a normal delivery in Korea. The price jumps even more when the hospital fees are included.
But doctors generally argue that an increase in the number of older women having babies, which may raise the risk of problems in pregnancy, is the real factor behind the high number of C-sections in Korea. The advent of technology that allows the detection of minor abnormalities in the placenta and fetus also allows many doctors to recommend C-sections to mothers as the safest alternative to ward off unexpected complications. Some doctors contend that a growing number of young mothers demand C-sections as a way to avoid the pain and strains of labor.
Kim Mun-jong, an obstetrician at Yonseiphil, a Bundang clinic that has one of the country’s lowest cesarean rates, partially acknowledges the public criticism about doctors compromising their mission, but says the phenomenon is mostly a result of a public medical insurance system that fails to protect doctors in case of an accident.
“It’s a bit of an overstatement that doctors are pushing cesarean deliveries for economic interest,” Mr. Kim says. “They may be quicker to make the call in performing C-sections when they see suspicious signs. But in clinics where manpower is limited and one or two doctors have to go on shifts, C-sections are often considered a quick solution [for doctors] to avoid further risks and protect themselves from legal disputes.”
Byeon Su-ja, a senior member of the Korea Midwife Association, contends that C-sections might be an inevitable choice in the current medical system where doctors at local university hospitals are relatively young and inexperienced, compared to midwives with 20 to 30 years of experience and knowledge to handle unusual circumstances.
Ms. Byeon also notes that Korea’s high C-section rate might also have to do with the availability of information among the public. “Medical lawsuits are more common in Korea nowadays,” she says. “Patients know more about the operation’s procedures. And doctors are being very careful, making every effort from the beginning to avoid any possible slips.”

by Park Soo-mee