SEOUL — 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.
