More than a quarter of India’s births now happen through Caesarean-section (C-section) deliveries, driven primarily by high rates of surgical intervention in private hospitals.

A part of this increase may reflect better access to emergency obstetric care, experts say. As more women deliver in health facilities, doctors are better able to identify complications that require surgical intervention. But coercion and commercialisation are to blame for unnecessary C-section deliveries, they say.

Nationally, the share of births by C-section increased from 21.5 percent in 2019-21 to 27.2 percent in 2023-24, according to the sixth National Family Health Survey (NFHS-6). In public hospitals, which see about three in five births, the rate is 17 percent. This is close to the globally accepted optimal level, said Kranti Vora, adding that it reflects their improved capacity to provide emergency obstetric care. Vora is a visiting faculty at the Society for Education, Action and Research in Community Health (SEARCH), which provides healthcare in Gadchiroli district.

But in private hospitals, 54 percent deliveries were by C-section. The World Health Organization (WHO), in a 2015 research note, said C-section rates above 10 percent do not reduce maternal or newborn mortality at the population level.

Conditions such as failure to progress in labour, foetal distress, placenta previa and breech or transverse presentation may necessitate a C-section delivery, explained Suchitra Pandit, consulting obstetrician and gynaecologist at Surya Hospitals in Mumbai. In addition, multiple pregnancies, severe pre-eclampsia, previous Caesarean sections, and maternal conditions such as obesity, diabetes and hypertension could also lead to the surgical intervention.

The WHO recommends Robson classification, a checklist of 10 obstetric parameters, to determine the need for a C-section. These include factors such as the history of a pregnancy and gestational age.

However, caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications, the WHO warned.

The medical imperative

Harshada (name changed), a 35-year-old kindergarten teacher, first conceived through in-vitro fertilisation (IVF), and doctors recommended a C-section because of the high-risk nature of the pregnancy. The surgery went smoothly and she delivered a healthy baby girl. Encouraged by that experience, she returned to the same private charitable hospital for her second pregnancy a year later.

On the day of delivery, doctors told her she had developed high blood pressure and advised another C-section delivery. But what was expected to be a routine surgery quickly turned into a medical emergency. Doctors were unable to control heavy bleeding after the operation and subsequently decided to perform a hysterectomy, removing her uterus, Harshada explained.

Her condition continued to deteriorate after the surgery as she had developed jaundice. She sought treatment at a government facility as she could not afford private hospital care. With her uterus removed, Harshada has entered menopause years earlier than expected and continues to deal with the physical and emotional effects of the surgery.

For the IVF, both deliveries and subsequent complications, the family incurred more than Rs 6 lakh in medical expenses, for which they had to take out loans.........

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