Opinion
The rise of C-sections reflects a booming birth business
Summary
- A rising trend of surgical intervention in childbirth calls for action that Indian states must take
Contrary to popular belief, the term ‘Caesarean section’ is not directly named after Julius Caesar, although he is thought to have been born through this procedure. The modern use of the technique would likely astound the Roman general. C-sections are performed for various reasons, often categorized as medically advised, elective and recommended (possibly with a profit motive). The first kind are crucial for the safety of both the mother and baby, such as when vaginal delivery poses risks of foetal distress and/or maternal health complications. Elective C-sections are those chosen by the mother for reasons that are not strictly medical, such as personal comfort or scheduling considerations.
Some doctors, however, are criticized for advising C-sections with financial incentives in mind, given that these procedures are more expensive than natural births. This last category is especially problematic in India, where their rate has been rising, raising concerns about unnecessary medicalization of childbirth. According to the National Family Health Survey (NFHS), C-section deliveries leapt from 17.2% in 2015-16 to an unsettling 21.5% in 2019-21. In private hospitals, the statistics are even more disconcerting, with nearly half of all deliveries—48% to be exact—performed this way. This marks a significant rise from an already high 41% in 2015-16. The World Health Organization pegs the ideal C-section rate at 10-15% of all births in a country.
There is a discernible disparity in the rates of C-section deliveries and hysterectomies across Indian states, as highlighted by NFHS-5 data. Telangana, Tamil Nadu, Andhra Pradesh, Jammu and Kashmir and Goa have notably high C-section rates, with Telangana topping the list at 60.70%. On the other end, Nagaland records a mere 5.2% rate. On hysterectomies, Andhra Pradesh, Telangana, Bihar and Ladakh show elevated figures. The disproportionately high numbers in some states raise concerns about a potential institutionalized C-section trend among private hospitals that might be driven by factors beyond medical necessity.
In most cases, the agency of the woman is generally compromised. While medically advised C-sections are usually unavoidable, the line between elective and profit-motivated recommendations is sometimes blurry. Women may feel pressured to opt for one without full information from healthcare providers, thus compromising their autonomy in childbirth decisions.
The surgical procedure can have both short- and long-term implications for women’s and children’s health. A study published in Lancet found that women who undergo C-sections are likelier to experience complications such as uterine rupture, problematic placentation, ectopic pregnancies, stillbirths, and pre-term births, with these risks escalating with each subsequent C-section. Infants delivered this way are exposed to different hormonal, physical and microbial environments than those born vaginally, which in the short-term increases their vulnerability to immunity-related problems, allergies, asthma and illness from reduced gut microbiome diversity. While the long-term risks are not as thoroughly studied, there is a correlation between C-section deliveries and the incidence of obesity and asthma in later childhood.
C-sections are costly. A conservative estimate by Rema Nagarajan show that the annual excess expenditure on it in India is about ₹5,000 crore. This assumes that only 17% of all such deliveries are medically necessary, with the rest adding up to extra costs. It takes into account the costs of C-sections indicated in the National Sample Survey 75th round for 2017-18 (i.e., ₹16,475 higher than a natural childbirths in rural areas and ₹19,548 higher in urban settings). The NSS data reveals that private hospitals charge 6-7 times more, and this ratio may have changed since.
An all-India uptick in institutional deliveries appears to be linked with an increase in C-sections, raising questions about what motivates these recommendations. The growth of private and government-backed insurance schemes creates a financial safety net for patients, but it also inadvertently incentivizes doctors to recommend more expensive procedures. Knowing that insurance will cover the costs may lower the barrier for decision-makers to opt for this more costly surgical approach, even when not medically necessary. This not only has potential health risks, but also puts an unnecessary strain on healthcare resources.
Health being a state subject, the onus of curbing this trend lies with the state. On its part, the Union government has undertaken several measures. Advisories have been sent to state and Union territory health officials and the Federation of Obstetrical and Gynaecologists in India, urging them to adhere to WHO guidelines on C-sections. Further, a CS audit initiative called LaQshya has been rolled out in public hospitals to ensure judicious use of the procedure. Additionally, both public and private facilities are monitored for C-section rates through the Health Management Information System, with high rates flagged to states for review.
This trend of high C-sections not only reflects a disservice to women’s choice and well-being, but strains healthcare resources. It shakes the pillars of trust and prudence that should define medical care, replacing them with a transactional culture that does not suit childbirth . States should act.
These are the authors’ personal views.
