Caesarean deliveries’ rising numbers may not be all bad

Nationally, the rate of cesarean deliveries has risen from 7.1% in 1998 to about 41% in 2024. In the private sector, the figure now approaches 57%

My first encounter with maternity care was in the sugarcane belt of rural Maharashtra, in the year 2000. I had conducted 18 deliveries at a primary health centre over one year. This was not even a tenth of the childbirths that had occurred at home that year. As was confirmed by the second round of the National Family Health Survey (NFHS-2), childbirth in rural Maharashtra mostly happened at home. Hospitals were sought only when events had already gone wrong. In the past 25 years, with expansion of health care services, government incentives and the growing recognition that medically unsupervised births can become life-threatening, today, more than 90% of births occur in institutions. Over the same period, infant mortality has fallen from about 66 to 24 per 1,000 births, neonatal mortality from 44 to 18 per 1,000 and maternal mortality from nearly 400 to below 100 per 100,000 live births. As childbirth has moved into hospitals, caesarean birth has become steadily more common. Nationally, the rate has risen from 7.1% in 1998 to about 41% in 2024. In the private sector, the figure now approaches 57%.

Caesarean birth was associated with a 70% reduction in the odds of stillbirth or neonatal death. This does not prove that more caesareans are always better. But definitely, the relationship between caesarean rates and outcomes is too complex to be contained by a simple population threshold. [Photo credit: AFP]

One reading of this rise in caesareans is that it’s evidence of excessive intervention by obstetricians. But the population giving birth today is not the population that was giving birth 25 years ago. Women are having their first child later. They are, on average, heavier, more likely to have metabolic disease, and more likely to conceive with the help of assisted reproduction. These factors alter the risks of labour.

At the hospital where I now work, the mean age at delivery is 33.4 years. NFHS-6 figures suggest women aged 35-49 years are approximately twice as likely to undergo a caesarean delivery as women aged 15-24 years. Similarly, caesarean rates were approximately 35% among women with 12 or more years of schooling, compared with 8% among women with no schooling.

This phenomenon is not confined to India or to privately funded health care. In England, where maternity care is predominantly provided through the publicly funded National Health Service (NHS), 45% of births in 2024-25 were by caesarean section. Even the Nordic countries, long held up as evidence that caesarean rates can be kept exceptionally low, have recently crossed 20.5%. This makes the familiar explanation of “greed driven private health care” look insufficient.

There’s another issue with the way we have traditionally spoken about an “optimal” caesarean rate. For decades, the WHO position has been widely understood to mean that once caesarean rates rise beyond roughly 10-15%, the additional operations cease to improve neonatal or maternal mortality at the population level and may therefore represent unnecessary intervention. Neonatal mortality is not the same thing as perinatal or intrapartum mortality. Some of the gravest consequences of a difficult labour never enter the neonatal mortality figures at all. The baby may die before birth, during labour, or shortly afterwards from intrapartum hypoxia and birth asphyxia.

Here, the numbers become uncertain. India doesn’t have sufficiently reliable national data on perinatal mortality. Stillbirths and very early neonatal deaths are inconsistently recorded, and the estimates produced by our principal national datasets disagree substantially. NFHS-5 put perinatal mortality at approximately 32 per 1,000 births; the Sample Registration System reported about 18. When two national measures of the same phenomenon differ by almost a factor of two, and the outcome from which we infer an “optimal” caesarean rate fails to adequately capture intrapartum stillbirth, very early neonatal death, and serious neonatal morbidity, then the apparent disappearance of benefit beyond some numerical threshold may be partly an artefact of what has (and hasn’t) been measured.

A striking example comes from Australia. A population-level matched cohort study examined more than 867,000 births, comparing standard public maternity care with private obstetric-led care. Caesarean rates remained substantially different: 32% in standard public care versus 48% in private obstetric-led care. But here is the jaw-dropper. The higher caesarean rate in private care was accompanied by substantially fewer adverse neonatal outcomes. Stillbirth or neonatal death was approximately twice as common in standard public care, while neonatal ICU admission was approximately three times as common. Caesarean birth was associated with a 70% reduction in the odds of stillbirth or neonatal death. This study does not prove that more caesareans are always better. But definitely, the relationship between caesarean rates and outcomes is too complex to be contained by a simple population threshold. Perhaps the percentage of caesareans is the wrong place to begin. Shouldn’t it be: In which women, under what circumstances, and judged by which outcomes?

In 2016, I wrote an article called Natural Births in the Age of Litigation. I ended that article with an exhortation: keep calm and labour on. A decade later, I am not so sure.

Ruma Satwik is a Delhi-based gynaecologist. The views expressed are personal