Labors of a Caesarean Culture

Ahn Hyang Shim, 28, and her husband were filled with expectation as they entered Jinju Kaya Jamo Hospital on the outskirts of Pusan for the birth of their first child. They were told Ahn would need a caesarean because she hadn’t produced enough water, but the doctor quickly reassured them that this was routine.

That was the last time Ahn’s family saw her conscious. During the caesarean she fell into a coma, and she remains in a vegetative state more than nine months later.

“We found out later that low water levels are an excuse they often used,” says Ahn Keun Yol, her grief-stricken father. “She’s our only daughter. I can’t tell you how it saddens our hearts to watch her lying there unconscious.”

Proportionately, South Korea performs more caesareans than any other nation, with 43% of its babies entering the world under the knife, compared with 20% in the United States. Public health experts say many Koreans, awed by modern Western medicine, believe that caesarean deliveries are safer than natural births.

In fact, studies show that women who undergo caesarean operations are four times more likely to fall into a coma, face infection or mental stress or suffer other problems.

But more than simple misperception appears to be driving up the caesarean numbers. Until recently, doctors and hospitals earned three times more, or $1,490, for a caesarean birth than for a natural one. Add in longer hospital stays, and the fees jumped as high as $8,000.

“The major blame should go to the doctors,” says Kim Ki Young, deputy research manager with South Korea’s National Health Insurance Corp. “They’re always urging women and frightening them in order to boost their fees.”

Doctors, however, cite factors other than profit, including a legal system that absolves physicians of most liability in the case of caesarean births but leaves them vulnerable when accidents occur during natural ones.

Women often report being told weeks in advance that they will need a caesarean, even though medical literature suggests that the procedure should be a last resort generally decided on in the delivery room after signs of trouble appear.

Another factor in the incredibly high levels, public health officials say, is convenience. Doctors prefer to handle births during regular office hours rather than see their schedules upset by a long labor that lasts late into the night.

The sharp increase in South Korean caesareans--the rate has doubled since 1995 and tripled since 1990--has created a backlash from women’s groups and a financially troubled government health insurance system faced with mounting medical costs.

Statistics due out in May are finally expected to show the rate leveling off. Still, experts don’t foresee a dramatic drop any time soon because it’s generally recommended in most countries that women who undergo caesareans do the same with their next child.

South Korean public health officials say the 43% figure is so high that they have been reluctant to report it to international research organizations. Recently, in an effort to reverse the trend, the government insurance corporation--part of a universal system funded by company and employee premiums--has dramatically reduced its reimbursement schedule for a caesarean, although the operation still generates more income for doctors than does a natural birth.

Doctors have bridled at suggestions that they sacrifice patient health for profits. Some have questioned the statistics, while others have accused insurers of interfering.

But the most common argument is the different ways the two procedures are treated in court. Under the assumption that a birth requiring a caesarean must be problematic by definition, the law saddles doctors performing caesareans with much less liability than in cases of natural birth. The fact that the law spurs more caesareans was an unintended consequence.

“The courts are always finding doctors guilty, so it’s common sense they try and avoid natural childbirth,” says Park Moon Il, professor of obstetrics at Seoul’s Hanyang University.

The number of childbirth malpractice suits in South Korea remains tiny by U.S. standards--49 for the entire country in 1999 out of 616,000 births. But the Health Ministry plans to submit legal changes to the National Assembly this year that would equalize liability in caesarean and natural births.

Not all the blame, however, can be placed on doctors’ shoulders. Women also play a role for some very unscientific reasons. One commonly held belief in Korean society is that women who undergo caesareans will be thinner and physically more attractive than those who give birth naturally. Another holds that the sex life of women who undergo caesareans will be better than that of their natural-birth peers because the birth canal will not have been distended.

Also prevalent in South Korea’s education-obsessed society is the view that squeezing the baby’s head through the birth canal risks dulling the child’s intelligence, ultimately hurting the youngster’s chances of getting into a prestigious university.

“The important thing is to eradicate these myths,” says Kim Sang Hee, director of WomenLink, a South Korean nonprofit group.

Saju, Korea’s art of numerology derived from ancient Chinese practices, is another culprit. Superstitious mothers-to-be visit saju masters for advice on the best days to give birth to children who will be healthy, wealthy and wise. Armed with the input, they request caesareans.

Saju master Kim Kwang Il says four or five expectant mothers visit him each month for a reading. Saju is not absolute, he says, and must be tempered by the reading of a person’s face.

