Why Caesarean section deliveries are rising at an alarming rate in India

In the sultry summers of northern India, a Haryanvi farming family was trying to take their 22-year-old daughter-in-law to the city hospital after the community health centre in the district town near their village said it could not help. The woman had developed a complication known as preeclampsia, a high blood pressure disorder that usually occurs after 20 weeks of pregnancy.

“By the time she reached us in Gurgaon, her condition had worsened. The baby died, and the mother was in the intensive care unit,” says the doctor who attended to her.

If treated on time, the baby would have lived, the doctor says, adding that an early delivery, through a caesarean section surgery, one in which the baby is delivered through the abdomen and uterus, would have helped a great deal.

Pregnancy-related complications are one of many reasons why C-sections are burgeoning in India. IIT Madras researchers report a sharp uptick across the country from 17.2 per cent to 21.5 per cent in the five years to 2021. In the private sector, the C-section rate was 43.1 per cent in 2016, rising to 49.7 per cent in 2021 -- nearly one in two deliveries.

According to the National Family Health Survey (NFHS), 32.3 per cent of urban Indian births involve surgery. The figure is lower, at 17.6 per cent, for rural India, but both urban and rural surgeries have risen sharply, leading to an overall rise from 8.5 per cent of all births in 2005-06 to 21.5 per cent in 2019-21 (Chart 1) .

Many factors

“In urban areas, more women are delaying their pregnancies, which carry a higher risk of complications. Moreover, people opt for one or two children at best, which makes the pregnancy very precious and no one wants to take any risks,” says Astha Dayal, Lead consultant, Obstetrics and Gynaecology, CK Birla Hospital, Gurugram. “Even if there is a slight drop in the heartbeat of the child, no one wants to take a risk,” Dayal says.

In rural settings, lack of monitoring often leads to not knowing the potential risks that may arise at the time of delivery.

Alka Kriplani, Chairperson-Obstetrics, Gynaecology & ART, at Paras Hospitals, says several cases of neglected deliveries land up at government medical colleges. “There is no option left but to go for a C-section.”

Kriplani cites low lying placenta of the mother, foetal growth restriction, obstructed or prolonged labour, any form of foetal distress, breech presentation, severe anaemia, etc, as the reasons why a doctor would opt for a C-section.

The cost differential between a natural birth, through the vagina, and C-section is not much. In cities, it is Rs 30,000 to Rs 40,000. For the additional cost, families often get to choose date, time, and outcome.

“If there is even a slight delay or any complication in taking the baby out, lack of oxygen supply to the brain can cause permanent damage,” says Uma Vaidyanathan, Senior Consultant, obstetrics and gynaecology, at Fortis Hospital Shalimar Bagh.

Significantly, the proportion of those with pregnancy complications decreased from 42.2 per cent to 39.5 per cent, implying that the increased rate of C-section delivery was largely influenced by non-clinical factors. Women's own preferences, their socio-economic level and education, and risk-averse physicians practising conservative medicine could be some of these non-clinical factors, says the IIT Madras study.

Not only in India

Kriplani points out that it is not just India, globally almost a third of all deliveries are C-sections.

A World Health Organisation (WHO) report in 2021 said worldwide caesarean section rates had risen from around 7 per cent in 1990 to 21 per cent today, and were projected to continue increasing over the current decade.

According to the National Institute of Health and Care Excellence (NICE), UK, the factors that lead to caesarean births include higher maternal age and body mass index. Common indications for emergency caesarean births are slow progression of labour or concern about the foetal condition.

Dayal says doctors typically follow the NICE guidelines when taking the clinical decision on whether to opt for a C-section.

IVF a factor?

Vaidyanathan mentions in vitro fertilization as one of the factors. IVF is a complex series of procedures to which couples usually take recourse at a relatively advanced age, leading to late pregnancies that are associated with higher risks. That this is also a precious pregnancy, attained after much time and effort, couples want to eliminate risk to the extent possible, and therefore opt for the C-section, though not all IVF pregnancies need it.  

However, Kshitiz Murdia, CEO and Co-Founder, Indira IVF, does not agree. “In India, more than 20 million childbirths happen every year. Around 300,000 IVF cycles happen in the country every year. Even if we assume that 50 per cent of these are a success, it is not more than 150,000 IVF deliveries. This number is too small in the overall scheme of things,” he tells Business Standard.

Several doctors say that private hospitals, at least the large corporate chains, have provisions for special consent from patients in case they want to opt for elective C-sections. “We don’t take clinical decisions based on the whims and fancies of patients, but in case someone positively wants to go for a C-section birth they have to sign a special consent form saying they are opting for a C-section though their doctor has not recommended it,” Dayal says. (Chart 2)

Ian Askew, Director of WHO’s Department of Sexual and Reproductive Health and Research, said in the 2021 report that not all the caesarean sections carried out at the moment are needed for medical reasons. 

Good news

In a positive turn of events institutional deliveries are rising in India. This has helped the maternal mortality rate. More than half of deliveries took place in the woman’s own home in the five years leading up to the government’s NFHS third round in 2005-06 (NFHS-3). Nearly 90 per cent of deliveries were in an institutional setting when the survey was repeated in 2019-21.

The maternal mortality rate in India has been declining because of more access to medical facilities. Around 254 women died for every 100,000 live births between 2004 and 2006, shows government data. This dropped to 97 in 2018-20. However, this is still higher than in most emerging and large economy peers (Charts 3,4).