C-sections more likely in private hospitals than government ones, finds IIT Madras study

A C-section is a surgical procedure that involves making an incision in the mother’s abdomen to deliver the baby. “When medically justified, the procedure can be lifesaving. When not strictly necessary, however, it can cause several adverse health outcomes, lead to unnecessary expenditure, and place a strain on scarce public health resources,” the researchers said in a statement.

With April being Caesarean Awareness Month, we delve into the findings of the study and the possible reasons for the increasing number of C-sections today.

Also Read: Young, obese women at higher risk of surgical site infections after C-section

Findings of the study

In an in-depth analysis of Tamil Nadu and Chhattisgarh, the researchers found that despite both pregnancy complications and high-risk fertility behaviour being more prevalent in Chhattisgarh, Tamil Nadu recorded a higher prevalence of C-sections.

“Factors that could contribute to adverse birth outcomes and possibly justify C-sections (such as the mother’s age being less than 18 years or greater than 34 years, the interval between births being less than 24 months or the child being the fourth or more born to the mother) are considered high-risk fertility behaviour,” the university explained.

Prevalence of C-Section deliveries across the states of India (NFHS-4 and NFHS-5). (Study)

Elaborating on the importance of these findings and their implications for health policymakers in the country, Prof VR Muraleedharan, one of the researchers, said, “A key finding was that the place of delivery (whether the delivery was in a public or a private facility) had the greatest impact on whether the delivery was by C-section, implying that ‘clinical need’ factors were not necessarily the reason for surgical deliveries. Across India and Chhattisgarh, the non-poor were more likely to opt for C-sections, while in Tamil Nadu, the case was surprisingly different, as the poor were more likely to have C-sections in private hospitals.”

The study found that the prevalence of C-sections across India increased from 17.2 per cent to 21.5 per cent between 2016 and 2021. “Interestingly, across regions, almost half or more of deliveries in the private sector (49.7 per cent in India, 58.9 per cent in Chhattisgarh, 64.2 per cent in TN) were C-sections, much higher than the 16.1 per cent, 9.7 per cent, and 38.9 per cent in the public sector in India, Chhattisgarh, and TN respectively, as per NFHS-5,” the study noted.

In the private sector, these numbers stood at a whopping 43.1 per cent (2016) and 49.7 per cent (2021), meaning that nearly one in two deliveries in a private hospital was a C-section.

According to the World Health Organization (WHO), the recommended rate for C-sections to be between 10 per cent and 15 per cent. As per the study, 28 out of 36 states and Union Territories in India exceeded the 15 per cent upper limit.

Speaking to South First, Dr Vijaya Krishnan, Director and Co-founder of Hyderabad-based The Sanctum Natural Birth Center, says, “What is alarming is that India has tripled its Caesarean rate, starting from around 2005-2006 to the last NFHS survey, which is around 23 per cent. When you compare the increase in C-section rates worldwide, India is doubling the world average of the rate of increase in C-sections.”

She adds, “Why is the rise in C-section rate so alarming? The C-section rates worldwide are seen as a global quality of maternity care indicator. In India, as in many developing countries, there is a dichotomy — there is ‘too much, too soon’, meaning ample access to services, and there is ‘too little, too late’, meaning fewer resources and less access to services.”

She points out that this is exactly what the article highlights. “It talks about the increase in two very disparate regions — Chhattisgarh and Tamil Nadu. In both regions, the increase is primarily seen in the private setting. However, in Tamil Nadu, it is worrisome that the ‘poor’ seem to be at a higher risk of a C-section,” she says.

Also Read: Implementing WHO guidelines can cut unnecassary C-section deliveries

Possible reasons for the high numbers

The researchers found that better-educated women living in urban areas were more likely to deliver via C-section, suggesting that greater autonomy and better access to healthcare facilities play a role in the increase in prevalence of C-sections, the statement noted. As per the study, “those who had completed a higher education were 1.2 times more likely in India and 1.9 times more likely in Chhattisgarh to have delivered via a C-section.”