“But you want to avoid bad saju,” he adds. “If the child is due to be born on a bad date, you want to change that. It’s natural--no parent wants anything bad for their child.”

Kang Hye Sook, a 40-year-old mother of twin boys, used saju to decide her due date. “I don’t regret having a caesarean, but sometimes the scar itches on rainy or cloudy days,” she says. “I hear that means the baby was scared of the anesthetic.”

Women’s groups have been at the forefront in trying to not only reduce the nation’s high caesarean rate but also change South Korea’s “birth culture.” All too often, they say, a largely male medical establishment has treated childbirth more like a disease than a joyous event to be shared by the entire family.

WomenLink advocates greater involvement by husbands--a relatively new concept in South Korea’s traditionally male-dominated society--plus an expanded role for mothers in medical decisions and less stressful birthing environments than the traditional cold steel and harsh lighting found in the average delivery room.

“The joke is that doctors think they own the baby rather than the mother,” says Myung Jin Sook, the group’s secretary-general.

Raising Awareness of Alternative Methods

The media also have helped raise awareness by publicizing the risks of caesareans and outlining alternative delivery methods new to South Korea, including birthing in water.

The publicity has resulted in more women questioning doctors when told that they need a caesarean. “I can see a change taking place among medical consumers and future mothers,” says Chung Hee Kyung, a senior reporter of the Women’s News, a weekly newspaper. Still, most believe that it could take many years before a fundamental shift in the culture is visible.

Medical experts say part of the sharp rise in the caesarean rate stems from South Korea’s greater affluence over the last few decades, during which its society enthusiastically embraced Western medicine. Only now is the pendulum swinging back as Koreans rediscover the benefits of midwives and other long-standing medical traditions.

Kim Yon Ok, 56, selling cookies from a street stall in Seoul, the capital, thinks that some of South Korea’s soul has been lost with its headlong rush into modernity. She says she was too poor even to afford a midwife, but her mother helped her deliver in their living room, passing on birthing skills she learned from her own mother.

“Young mothers these days are so impatient and afraid of labor pain, they easily get pushed into a caesarean by their doctor,” she says as she pours batter onto a small griddle.

The first caesarean operation in Korea was performed sometime after 1917 at the Severance Medical College hospital in Seoul, which was set up by an American missionary, but home birthing remained common until the 1960s.

Traditionally, rice husks were strung over the door of the family compound after a birth, warning people to stay away for a few days to prevent infection--with red peppers added if it was a boy. After 1989, the entire population came under the national health insurance system, and 99% of births today take place in hospitals practicing Western medicine.

The move to reduce caesareans comes too late for Ahn Hyang Shim, who lies motionless most of the day in her hospital bed. Her family has put a picture of her newborn daughter on her monitoring equipment, hoping that one day soon she will wake up. Occasionally her eyes flutter, but she doesn’t respond or recognize family members. Her husband and parents massage her hands and talk to her in soft, loving tones and pray for her at a Buddhist temple.

The baby is healthy and being taken care of by her father and grandmother at their home on the small island of Namhae in the south. But both the adults are tired these days, and the neighbors no longer come by to help as much as they did at the beginning.

One Patient’s Family Preparing Lawsuit

The doctors originally admitted that the hospital made a mistake in one of the tests administered before the caesarean, but officials later reversed course and now are evasive, Ahn’s father says. In frustration, Ahn’s family is preparing a lawsuit despite the court’s tough standards for questionable caesareans.

Ahn’s attending anesthesiologist, Kim Seung Hye, quit the hospital in February and has reportedly left the country on an extended trip. Park Eun Soo, administrative director at Jinju Kaya Jamo Hospital, says the institution didn’t do anything wrong. It appears that amniotic fluid entered the bloodstream and traveled to Ahn’s heart, he says, “which, by the way, we’re not liable for.”

“Unless the mother dies and an autopsy is conducted, we can’t be sure of the cause,” he adds. “Judging from the fact that she hasn’t come out of the coma in almost 10 months, though, it’s doubtful she’ll ever recover.”

For family members, the fact that they have suffered such a cruel fate at a time of such potential joy has been devastating.

“How could we ever expect such a thing? We were told everything was normal,” Ahn’s father says. “It just breaks our heart.”

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Chi Jung Nam in The Times’ Seoul Bureau contributed to this report.