Image: iStock
India has been witnessing an increase in Caesarean Sections in recent years. Between 1992-93, the rate of CS births in India was 3% which rose to 10% in 2005-06. While this rate is lower than other developing nations like China, or Brazil, considering that India is the second most populous country in the world, an increase in small percentage has a large effect.
As per the WHO guidelines, the recommended a 5-15% range of CS is acceptable, which is in light of the optimum rate being unknown, and the onus is on a specific region to ascertain its CS limits. The recommended range also means that anything below 5% would mean there are many women who have no access to obstetric surgical care while a rate higher than 15% means there is an over-utilization of CS for reasons other than life-saving emergencies. In fact, the WHO considers the proportion of CS to the total births as an important indicator of emergency obstetric care.
While the national CS rate may not seem alarming, at a regional level it becomes a cause for concern. Privatization of hospital services has also contributed to the rise in CS rates. The CS birth rates of six Indian states are above 20% points. It has been found that at least one in two women in Andhra Pradesh and West Bengal opts for a CS delivery at a private healthcare institution; which is a higher ratio than in Brazil or Turkey. The high CS rates are indicators of unnecessary medical intervention at private medical institutions and a source of profit for doctors and the institutions. On the other hand, the CS rates in government institutions are close to an above 15%. Further details in the table below:
Rate of caesarean delivery to total institutional birth in large states of India, 2007-08
| State/Country | Percentage of women* who have experienced CS | ||
|---|---|---|---|
| Public institution | Private Institution | Difference between private and Public institution | |
| India | 12 | 28.1 | 16.1 |
| Jammu & Kashmir | 25.9 | 36.3 | 10.4 |
| Punjab | 18.6 | 24.2 | 5.6 |
| Haryana | 14 | 23.8 | 9.8 |
| Delhi | 15.2 | 27.6 | 12.4 |
| Rajasthan | 5.2 | 17 | 11.8 |
| Uttar Pradesh | 9.4 | 22.8 | 13.4 |
| Bihar | 3.8 | 20.9 | 17.1 |
| Assam | 10.5 | 40.5 | 30 |
| West Bengal | 15.9 | 55.6 | 39.7 |
| Orissa | 15.1 | 35.4 | 20.3 |
| Madhya Pradesh | 4.6 | 29.3 | 24.7 |
| Gujarat | 7.7 | 17.3 | 9.6 |
| Maharashtra | 10.7 | 20.5 | 9.8 |
| Andhra Pradesh | 20.5 | 50.2 | 29.7 |
| Karnataka | 15.2 | 27.5 | 12.3 |
| Kerala | 27.8 | 34.2 | 6.4 |
| Tamil Nadu | 15 | 35.3 | 20 |
Percentage distribution of caesarean section delivery by place of residence – India and its states, 2007-08
| States/Country | Percentage of women who have caesarean delivery among women who had given birth since 01.01.04 | Difference between urban & rural (U-R) Total number of women | |||||
|---|---|---|---|---|---|---|---|
| Total | Rural (R ) | Urban (U) | |||||
| India | 9.2 | 6.2 | 16.8 | 10.6 | 217997 | ||
| Jammu & Kashmir | 15.8 | 11.6 | 34.5 | 22.9 | 5238 | ||
| Himachal Pradesh | 10.2 | 9.4 | 15.1 | 5.7 | 2594 | ||
| Punjab | 14.6 | 12.6 | 17.7 | 5.1 | 5378 | ||
