Cutting Edge Births: Is there a developing epidemic of Cesarean Sections in India? 

Cesarean Section is a surgical intervention that is used in childbirth to deliver a baby or babies. In this instance, a surgery is performed to open the abdomen and uterus of the pregnant woman and the baby is delivered through this opening.

Delivery and Childbirth by Cesarean section may be a planned procedure or may be done as an emergency due to complications to the mother or baby during pregnancy. When planned, the indications for a cesarean section may include prior delivery or childbirth by cesarean sections, abnormal presentations or lie of the baby, multiple pregnancy (more than one baby is present), medical complications for the mother or the baby.  Sudden deterioration of the health of the mother and/or baby may require an emergency cesarean section. In addition to that, there is also a maternal demand for cesarean section based on the convenience of the mother or family (and doctor) including the consideration of auspicious times/dates.

Cesarean sections are not without complications although they offer several benefits.  The World Health Organization (WHO) considers a cesarean rate of 10-15% as ideal for a country (In other words, an ideal rate is that up to 10 to 15 out of every 100 pregnant women deliver a baby through a cesarean section). The WHO states that the number of maternal and newborn deaths decrease when cesarean section rates rise towards 10% across a population. There is not much of a benefit when the Cesarean section rates rise more than 10%. The WHO also recommends the use of a standardized classification system (Robsons Classification) to estimate the rates of cesarean section.

In India, The National Family Health Surveys (NFHS) provides information on the population, health, and nutrition, for each state and union territory. The fourth round of these surveys, The NFHS-4, was carried out in 2015-16 and fact sheets on key trends and indicators is currently available online.

We looked at these fact sheets to explore the trends in cesarean sections across India.

The overall cesarean section rate in India has increased to 17.2% in 2015 from 8.5% in 2003 and is just over the WHO recommended rates. 40.9% of deliveries in the private sector were through a cesarean section compared to 11.9% in the public sector.

State wise Rates of Cesarean Section based on the NFHS-4

Total CS 2015

Only 9 (25%) of the 36 states and Union Territories in India have a CS rate lower than 10%. If we consider a 15% cutoff, 14 (39%) of the 36 states and Union Territories in India have a CS rate lower than recommended. The state of Telengana has a very high rate of Cesarean Sections, 58% !


Cesarean Section Rates (NFHS-4) by Urban Rural Areas

Urban Rural CS

The Cesarean Section rates are significantly higher in urban areas compared to rural areas. The urban rural gap was smaller for Kerala and Punjab and was reversed (more in rural areas than urban) for Puduchery and Daman and Diu.

Cesarean Section Rates by Public and Private Facilities

CS by Facility 2015

The rates of cesarean section are much higher in the private sector compared to the public sector. Kerala was the only state that showed nearly similar rates for cesarean section in the public and private sector

Cesarean Section Rates (NFHS 4) compared with 2003

Comparison of 2015 CS rates with 2003

CS facility 2015 compared with 2003

Compared to 2003, there is an increasing trend towards Cesarean section rates. The CS rates in the public sector have reduced for most states and UTs compared to 2003, however, except for Himachal Pradesh, the CS rates in the private sector has increased from 2003.

What do we need to consider?

  1. The data shows an increasing trend towards delivery by cesarean sections
  2. The trends are more marked in the private sector
  3. The trends are more marked in urban areas
  4. The trend has led to India now having more than the WHO recommended rates for Cesarean Section
  5. 75% of the states and UTs in India have rates that are higher than the WHO recommended standards
  6. These data are not explored to find out reasons for these trends and hence we do not make any speculations on that.

If you are a researcher or a policy maker

  1.  The reasons for the increasing trends and their impact (medical, personal, social, economic among others) are to be carefully studied and documented. These may be
    1. Personal (individual) decisions,
    2. Medical reasons,
    3. Effects of other policies or practices including
      1. Economic incentives or reimbursement,
      2. Hospital based deliveries,
      3. Insurance payouts,
      4. Maternal Leaves and Work Security, and
      5. Even improved diagnostic capabilities for the early identification of problems in the pregnant woman or baby.
    4. Effects and consequences of the changing rates of CS. A risk benefit estimation that does not limit itself only to medical outcomes will be useful.

If you are a pregnant woman, consider

  1. Discuss the need for a cesarean section with your doctor
  2. Understand the risks and benefits and its potential influence on subsequent delivery and development of the child
  3. Find out from the doctor their CS rates for the women they take care of
  4. Make an informed decision

If you are a healthcare helping pregnant women and engaged in childbirth, consider

  1. Does this woman really need a cesarean section
  2. Document the indications, try to group indications based on the Robsons Classification
  3. Document the outcomes (short and long term) for the mother and baby
  4.  Estimate the rates for your facility or practice
  5. Understand your rates, indications, outcomes.
  6. Keep yourself updated on diagnostic criteria and methods and interpretations of these.
  7.  Discuss with your peers.



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