Why C-section deliveries are rising at an alarming rate in India

India has seen an alarming rise in the number of C-section deliveries, though, as a developing nation, the practice has been prevalent for some time. The caesarean section is a globally recognised maternal healthcare indicator.

The Ministry of Health and Family Welfare (MoHFW) states "Cesarean section (CS) when indicated is a life-saving procedure but when performed without appropriate indications can add risk to both mother and baby. Unnecessary caesarean sections also pull resources away from other services in [an] overloaded health system."

As per National Family Health Survey (NFHS) reports, the trend of C-section deliveries in India has been on the rise. It was 8.5 per cent in 2005-06, 17.2 per cent in 2015-16, and in 2019-21, it increased to 21.5 per cent.

Credit: MoHFW

While the World Health Organisation (WHO) recommends the percentage of caesarean deliveries not exceed 10 to 15 per cent in any nation, the Health Management Information System (HMIS) has reported 20.5 per cent of C-section deliveries in 2019-20, a number which went up to 21.3 per cent in 2020-21, and then to 23.29 per cent in 2021-22.

Credit: MoHFW

Among the Indian states, the highest percentage of C-section deliveries was in Telangana - rising from 55.33 per cent in 2020-2021 to 54.09 per cent in 2021-2022.

Credit: MoHFW

Over time, it has been observed that the percentage of C-section deliveries in private hospitals has been more than in public facilities. In 2019-20, private facilities saw 34.2 per cent of C-sections, which went up to 35.95 per cent in 2020-21 and then to 37.95 in 2021-22. Comparatively, at the same time, public facilities saw 14.1 per cent, 13.96 per cent, and 15.48 per cent of C-sections occur.

HMIS reported the highest percentage of C-section deliveries in private institutions in Andaman and Nicobar Islands and Tripura in 2020-2021 and in 2021-2022. Meanwhile, the lowest percentages were reported in Rajasthan (18.9 per cent), followed by Jharkhand (20.2 per cent) in 2020-21. For 2021-22, the lowest percentages were again in Jharkhand (20.09 per cent), Uttar Pradesh (20.11 per cent), and Uttarakhand (20.34 per cent).

A paper, titled Alarming Trends of Cesarean Section—Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India shows that among C-section procedures, there are some which are medically necessitated and others which are elective.

Credit: Alarming Trends of Cesarean Section—Time to Rethink: Evidence
From a Large-Scale Cross-sectional Sample Survey in India, Journal of Medical Internet Research

The paper, published in the Journal of Medical Internet Research studied data up to 2021. It notes "a total of 230,870 women who had a live birth in last 5 years preceding the survey were included in the study. A total of 49,634 and 42,884 women had undergone CS in the NFHS-5 and NFHS-4, respectively."

Analysis of the data shows that the likelihood of a C-section is more among educated families with a richer wealth status. It is also higher for those in urban areas and those "having better contact with health systems, as evident from the increased number of ANC visits."

Good family support, as evidenced by the partner's human capital, also results in greater odds of C-section without interaction with wealth status, education, or better availability of services in urban places. The research posits that a rise in C-sections could be attributed to "willingness to pay, especially among women belonging to families with wealthier status", and other factors like a physician's choice in the private sector. It has already been established that the probability of C-section delivery and elective C-section increases with better wealth quintiles.

Affluent women also have a greater likelihood of C-section by choice due to perceived lower risks. Better access to health services promotes C-sections. The paper further notes "Improved autonomy and capability to take decisions probably explain increased CS among educated women", adding, "education levels among heads of household also influence decisions for CS" and "Concerns around medical malpractices or viewing CS as a measure to prevent any mishappening could be the possible reasons that motivate families to support CS."

The rising C-sections in India are worrisome, with better education, wealth, and social factors being noted as contributory factors. Proper monitoring mechanisms are needed for C-sections, especially when elective.

"Improved awareness about the obstetric dangers and postpartum complications of cesarean deliveries over normal deliveries along with the strategical implementation of government initiatives can help us take a rational decision on CS deliveries," the paper notes.

Though low C-sections among underdeveloped sections can be a concern, the potential for medically unneeded overuse of C-section deliveries as income and education raises issues that need targeted interventions by ways of health policies to have more appropriate use of C-sections among affluent parts of society.

Another paper, titled Changing scenario of C-section delivery in India: Understanding the maternal health concern and its associated predictors, published in the Journal of Family Medicine and Primary Care notes more steps that can be taken by the government to address the problem.

"The Government should take a primary initiative of raising awareness on the importance of normal deliveries for healthy pregnant mothers which will result in maternal health literacy among women," the research concludes, adding that frontline workers are best placed to communicate the realities of different delivery processes to women so they can choose what best suits their needs and circumstances.

"Sensitisation of the importance of normal delivery when no medical complications are seen in women also needs to be conducted by awareness campaigns through various modes of communication," the paper adds. It posits the importance of a mandate where it would be noted that C-sections will only be executed when needed medically and these directives would be implemented in states where the C-section levels are high. The paper also urges to probe that private hospitals do not compel patients to get a C-section for monetary gain.