| Uttaranchal | 5.1 | 3.5 | 11.7 | 8.2 | 4155 | ||
| Haryana | 10.2 | 8.9 | 12.6 | 3.7 | 6857 | ||
| Delhi | 14.2 | 11.3 | 14.3 | 3 | 2502 | ||
| Rajasthan | 4.2 | 2.6 | 8.4 | 5.8 | 12573 | ||
| Uttar Pradesh | 5 | 3.5 | 9.7 | 6.2 | 38208 | ||
| Bihar | 4.4 | 3.4 | 9.8 | 6.4 | 21633 | ||
| Sikkim | 9.7 | 8.9 | 25.7 | 16.8 | 1450 | ||
| Arunachal Pradesh | 3.8 | 3.1 | 6 | 2.9 | 3256 | ||
| Manipur | 8.3 | 4.9 | 18.7 | 13.8 | 3586 | ||
| Mizoram | 4.6 | 2.4 | 7.8 | 5.4 | 2959 | ||
| Tripura | 8.7 | 5.7 | 34.6 | 28.9 | 1553 | ||
| Meghalaya | 3.3 | 2.6 | 8.3 | 5.7 | 3139 | ||
| Assam | 6.9 | 4.6 | 20.1 | 15.5 | 10089 | ||
| West Bengal | 12.8 | 8.6 | 29.3 | 20.7 | 6528 | ||
| Jharkhand | 4.2 | 2.7 | 13 | 10.3 | 11474 | ||
| Orissa | 10.4 | 8.6 | 18.9 | 10.3 | 7786 | ||
| Chhattisgarh | 6.2 | 3.4 | 15.9 | 12.5 | 6233 | ||
| Madhya Pradesh | 4.9 | 2.3 | 11.1 | 8.8 | 16111 | ||
| Gujarat | 8.1 | 5.7 | 14.5 | 8.8 | 7603 | ||
| Maharashtra | 10.4 | 7.3 | 17.4 | 10.1 | 10429 | ||
| Andhra Pradesh | 29.3 | 22.3 | 39.2 | 16.9 | 5181 | ||
| Karnataka | 14.2 | 11.3 | 19.5 | 8.2 | 7738 | ||
| Goa | 27.5 | 22 | 30.1 | 8.1 | 407 | ||
| Kerala | 31.8 | 30.1 | 34.7 | 4.6 | 3335 | ||
| Tamil Nadu | 23.2 | 19.2 | 27.7 | 8.5 | 6561 | ||
| Jharkhand | 4.2 | 2.7 | 13 | 10.3 | 11474 | ||
| Orissa | 10.4 | 8.6 | 18.9 | 10.3 | 7786 | ||
| Chhattisgarh | 6.2 | 3.4 | 15.9 | 12.5 | 6233 | ||
| Madhya Pradesh | 4.9 | 2.3 | 11.1 | 8.8 | 16111 | ||
| Gujarat | 8.1 | 5.7 | 14.5 | 8.8 | 7603 | ||
| Maharashtra | 10.4 | 7.3 | 17.4 | 10.1 | 10429 | ||
| Andhra Pradesh | 29.3 | 22.3 | 39.2 | 16.9 | 5181 | ||
| Karnataka | 14.2 | 11.3 | 19.5 | 8.2 | 7738 | ||
| Goa | 27.5 | 22 | 30.1 | 8.1 | 407 | ||
| Kerala | 31.8 | 30.1 | 34.7 | 4.6 | 3335 | ||
| Tamil Nadu | 23.2 | 19.2 | 27.7 | 8.5 | 6561 | ||
Spatial Variation in Caesarean Section Delivery in India, 2007-08
Image: Iussp.org
Some of the factors that might lead to high CS rates in India could be:
- The extreme shortfall of Obstetricians and anesthetists.
- Means to generate profits at private institutions.
- Post graduate students of obstetrics or anesthetics could unnecessarily perform CS.
- In India, doctors see CS as a way to avoid litigation unlike in the west where midwives are responsible for normal deliveries. In India, due to the large population, the midwife to population ratio is very low, and the doctor is held accountable for deliveries.
- Most institutions lack the infrastructure such as skilled neonatal intensive care, electronic fetal monitoring system, blood transfusion facility, etc. for normal deliveries.
- There is also an increase in demand from women of educated class who want to avoid labor pains. In India facilities for painless deliveries are rare.
- Indians also consider astrological significance in electing the day when a child must be delivered.
- It is also likely that medical students who pay enormous fees to private medical institutions could resort to CS deliveries to recover the fees.
- The total health expenditure of the Indian government towards health sector much lower lower than countries in the west.
