C-Sections Drop In Public Hospitals But Rise In Private Ones; West Bengal, Telangana See Highest

At the national level, cesarean deliveries in public hospitals declined from 15.5% in 2016 to 14.3% in 2021. Private hospitals recorded an increase from 45.4% to 47.5%.

Cesarean deliveries in India are moving in two opposite directions, declining slightly in public hospitals while rising steadily in private facilities, a new nationwide study based on National Family Health Survey (NFHS) data has found.

According to the study published in the journal PLOS Global Public Health, more than nine out of ten childbirths in private hospitals in West Bengal’s Murshidabad and Nadia districts are conducted through cesarean sections — the highest rates recorded anywhere in India. Additionally, the study notes that over 91 per cent of child deliveries occur in private facilities in Karimnagar, Telangana.

The study examined cesarean deliveries among first-time mothers with singleton births across all 36 states and union territories, as well as 720 districts, between 2016 and 2021. It found that while public hospitals have seen a slight decline in cesarean deliveries over this period, private hospitals have continued to record rising rates, deepening regional and sectoral disparities.

Public hospitals see a marginal fall, private sector continues to rise
At the national level, cesarean deliveries in public hospitals declined from 15.5 per cent in 2016 to 14.3 per cent in 2021. In contrast, private hospitals recorded an increase from 45.4 per cent to 47.5 per cent over the same period.

“This study identified 4 major findings. First, at the national level between 2016 and 2021, the prevalence of births delivered by cesarean section slightly decreased in the public sector by 1.2 per cent while it rose by 2.1 per cent in the private sector," the study stated.

It also noted that, “Interestingly, for public hospitals, even in the low-prevalence states, the prevalence has decreased (or is almost stagnant), indicating a need to strengthen public facilities for at least necessary cesarean births."

State-wise patterns show sharp contrasts
Telangana and Jammu and Kashmir consistently reported the highest cesarean rates in both public and private hospitals. In private facilities, cesarean rates in Telangana crossed 80 per cent in 2021. At the other end, states such as Bihar, Jharkhand and Uttar Pradesh continued to report very low cesarean prevalence in public hospitals, while Rajasthan recorded the lowest rates in private hospitals.

State boundaries explain C-section trends more than districts or villages
The study found that where a woman lives plays a larger role in determining cesarean deliveries than district- or village-level factors.

In the study, the three geographies refer to villages or urban blocks (the smallest sampling units in the survey), districts, and states, with state-level differences accounting for the largest share of variation in cesarean deliveries.

“Across all three geographies, interstate variation in cesarean section prevalence was the highest and has further increased over time," the researchers, affiliated with Harvard Center for Population and Development Studies and Centre for Research in Wellbeing and Happiness, FLAME University, Pune, wrote.

In private hospitals, “the state-level variance partitioning coefficient increased from 69.2 per cent in 2016 to 78.2 per cent in 2021," while in public hospitals, “it rose from 44.7 per cent to 48.6 per cent during the same period."

The analysis also showed that districts with high cesarean rates in 2016 continued to show high rates in 2021. “Districts that exhibited higher cesarean section prevalence in 2016 continued to show higher prevalence in 2021, indicating lesser improvements in high-prevalence districts," the study said.

Southern states such as Tamil Nadu, Telangana and Kerala had nearly all districts falling into the high-prevalence category. In private hospitals, states such as Telangana, West Bengal, Assam and Andhra Pradesh were “predominantly characterised by districts with high cesarean section rates."

Health risks, rising costs and urgent need for regulation
The study warned that unnecessary cesarean sections pose serious health and economic risks. “Unnecessary cesarean surgeries pose significant short and long-term risks, affecting fertility, future pregnancies, and child health outcomes," the study stated, adding that timely monitoring is crucial “to mitigate additional health and economic burdens."

Explaining the surge in private hospitals, the study noted that, “The substantial increase in cesarean section prevalence within private healthcare facilities, which is almost double compared to public facilities," may reflect “mothers’ preference for a less stressful delivery process and the desire to schedule births at auspicious times."

It also pointed to “better facilities managing high-risk deliveries, shortages of specialists in public hospitals, and expanded insurance coverage through Ayushman Bharat, which encouraged more surgical interventions."

The findings highlight the absence of uniform standards across states. “The elevated interstate disparities are reflective of a comparatively higher prevalence of institutional births (especially in the private sector) in southern states, which is critical since the likelihood of C-section is significantly greater in private facilities," the authors said, calling for stronger regulation of private healthcare, standardised protocols, and improved public-sector capacity to ensure cesarean sections are performed strictly based on medical necessity.

The authors added that one of the limitations of the study is that NFHS has used the sampling frame of the 2011 Census for sampling. “The data is available for 640 districts for 2016. However, in 2021, there were more than 700 districts. However, we believe that the same trends in multi-level variation will remain."

Authors: Prof. Sunil Rajpal, Faculty of Economics, FLAME University; Shreya Ronanki, FLAME Alumna; Nehantha Sathesh, FLAME Alumna; Prof. S. V. Subramanian, Professor of Population Health and Geography, Harvard University; Prof. Rockli Kim, Professor, School of Health Policy and Management, Korea University.