92% deliveries in hospitals, every third child born through a c-section
Findings of the latest survey on the state of India’s health conducted by the National Statistical Office in 2017-18 show a positive change: the proportion of women delivering a child in a hospital (or health care institution) has increased over the past two decades by nearly 73 percentage points in rural India and 37 percentage points in urban India.
At least nine of every 10 pregnant women now deliver a child in a hospital and thereby avail better health care facilities. But nearly every third woman who delivers a child in a hospital undergoes a caesarean-section or C-section surgery, which is a rate twice of what the international health care community considers ideal, and almost the same it is in the US. Personal preferences and older mothers are part reason for this, as is, in some cases, profiteering , but another reason, experts say, is that health care workers do not have the time, patience, or inclination to wait.
Four rounds of the nationally-representative National Family Health Survey have also recorded rising C-section rates over time – from 9.5% of all hospital births in 1992-93 to 22.8% in 2015-16.
According to the World Health Organisation, which considers the ideal rate for C-sections to be between 10% and 15%, these surgeries are effective in saving maternal and infant lives but only when they are required for medically indicated reasons. “There is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure,” the organisation said in a statement on C-section rates published in 2015. “At population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.”
To be sure, the C-section rate is high in many of the developed nations as well, for example nearly 32% of all institutional deliveries in the US are done through a Csection, while this figure is 33% for Australia, 28% for Canada and 35% for China, according to data compiled by the World Health Organisation.
This means the C-section rate in India is twice the ideal rate. It is only in the government sector hospitals in rural India where less than 15% women give birth through surgery. The C-section rate in government hospitals in the urban sector is nearly double at 26%. But when it comes to private sector hospitals, a majority of births (54% in rural areas and 56% in urban areas) are conducted through a C-section, which is almost four times more than the ideal rate. To be sure, the C-section rates are even higher in charitable hospitals, but only about 1% births take place in such hospitals. (See Chart 2)
About 29% of institutional births in India take place in a private sector hospital, but these hospitals conduct nearly 63% of all C-sections in the country. Government hospitals conduct nearly 70% of all deliveries but only 35% of all C-sections.
The higher rate of C-sections also means that Indians are spending more on child birth than they would otherwise. The average expenditure per child birth in case a mother undergoes C-section is nearly five times more than that in case of a normal delivery – around ~23,000 compared to ~4,700. The average expenditure in any case is six to seven times more in private hospitals compared to government ones . A normal delivery in a government hospital costs around ~2,100 on average compared to nearly ~15,000 in a private hospital. Similarly, in case of C-section delivery, the average expenditure in government hospitals is around ~5,500 compared to nearly ~33,000 in private ones.
Professor Indranil Mukhopadhyay, who teaches public health at Jindal School of Government and Public Policy, said “pure commercial interest” is behind the high C-section rates in India, particularly in private sector hospitals. “There are alarming figures and I call it an induced epidemic of some sort. Because regulations aren’t enforced well, doctors get commissions for referring patients to diagnostic labs and similarly get paid more when they conduct a C-section.”
Mukhopadhyay said that high C-section rates among more wealthier families is an indicator of the financial motive. According to the fourth National Family Health Survey conducted in 2015-16, the share of women in the poorest 20% households of India who delivered through a C-section was 4.4% compared to 35.9% among women in the wealthiest 20% families.
Dr Sanghita Bhattacharyya, public health specialist at the Public Health Foundation of India, said commercial interests, rising age of childbearing and changing preferences of women are all partly responsible for the rising C-section rates. “There’s a push from private players for conducting more C-section deliveries especially as public insurance schemes have started to gain ground, but apart from this the rising age of childbearing and the fact that many women now personally prefer a C-section could also be contributing factors.”