More than a quarter of India’s births now happen through Caesarean-section (C-section) deliveries, driven primarily by high rates of surgical intervention in private hospitals.
A part of this increase may reflect better access to emergency obstetric care, experts say. As more women deliver in health facilities, doctors are better able to identify complications that require surgical intervention. But coercion and commercialisation are to blame for unnecessary C-section deliveries, they say.
Nationally, the share of births by C-section increased from 21.5% in 2019-21 to 27.2% in 2023-24, according to the sixth National Family Health Survey (NFHS-6). In public hospitals, which see about three in five births, the rate is 17%. This is close to the globally accepted optimal level, said Kranti Vora, adding that it reflects their improved capacity to provide emergency obstetric care. Vora is a visiting faculty at the Society for Education, Action and Research in Community Health (SEARCH), which provides healthcare in Gadchiroli district.
But in private hospitals, 54% deliveries were by C-section. The World Health Organization (WHO), in a 2015 research note, said C-section rates above 10% do not reduce maternal or newborn mortality at the population level.
Conditions such as failure to progress in labour, foetal distress, placenta previa and breech or transverse presentation may necessitate a C-section delivery, explained Suchitra Pandit, consulting obstetrician and gynaecologist at Surya Hospitals in Mumbai. In addition, multiple pregnancies, severe pre-eclampsia, previous Caesarean sections, and maternal conditions such as obesity, diabetes and hypertension could also lead to the surgical intervention.
The WHO recommends Robson classification, a checklist of 10 obstetric parameters, to determine the need for a C-section. These include factors such as the history of a pregnancy and gestational age.
However, caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications, the WHO warned.
The medical imperative
Harshada (name changed), a 35-year-old kindergarten teacher, first conceived through in-vitro fertilisation (IVF), and doctors recommended a C-section because of the high-risk nature of the pregnancy. The surgery went smoothly and she delivered a healthy baby girl. Encouraged by that experience, she returned to the same private charitable hospital for her second pregnancy a year later.
On the day of delivery, doctors told her she had developed high blood pressure and advised another C-section delivery. But what was expected to be a routine surgery quickly turned into a medical emergency. Doctors were unable to control heavy bleeding after the operation and subsequently decided to perform a hysterectomy, removing her uterus, Harshada explained.
Her condition continued to deteriorate after the surgery as she had developed jaundice. She sought treatment at a government facility as she could not afford private hospital care. With her uterus removed, Harshada has entered menopause years earlier than expected and continues to deal with the physical and emotional effects of the surgery.
For the IVF, both deliveries and subsequent complications, the family incurred more than Rs 6 lakh in medical expenses, for which they had to take out loans. “We trusted the doctors and did whatever they told us," she said. "Today, we are still paying back the loans, and I have to live with the consequences for the rest of my life."
Vora and Pandit said the profile of pregnant women has changed significantly over the past two decades. Women are having children later in life, fertility treatments such as IVF have become more common, and conditions such as obesity, diabetes, hypertension and other pregnancy-related complications are increasing.
Vora noted that declining fertility means families often have only one or two children, making each pregnancy more valuable and increasing both parental and provider reluctance to accept risk.
"Once a woman has had a Caesarean, the likelihood of a repeat Caesarean in the next pregnancy increases," Vora said, adding that this creates a cumulative effect in which higher C-section rates today contribute to higher rates in the future.
Pandit also pointed to rising maternal age, high-risk pregnancies, previous Caesarean deliveries and maternal requests for planned surgery as factors contributing to higher C-section rates.
Vora added that obstetric practice has become increasingly defensive, with doctors often working under the fear of litigation and confrontation if a labour develops complications.
When C-sections stop saving lives
The WHO notes that when medically justified, C-sections can prevent maternal and neonatal deaths and complications. But higher C-section rates do not automatically translate into better maternal and neonatal outcomes, our analysis of state-wise data shows.
For instance, Telangana, which has the country’s highest C-section rate (62.2%) saw a maternal mortality ratio (MMR) of 48 deaths per 100,000 live births in 2022-24. In comparison, Tamil Nadu (47% C-section rate) and Kerala (41%), with lower rates, reported among India’s lowest MMRs at 25 and 24 deaths per 100,000 live births, respectively.
Even states with the highest maternal mortality had a higher C-section rate than envisaged by the WHO to prevent mortality. Uttar Pradesh, where 19.5% of births are delivered by C-section, had the highest MMR (154 deaths per 100,000 live births). Madhya Pradesh, with a C-section rate of 16%, recorded an MMR of 135.
But even as Karnataka's C-section rate of 46% is comparable to Tamil Nadu's, it had a maternal mortality ratio of 73, nearly three times Tamil Nadu's. Similarly, West Bengal and Punjab, which had 45% and 47% C-section rates, saw MMRs of 94 and 77 deaths per 100,000 live births.
"The objective is not to maximise Caesarean-section rates but to ensure that women who need surgery receive it," said Dileep Mavalankar, honorary distinguished professor of public health and former director of the Indian Institute of Public Health, Gandhinagar. "Beyond that point, improvements in maternal and newborn survival depend far more on the quality of care than on the number of operations performed."
“High-performing states like Kerala and Tamil Nadu already achieved good maternal and neonatal outcomes.” says N.S. Iyer, consultant for maternal, newborn, child and adolescent health at the United Nations Children’s Fund (UNICEF). “Rising C-section rates seem to reflect how maternity care is organised—crowded referral hospitals, fewer midwives, and less continuous labour support—rather than additional improvements in outcomes.”
