The C-section epidemic

In a country where childbirth has long been seen as a natural process, nearly half of all private hospital deliveries today involve surgery, as per the latest National Family Health Survey, NFHS-5.

Employed judiciously, C-section deliveries can save lives. But when they become the default, not the backup plan, one begins to wonder whether there is another story behind the numbers.

C-sections are a vital part of modern obstetric care. There is no question about their importance when labour becomes risky. But what was once intended as a procedure of last resort is now routine.

Public hospitals in India report an average C-section rate of about 14 per cent (NFHS-5), which falls within the limit recommended by the World Health Organization. But in private hospitals, the rate is 47 per cent! This isn’t a small difference — and too large to be explained away as medical complications.

Some studies point to changing preferences. Others blame urban lifestyles, obesity, late pregnancies or rising incomes. These might sound plausible at first, but the data tells a different story. If income or education were the main factors, we’d see a consistent pattern across the country. Instead, what we find is shaped more by institutional practices than individual choices.

In Tamil Nadu and Andhra Pradesh, for example, a woman’s background makes very little difference to whether she ends up having a C-section. Her wealth, her level of education or whether she lives in a village or a city do not significantly change the odds. What does matter is the kind of hospital she delivers in. In Tamil Nadu, births in private hospitals are more than three times as likely to result in surgery than those in public ones. In Andhra Pradesh, the difference is even greater (NFHS-5).

In Bihar and Uttar Pradesh, where access to public healthcare is more limited, private hospitals often step into the breach. Here, socio-economic factors do play a stronger role.

In Uttar Pradesh, urban women are about 20 per cent more likely to have a C-section than rural women. Women with higher levels of education are more than twice as likely to undergo surgery as those with little or no schooling.

But even in these states, the institutional trend is what stands out. In Bihar, private hospitals perform C-sections over 16 times more often than public ones; in Uttar Pradesh, more than 8 times. This suggests that while income and education shape where a woman gives birth, the decision to operate is influenced more by the kind of institution she enters (NFHS-5).

This is not just about preferences or risk. It is about how the healthcare system is structured and what kinds of behaviour it encourages or rewards. And those incentives come with consequences.

Unnecessary C-sections are not without risk.

For mothers, they can lead to postpartum depression, uterine rupture and complications in future pregnancies such as placenta previa (a pregnancy complication where the placenta attaches low in the uterus, either partially or completely covering the cervix). For babies, surgical births are linked to higher chances of asthma, obesity and autoimmune conditions. These are not rare outcomes. They are well-established risks that increase when surgeries are performed without strong medical reasons.

The financial cost is equally troubling. For a low-income family, the price of a C-section can be steep — in private hospitals, this can be as high as 27 per cent of their annual household income. Across the country, more than 9 per cent of C-sections push families to borrow or sell assets to cover the cost.

It does not have to be this way. If private hospitals followed optimal C-section rates, India could avoid more than 18 lakh unnecessary surgeries every year.

Some of the drivers are medical — increasing maternal age and higher BMI, for instance — but the stronger forces are institutional.

C-sections are quicker, more predictable, and far more profitable. Vaginal deliveries can take hours and require monitoring. A C-section, by contrast, can be completed in under an hour and scheduled conveniently. For overworked ob-gyns or single-doctor clinics, this is a logistical solution disguised as medical care. Hospitals, too, benefit: they earn 30–50 per cent more from a C-section than a natural birth. In a healthcare system strained by workforce shortages and lack of oversight, the scalpel often wins.

But there are models worth emulating.

Telangana has combined cash incentives for institutional births with additional rewards for natural deliveries, while auditing private hospital behaviour (The News Minute, 2022).

In Bengaluru, the Astrika Foundation has shown how trained midwives can safely and effectively assist in natural births, reducing unnecessary medical interventions while ensuring better maternal care.

Yet meaningful reform is impossible without better data. Right now, India is making maternal health policies in the dark.

The Reproductive and Child Health (RCH) portal is outdated, patchy and voluntary — many states simply do not report. Even when data is available, it often lacks critical delivery metrics. Under the Medical Council Act, doctors are supposed to declare the number of C-sections they conduct, if asked. But this remains unenforced and ineffective.

There is also an urgent need to expand and restore trust in India’s maternal health workforce. Auxiliary nurse-midwives, once the backbone of rural care, are now overworked, with their focus diverted to vaccinations. We must invest in more trained midwives and scale midwifery-led care units (MLCUs), which have been neglected despite strong global evidence in their favour.

What we are witnessing is not just a medical trend — it’s incentive-driven behaviour. In health economics, there is even a term for it: ‘physician-induced demand’. This phenomenon has normalised surgical shortcuts and transformed childbirth into a revenue model.

Fixing it won’t happen through awareness campaigns alone.

It will require robust data, political will and the courage to rebuild a healthcare system that prioritises care over convenience and dignity over profit.

The authors are former LAMP fellows