For Sari Tjakrawiralaksana, 42, the pain of giving birth to her son 10 years ago did not only stem from post-cesarean wounds, but also the undermining remarks coming from her relatives.

“Ten years ago in Indonesia, mothers giving birth through cesarean section [c-section] of their own will were not seen as being mothers as a whole,” she told The Jakarta Post on Sunday.

Sari recalled her long wait for any cervix dilation, which was nowhere in sight although she had experienced constant and intense contractions every five minutes for the whole day. After consulting with her husband and mother, she told her doctor of her decision to proceed with the surgery.

“Our considerations at the time were only my son’s condition and myself, as at the time I was already exhausted,” she said.

Despite the stigma that is often attached to it, c-section births are getting more common in Indonesia. Last year, 17.6 percent of all births were delivered through c-section, according to the Basic Health Survey (Riskesdas). This represents a steady rise from 15.3 percent in 2010.

The figure is higher than the World Health Organization’s estimation that 10 to 15 percent of all births medically require a c-section. Some studies, however, suggest the ideal rate should be a little higher than that.

The rising trend of c-section deliveries in Indonesia has put much pressure on the Health Care and Social Security Agency (BPJS Kesehatan), which manages the national health insurance (JKN) program.

C-sections accounted for 57 percent of all 5.3 million hospital deliveries under the JKN scheme recorded between 2014 and 2018, costing the BPJS Rp 15.75 trillion (US$1.1 billion) as compared to the Rp 4.9 trillion it spent on natural deliveries in hospitals over the same period.

From January to September this year, the BPJS recorded 608,994 c-section births in hospitals, costing it Rp 3.3 trillion, as compared to 417,237 natural deliveries that cost Rp 807 billion.

The high cost of c-section births significantly contributes to BPJS's ballooning deficit, which is predicted to reach Rp 32 trillion by the end of this year.

The high prevalence of c-section deliveries has raised concerns from Health Minister Terawan Agus Putranto, who highlighted the need for the BPJS and hospitals to be more selective in carrying out c-sections amid the agency’s severe financial deficit. He said the JKN should not be treated as unlimited, but rather should only be used for basic medical services.

“There should be self-correction on what necessitates a c-section and what doesn’t so that there won’t be cost overruns,” Terawan told reporters on Nov. 29 in Jakarta.

“This is about excessive use [...] of measures that could’ve been carried out differently. For instance, if you want to give birth on [good Javanese days] then just pray, but don’t ask for a c-section.”

The Health Ministry’s researcher on mother and children’s health, Suparmi, found in her study that some expecting mothers opted for a c-section over fear of birth pain or because they wanted certain birth dates.

The study, which used data from the 2012 Indonesian Demographic and Health Survey, found that 14 percent of the 12,972 respondents had undergone a c-section. Of all c-section patients in the study, 12.4 percent admitted they did not have pregnancy or delivery complications.

The study, which was conducted before the introduction of the JKN, further concluded that women from middle to higher income households, living in urban settings, aged above 35 and with health insurance had a higher chance of having a c-section.

First time mothers, those giving birth to twins and those with pregnancy complications also often undergo the procedure.

“There needs to be further study into the rising trend. Is it really because of necessary medical indications or is it because of the JKN scheme?” Suparmi said, referring to the universal healthcare scheme that had covered 82 percent of the population by January this year.

“Mothers may have to suffer unnecessarily from bleeding or a longer recovery period if the surgery was actually not needed,” she said.

Under the JKN scheme, pregnant women generally need to obtain referrals from community health centers (Puskesmas) or clinics declaring that they have a certain medical condition to be eligible for hospital check-ups and delivery.

This means that hospitals can only carry out c-sections on clear medical indications, otherwise they cannot claim reimbursement from the BPJS.

BPJS Kesehatan spokesperson M. Iqbal Anas Maruf said the rising number of c-sections was in line with the rising number of JKN holders and the adjustments in the standard healthcare fee system.

“BPJS Kesehatan has verified each claim according to existing regulations. Claims have gone through proper verification procedures before being disbursed,” he told the Post on Sunday.

United Indonesian Doctors Association chairman James Allan Rarung attributes the rise of c-section births to developments in medical technology and the Indonesian healthcare system that enable medical professionals to better detect labor risks early on.

“The JKN encourages more pregnant women to do routine check-ups, widening the chance for medical workers to detect any high risks in pregnancy and labor and take necessary measures,” said Allan, who is also an obstetrician-gynecologist.

Allan, however, admitted that in some cases of risky pregnancy, the doctor may not risk a natural delivery if they are afraid the patient or their family might sue them if there is any problem with the labor.

“In Indonesia, the safety net for doctors is still weak. In other countries, hospitals will protect their doctors with lawyers and such, but that’s not the case here. So it’s only normal for doctors here to be more fearful, and this concern needs to be raised,” he said.

Allan acknowledged that a number of doctors might have done the procedure under questionable conditions, but such cases had been handled by the quality and cost controlling team, comprising professional organizations, that had the authority to conduct a medical audit for BPJS Kesehatan.

“If [the ministry] wants to regulate [c-sections], it can do so, but don’t reduce patients’ rights. One of women’s rights is to decide how they would like to deliver their babies,” he said.

University lecturer Rinda Naswari, 29, used the JKN for the c-section delivery of her second child. The doctor found it would be risky for her to deliver naturally because she had undergone a c-section for the birth of her first child a year before.

Rinda herself preferred to have a c-section because she could not predict the pain of natural delivery.

“Even if the doctor advised me not to, I would still ask for c-section,” she said.

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