"Some increase is expected when more women deliver in hospitals and complications are identified. But after about 10-15%, it cannot be explained by complications alone," said Mavalankar.
"If we take the WHO standard and even allow some margin, around 20% of deliveries may genuinely require a Caesarean section. What we are seeing now is that three out of every five Caesarean sections in India's private sector are medically unnecessary," said national co-convener of Jan Swasthya Abhiyan, Abhay Shukla.
Jammu & Kashmir had the highest C-section rate in private hospitals at 90%, followed by 88% in West Bengal and 84% in Telangana.
Rising Caesarean rates are no longer confined to large cities, said Anand Pawar, executive director of Samyak, a Pune-based advocacy group that works for sexual and reproductive health rights of women in Maharashtra and Rajasthan. In many rural and semi-urban areas, institutional deliveries have increasingly shifted into private maternity facilities, where women are often encouraged to view childbirth as a high-risk event requiring medical intervention. Pawar said fear and anxiety around pregnancy complications are frequently used to steer women towards surgical deliveries.
And this is showing up in the numbers. Across India, 40.5% of urban births were delivered by C-section, compared to 22.8% of rural births.
Further, a 2018 study across 51 countries found that neonates born by vaginal birth had more than double the chance of being breastfed in the first hour as compared to C-section births, as IndiaSpend reported in August 2018. Women who deliver by caesarean section often face important challenges in initiating breastfeeding, such as managing the effects of anesthesia, recovering from surgery and finding help to hold the baby safely, the study noted.
Early initiation of breastfeeding is important for both the mother and the child. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. It is recommended that children be put to the breast immediately or within one hour after birth. IndiaSpend reported in 2019 that a delay of just a few hours can increase the risk of mortality.
Rising costs
As more women give birth in health facilities and C-section rates continue to rise, childbirth remains a significant source of out-of-pocket spending for many Indian households, particularly those using private hospitals.
A delivery in a private hospital costs more than Rs 39,000, on average. This is 17 times the cost of delivery in a public hospital. For many households, as IndiaSpend reported in June 2026, high out-of-pocket spending leads to borrowing, selling assets, or cutting down on other essential expenses such as food and education.
Between 2018 and 2025, average childbirth expenditure in rural areas rose 73%, while in urban India, it rose 63%. States with high C-section rates also have some of the most expensive private maternity care in India. In Telangana, delivery in a private hospital costs Rs 53,355, 31 times as the spending in a public facility (Rs 1,714). Tamil Nadu’s expenditure per childbirth was nearly Rs 70,000 in private hospitals, about 50 times the costs in a public facility.
Iyer said states such as Kerala and Tamil Nadu had largely completed the transition from a maternal mortality problem to a maternity care market, where most women deliver in institutions and private hospitals play an increasingly dominant role. Once institutional delivery becomes nearly universal, he argued, further growth often comes through greater medical intervention, specialised care and higher-cost services rather than improved access alone.
"These were the states which had the first and largest public-private health insurance schemes," Shukla said. "The government subsidised people to go to the private sector. They expanded the market and induced people to seek care in private hospitals on a much larger scale than before." He added that while these schemes increased utilisation of services, they also accelerated the growth of private-sector maternity care, where C-section rates are substantially higher than in public facilities.
The push for surgery
Shukla argued that high C-section rates in private hospitals cannot be explained by medical need alone and reflect the increasing commercialisation of maternity care.
Pawar described how, in rural and semi-urban areas, private maternity centres often become the default option for pregnant women, with doctors and referral networks shaping perceptions of risk and encouraging women to view C-section delivery as the safer option.
Experts also pointed to what might be called the "arithmetic" of hospitals. A normal delivery can take six to twelve hours—or longer—of continuous monitoring, labour support and observation, while a C-section is scheduled, predictable and completed within a much shorter time frame.
Iyer said that this challenge has become more acute as the traditional cadre of trained midwives has largely disappeared from the health system. In the past, midwives and experienced labour-room nurses played a central role in monitoring women through labour and supporting normal deliveries. Today, deliveries are increasingly concentrated in district hospitals, medical colleges and specialist maternity facilities, where doctors must manage large numbers of patients with limited staff and crowded labour rooms.
"Normal deliveries are being conducted by nurses and midwives in many countries, and even in India much of the monitoring can be done by trained nursing staff," Vora said. "Normal delivery requires less resources, but more patience and time." She added that obstetricians often remain responsible for a woman throughout labour, knowing that complications can arise unexpectedly at any moment.
Financial incentives may further reinforce these pressures. Mavalankar argued that payment systems often reward C-sections more than normal deliveries, creating incentives that favour surgery. Referring to earlier experiments in Gujarat, he noted that when private hospitals were paid a fixed amount regardless of whether a woman delivered vaginally or by C-section, surgical delivery rates remained comparatively low.
Pawar described a parallel dynamic in private rural hospitals, where maternity centres operated by BAMS and BHMS practitioners invest in infrastructure, operation theatres and specialist consultants, creating financial pressure to recover costs.
IndiaSpend has reached out to the Ministry of Health and Family Welfare, and health ministries in Telangana, Andhra Pradesh and Tamil Nadu for comment. We will update this story when we receive a response.
This article was originally published on IndiaSpend and has been republished here with permission.
