The research uncovered revealing insights into provider motivations, an area that only a few studies have previously explored.
Published Aug 31, 2025 | 7:00 AM ⚊ Updated Aug 31, 2025 | 7:00 AM
Synopsis: Rising C-section rates in South Asia call for immediate action across multiple levels of the healthcare system. Experts stress that change will require coordinated efforts involving women, healthcare providers, and policymakers. Strengthening antenatal counselling and public awareness campaigns can empower women to make informed decisions based on medical necessity rather than convenience or social pressure.
Consider an imaginary expectant mother named Priya—a software engineer from Hyderabad who discovered she was pregnant with her first child. In her urban, educated circle, the decision seemed clear-cut: a caesarean section would be safer, more convenient, and less painful than natural childbirth.
Her husband’s higher education status, their comfortable financial position, and health insurance coverage that included reimbursement for surgical procedures all pointed toward the operating room rather than the delivery ward.
This hypothetical scenario reflects a sweeping transformation across South Asia, where caesarean section rates have skyrocketed far beyond medical necessity, creating what researchers are calling a dual burden of inequitable maternal care.
A study published in The Lancet Regional Health – Southeast Asia reveals that the region now faces both “too little, too late” for women who lack access to medically necessary interventions and “too much, too soon” for those receiving unnecessary surgical deliveries.
The statistics paint a picture of dramatic change across the subcontinent. According to NFHS-5, in India, caesarean rates have surged from just 8.5 percent in 2005 to 21.5 percent in 2021, with private hospitals now performing surgical deliveries for nearly half of all births at 49.7 percent. The Southern states in India lead this trend, with Telangana recording the highest rate at 60.7 percent of all births, followed by Tamil Nadu at 44.9 percent and Andhra Pradesh at 42.4 percent.
The regional pattern extends beyond India’s borders. Bangladesh witnessed an even more dramatic leap from 18 percent in 2011 to 45 percent in 2022. Pakistan’s rates climbed from a modest 3.2 percent in 1990 to 20 percent in 2018, while Sri Lanka saw increases from 32.1 percent in 2014 to 44.4 percent in 2023.
These figures far exceed the World Health Organization’s recommended threshold of 10-15 percent for population-level caesarean rates.
What drives a mother to choose surgery over natural birth? The answer lies in a complex web of personal, professional, and systemic factors that researchers have mapped using a socio-ecological framework spanning individual, community, provider, and organisational levels.
“The findings indicate that CS rates are influenced by a range of factors operating at the level of women, community, healthcare provider, and health system levels,” the study reads, highlighting the multi-layered nature of this healthcare challenge.
At the most personal level, demographic patterns emerge with striking consistency. “Maternal characteristics such as higher socioeconomic status, education level, urban residency, advanced maternal age, higher birth order, and obesity were consistently associated with increased CS rates,” the study found.
These factors paint a clear picture of who is most likely to undergo surgical delivery across South Asia.
But the influences extend far beyond medical factors. In today’s connected world, “studies highlighted the role of media exposure, familial and community norms, and maternal employment status in shaping delivery preferences,” the study said.
Access to internet, phones, and television often portrays caesarean sections as safer or more modern, influencing maternal perceptions and preferences.
The study noted that “several individual-level factors consistently associated with CS may reflect broader patterns in care access, expectations, and provider interaction.”
The research explained that “higher education and socioeconomic status may be associated with greater autonomy, access to private care, or perceptions of safety. Urban residence and maternal employment could reflect preferences for scheduled deliveries due to work or household constraints.”
Family dynamics add another layer of complexity. Husbands with higher education levels, employment status of expectant mothers, religious beliefs, and previous childbirth complications all weave into the decision-making fabric. Community norms and pressure from family members create socio-cultural expectations that can override medical recommendations.
Perhaps most significantly, health insurance coverage emerges as a powerful influence, making caesarean procedures more accessible and affordable for families who might otherwise choose natural birth. The presence of insurance often includes reimbursement for surgical procedures, fundamentally altering the economic equation of childbirth decisions.
On the provider side, the picture becomes more troubling. “Factors related to healthcare providers included the convenience of scheduling, financial incentives, and concerns regarding legal repercussions, which were reported as influencing the decision to perform CS,” the study documented.
The challenge of night-shift deliveries, security concerns, and the desire to avoid unpredictable timing of natural labor all push doctors toward planned surgical procedures.
Financial incentives create additional pressure. Fee-for-service models and reimbursement structures can influence clinical decision-making regarding delivery methods, particularly in private facilities where business models focus on patient volume and revenue.
The stark difference in costs reflects this reality: families spend an average of ₹44,000 for a caesarean in Indian private hospitals compared to just ₹8,800 in public facilities.
Fear of litigation adds another dimension to provider decision-making. Concerns about legal action and patient safety drive healthcare professionals toward what they perceive as defensive medical practices.
The organisational and system-level factors reveal perhaps the most concerning aspects of the caesarean surge.
“At the health system level, private sector healthcare delivery, the lack of routine audits, insufficient staffing, and the presence of health insurance schemes were identified as contributors to rising CS rates,” the study found.
The dominance of private healthcare facilities emerges as a critical driver, with studies consistently showing that women attending antenatal care checkups or delivering in private settings face significantly higher likelihood of surgical delivery.
The study stressed that “understanding these associations within the care-seeking and health system context is essential for interpreting patterns in CS use across diverse settings.”
