One in two women who go to a private hospital undergoes a Caesarean section (C-section) to deliver a child, according to the latest National Family Health Survey (NFHS) data.
The increasing trend in private medical facilities, which have seen a rise in such operations from 40.9% to 47.4%, has led to a jump in pan-India numbers with total C-sections increasing from 17.2% in 2014-2015 to 21.5% in 2019-2020, according to NFHS-5. This means that one in five women who go to any medical facility, private or public, undergoes a C-section.
When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. According to WHO, the ideal rate of C-sections is between 10% and 15%. When the rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10%, there is no evidence that mortality rates improve.
There are many States and Union Territories where private hospitals conduct seven or eight out of 10 deliveries through C-section. These include West Bengal (82.7%), Jammu and Kashmir (82.1%), Tamil Nadu (81.5%), Andaman and Nicobar (79.2%) and Assam (70.6%). While many of these States have had a poor record in the past too, there are many others that have seen a big jump in such surgeries.
These include Assam (17.3 percentage points increase to 70.6%), Odisha (17 percentage points 70.7%), Punjab (15.8 percentage points to 55.5%), Tamil Nadu (12.5 percentage points to 63.8%) and Karnataka (12.2 percentage points to 52.5%). As many as 26 States and UTs have shown a rise in surgeries in private hospitals.
C-section deliveries have also increased in public hospitals, but this could partly be due to an increase in institutional deliveries in such facilities from 52.1% in 2014-2015 to 61.9% in 2019-2020. States with the biggest surge across public health facilities were Sikkim (12.3 percentage points to 30.4%), Punjab (12.1 percentage points to 29.9%), Goa (11.6 percentage points to 31.5%), Chandigarh (10.9 percentage points to 30.4%) Tamil Nadu (9.7 percentage points to 36%).
C- section rates rose from 11.9% to 14.3% for public health facilities across the country. At the other end of the spectrum is Bihar, which has only 4% C-sections in public health facilities, indicating inability to provide critical care to prevent maternal and infant deaths.
There are different factors at play for the rise in caesarean operations in private hospitals and in public hospitals, say experts.
Women having babies at a later age, increase in in-vitro fertility and sedentary lifestyle of mothers are some of the reasons for the rise in these operations. “There are also caregiver and hospital factors. Doctors doing solo-practice and delivering 20-25 babies in a month can’t stay awake in the night so they prefer to schedule an operation. As far as corporate hospitals are concerned, there is an emphasis on more numbers and doctors spending 20-30 days on 10 deliveries is frowned upon,” says Dr Rinku Sengupta Dhar, Consultant and Head, Maternity Programs, Sitaram Bhartia Hospital.
Public hospitals see a rise in C-sections because of poor doctor-patient ratio and concentration of high-risk pregnancies at one place with less doctors and less caregivers.
Different interventions are needed for public and private hospitals as well as for different parts of the country, says Subashri Balakrishnan, member, Common Health- a coalition for maternal health and safe abortions.
“C- section audits must be strictly enforced in public hospitals, whereas in private sector there is a need to check widespread commercialisation by regulating medical practices and costs. But there are also States with an unmet need for C- sections where they are needed to prevent maternal deaths and poor foetal outcomes. For example, Bihar has only 4% C-sections in public hospitals. Such States need an overall improvement in the health system such as more number of anesthetists and specialists, blood banks, etc.”