Caesarean Problem

The preliminary data for the latest National Family Health Survey (NFHS-6), conducted in 2023-24, were published recently. One of the key findings of this data is a sharp increase in the rates of caesarean section deliveries in India. Not only is it a matter of

concern from a health perspective but it also raises questions about the need for tighter health sector regulation.

NFHS-6 data show that the number of births delivered by caesarean section rose from 17.2% in 2015-16 to 27.2% in 2023-24, a very sharp increase in just eight years. Of particular concern is the stark contrast between public and private health facilities: 54% births in private health facilities were delivered by caesarean section in 2023-24 versus 16.9% births in public health facilities. Caesareans accounted for more that 50% of births even in rural private facilities, and were almost 60% in urban areas.

Some of the increase in caesarean section births can be justified by the increase in the number of institutional deliveries as caesarean section can be lifesaving in situations such as breech or transverse lie, placenta previa, twins and higher order multiples, uterine rupture and so on. Even after allowing for such complications, World Health Organization estimates around 10%-15% as the acceptable level of caesarean section births, stating that a rate beyond this level is unlikely to improve maternal, neonatal and infant mortality rates. After factoring in the increase in maternal age, obesity, IVF pregnancies, diabetes, and other medical conditions, other studies too have reached similar conclusions with the upper limit in the 16%-19% range.

The NFHS-6 data, furthermore, suggest that the problem is especially stark in certain states and a Union territory. The share of caesareans in private facilities is 81% for Assam, 84% for Telangana, and is an astonishing 90% for Jammu and Kashmir! The rates for public facilities are 17%, 48% and 49%, respectively, for the same states and the Union territory. Note that West Bengal has an overall caesarean birth rate of 45% — with 88% for private and 29% for public health facilities. This is especially worrying as the state’s per capita income is 20% below the national average. Since the preference for private clinics generally rises with income, there is a danger that relatively poor states like Bengal and Assam will end up with exceptionally high rates with development and urbanisation.

In short, the high rate of caesarean deliveries in Indian private healthcare facilities is well in excess of international norms that suggests commercial factors beyond medical necessity. A study conducted by IIM Ahmedabad in 2018 estimated nine lakh preventable, unplanned caesarean deliveries in private hospitals in India in 2016. The problem has clearly grown manifold.

The disparity in hospitalisation charges is a likely source of the problem. A report published in 2026 by the ministry of statistics and programme implementation found that average medical expenditure per childbirth in a private health facility is Rs 39,381 compared to Rs 2,316 in a public health facility. Moreover, the study found that a caesarean delivery in a private health facility costs almost 90% more than a normal delivery in the same facility. It should also be noted that commercial incentives are not only related to the difference in pricing. Caesarean surgeries are usually planned and can be conveniently scheduled unlike the uncertainty of vaginal births. This allows for more efficient revenue-extraction from a given facility.

The rate of caesarean births has gone up significantly in many developed and developing countries around the world (it is 45% in the United Kingdom; 41% in China; 57% in Brazil; 32% in the United States of America) and has triggered a global debate. In this context, it is interesting to note that the Nordic countries continue to have relatively low caesarean rates even at very high per capita incomes: Norway 16.3%, Iceland 14%, Sweden 20%, Denmark and Finland 20.3%. Also note that they enjoy among the lowest maternal and neonatal mortality rates at childbirth. The secret is a midwife-led continuous care system that opts for surgical intervention only when medically necessary. Moreover, there is encouragement for vaginal birth even after a previous surgical birth. This disincentivises unnecessary interventions.

Interestingly, there are some Indian states where caesarean births have spread slowly despite rising per capita income and urbanisation. For instance, Gujarat has an overall caesarean rate of 29%, with 40% for private and 16% for public facilities. More research is needed to understand the exceptions but a possible explanation may be the state’s Chiranjeevi Yojana, a public-private partnership aimed at poorer families, that pays hospitals a fixed rate for births irrespective of the type of method. The flat fee neutralises the incentive problem.

Although private facilities play an important part in the healthcare ecosystem, the NFHS-6 data remind us that a completely free market may not lead to optimal outcomes for healthcare given the asymmetry of information between the patient and the healthcare provider about the need for an expensive intervention. This is true of all health-related services but childbirth is such an important life event, it leaves parents in a particularly vulnerable situation.

The good news is that there is a growing global movement, backed by WHO, to bring back midwifery-based care systems and discourage excessive caesareans. In 2018, the Indian government started a National Midwifery Initiative and created the Nurse Practitioner in Midwifery cadre. It includes a dedicated 18-month course focused on core clinical training as well as a hands-on internship. The initiative is still being rolled out in the states and it is too early to judge its impact. The issue of spiralling caesarean rates, meanwhile, is a particularly stark reminder of the need for tighter regulation of the healthcare sector and for the provision of public facilities.

Sanjeev Sanyal is member, EAC-PM. Payal Sharma is a young professional, EAC-PM. All opinions are personal