The research pointed out that “more ANC visits may increase exposure to provider or facility-level preferences for CS, particularly in private settings,” revealing how even routine prenatal care can inadvertently steer women toward surgical delivery.
This private sector influence is reinforced by several factors, including the considerable autonomy with which many facilities operate.
Angel Sudha Veparala, lead author of the study from the Institute of Public Health Bengaluru noted: “Our review found that C-section rates are generally higher in private facilities, and structured reporting or audits could help improve transparency, understand trends, and support appropriate care,” she told South First.
“The WHO has recommended specific interventions to reduce unnecessary C-sections, including conducting audits, implementing structured second opinions, and providing timely feedback to healthcare professionals. These are the kinds of measures that should be standard practice,” Veparala explained. However, variations in team structures and decision-making processes across facilities can make it difficult to apply audits and second opinions uniformly,” she added.
Infrastructure challenges compound the problem. Staff shortages, inadequate availability of obstetricians and anaesthetists around the clock, poor working conditions, and limited transportation options all create environments where caesarean sections become the path of least resistance.
The research uncovered revealing insights into provider motivations, an area that only a few studies have previously explored.
“One study from Delhi highlighted how systemic pressures influence provider decisions,” explained Veparala.
“Normal deliveries often require providers to be present with a woman for 15–18 hours, compared to around half an hour for a C-section. In facilities with limited staff, this makes it difficult to devote the necessary time to each mother. Additional challenges such as night duties without nearby childcare or safe transport further push providers toward choosing C-sections. These findings show how structural constraints, rather than individual preferences, shape such decisions,” the study noted.
When facilities lack the resources to properly support natural births, surgical intervention becomes an institutional default.
The use of monitoring technologies like cardiotocography can paradoxically increase caesarean rates by raising concerns about fetal well-being, leading to precautionary surgical decisions without clear clinical necessity. In resource-constrained settings, the interpretation of such monitoring often errs on the side of intervention rather than patience.
The review reveals a troubling paradox in South Asian maternal care. While caesarean rates soar among urban, educated, and wealthy women, many who genuinely need surgical intervention lack access.
Veparala explained this fundamental inequality: “There’s a clear pattern of underuse of C-sections among poor women who genuinely need them, while there’s simultaneously an overuse among wealthy women who may not require surgical intervention.”
Veparala detailed the geographic and economic dimensions of this disparity: “In urban populations, it’s relatively easy to access any private hospital and undergo a C-section, compared to tribal and remote areas where accessibility to this life-saving procedure is significantly limited.”
The data dramatically illustrates this point, as findings from one of the studies included in the review show: India faces an annual deficit of nearly half a million caesarean sections where women cannot access the procedure even when needed, while at the same time recording an excess of around 1.8 million caesareans performed unnecessarily. This points to the deep inequities in access and use across different states.”
This inequity extends beyond individual families to entire healthcare systems. The financial burden is staggering: following WHO guidelines could have saved India $293.36 million and prevented 1.67 million unnecessary caesarean deliveries in private facilities in just one year. For families, the out-of-pocket costs often push them into debt, particularly when complications arise or when they choose private over public care.
For affluent urban women, the decision-making process follows entirely different parameters.
“When we consider the socioeconomic status of urban women and their exposure to family and friends’ experiences, combined with their financial ability to pay for surgery, along with concerns about pain and the perceived convenience and comfort, the choice becomes much easier. This combination of factors explains why women with higher economic status increasingly prefer C-sections,” Veparala observed.
In India, data shows a shortfall of 0.5 million medically indicated caesareans among low-income women, while high-income women receive an excess of 1.8 million unnecessary procedures.
This inequity extends beyond individual families to entire healthcare systems. The financial burden is staggering: following WHO guidelines could have saved India $293.36 million and prevented 1.67 million unnecessary caesarean deliveries in private facilities in just one year.
For families, the out-of-pocket costs often push them into debt, particularly when complications arise or when they choose private over public care.
The health implications of unnecessary caesarean sections extend far beyond the delivery room. Newborns delivered by surgery face increased risks of asthma, obesity, type 1 diabetes, and allergic diseases later in life. For mothers, surgical delivery means longer hospital stays, higher risks of infections, potential uterine rupture, and complications in subsequent pregnancies.
These long-term consequences rarely factor into immediate decision-making, particularly when families focus on perceived safety and convenience of planned surgical delivery. The medicalisation of what is fundamentally a natural process has shifted cultural expectations and normalised surgical intervention.
Rising C-section rates in South Asia call for immediate action across multiple levels of the healthcare system. Experts stress that change will require coordinated efforts involving women, healthcare providers, and policymakers.
Strengthening antenatal counselling and public awareness campaigns can empower women to make informed decisions based on medical necessity rather than convenience or social pressure.
For healthcare providers, revisiting financial and professional incentives, improving working conditions, and reinforcing adherence to clinical guidelines can help ensure that surgical deliveries are reserved for cases where they are truly needed.
At the health system level, stronger regulation of private facilities, investment in staffing and infrastructure, and robust accountability mechanisms are essential to guarantee safe, equitable maternal care.
Regional collaboration and knowledge-sharing can also accelerate progress. By learning from best practices and promoting research into underexplored areas—such as organisational norms, professional hierarchies, and interventionist cultures—South Asian countries can develop policies that balance safety, access, and efficiency.
Veparala noted that taken together, these steps offer a path toward reducing unnecessary C-sections, improving maternal health outcomes, and safeguarding women’s reproductive rights across the region.
(Edited by Amit Vasudev)