Across regions, the majority of women had a normal BMI, but the study noted that there is a marked difference in the proportion of overweight or obese women (1.6 per cent in Chhattisgarh as compared to 12.9 per cent in TN in NFHS-5). A majority of the respondents said they had given birth to average-sized babies. Most (60.5 per cent in India, 66.8 per cent in Chhattisgarh and 69.3 per cent in TN) said they had no pregnancy complications, as per NFHS-5.

The analysis also showed that maternal age is significantly associated with Caesarean deliveries. The odds of having a C-section increased with the age of the mother and are 2.1 times for women in the 35–49 bracket when compared to those aged 15–24.

Significantly, the proportion of those with pregnancy complications decreased from 42.2 per cent (in 2016) to 39.5 per cent (in 2021), implying that the increased rate of C-section 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,” the researchers noted.

Commenting on this, Dr Vijaya says, “The age factor, the education factor, the wealth factor, and the BMI factor are all factors that have been talked about at the global level in research. However, Dr Eugene Declercq’s study tells us that these factors alone cannot account for the alarming increasing C-section rates.”

She highlights that one of the other things that the study also reminds us is that other than practitioner preferences, women’s wealth status, the family’s wealth status is also one of the indicators of increased Caesarean rates, probably because they can pay out-of-pocket, especially in the private sector, as well as a fear of childbirth and the pain associated with childbirth.

“Many organisations have pointed out that this fear can be reduced with good information exchange, both during antenatal check-ups and childbirth education classes, which are meant to empower and educate a woman and her family about her own body’s ability to manage labour and also the short-term and long-term risks of a C-section,” Dr Vijaya, an Internationally Certified and Licensed Professional Midwife, says.

To the list of non-medical reasons for a C-section, she adds, “Muhurtham Caesareans are also on the rise. An article in 2023 pointed out that in the state of Telangana, one of the major factors for the rise in C-sections was choosing an auspicious day to bring the baby earthside.”

Also Read: Telugu states have high prevalence of high-risk pregnancies, says study

Private vs public healthcare

Overall, in India, women delivering at private hospitals were four times more likely to have a C-section (noted over the period of study between 2016-2021). In Chhattisgarh, women had a ten-times higher chance of delivering by C-section in a private hospital, while in Tamil Nadu, they had a three-times higher chance.

“This could be due to a lack of adequate infrastructure in public healthcare facilities,” the researchers highlighted.

Proportions of C-sections in the Public and Private Sectors for NFHS-3, 4 and 5. (Study)

The study observed that “Tamil Nadu is lauded as a model for public health care delivery in India with 100 per cent of the prescribed number of Community Health Centres (CHCs) functional and a 39 per cent shortfall in the sanctioned number of obstetricians and gynaecologists, while Chhattisgarh has 80 per cent of the required CHCs and a 77 per cent shortfall.”

Dr Vijaya says, “The institutionalisation of childbirth has led to better neonatal morbidity and mortality statistics, however, it has failed to show the same kind of incremental improvement in maternal mortality and morbidity statistics. But with the institutionalisation of childbirth has come a remarkable increase in the Caesarean trends. And while this trend is seen worldwide, in India, it is almost unchecked, especially in private facilities where there are almost no checks and balances.”

On a positive note, the number of antenatal visits is on the rise across the country, as is women’s literacy, leading to greater opportunities for patient education on the adverse effects of unnecessary C-sections, the study noted.

“So, what can be done to reduce the C-section numbers nationally? The first step is to improve the understanding of women and families about the short-term and long-term risks C-sections pose. The second would be to educate and empower them that the pain of labour has a purpose and that it was meant to be hard but it was always meant to be safe. Thirdly, India needs good government oversight and mandatory reporting from all facilities to ensure better awareness and remedial steps to decrease interventions and Caesareans,” says Dr Vijaya.

Advocating for the growth of midwifery in India, she says, “It is time for a robust midwifery cadre that can take care of 85 per cent of the population who is healthy, normal, and low-risk, where the obstetrician comes in only for those 15 per cent of cases where there is either complex needs or when a true emergency arises.”