India’s silent caesarean crisis

When Andhra Pradesh Chief Minister N. Chandrababu Naidu used the Assembly floor in late September 2025 to criticise private hospitals for routinely resorting to caesarean deliveries, the language was unusually sharp. He alleged that around 90 per cent of deliveries in private hospitals were by C-section, and said the state would act against unnecessary surgeries. The data he tabled made his concern harder to dismiss: Andhra Pradesh recorded 56.62 per cent caesarean births in 2024–25, among the highest in India.

Six weeks later, that figure still stands as a warning of a system drifting towards routine surgical childbirth. More importantly, it reflects a broader national trend that has grown steadily without adequate scrutiny.

Across India, C-sections have been rising for over a decade. NFHS-5 (2019–21) puts the national rate at 21.5 per cent, up from 17.2 per cent just a few years earlier. Southern states sit much higher: Telangana reports about 60 per cent on recent survey and audit data, with Kerala, Tamil Nadu and Karnataka also well above the national average. What was once viewed as an issue concentrated in a few urban hospitals is now a structural feature of India’s maternal health system.

One reason is that institutional delivery has risen dramatically. In Andhra Pradesh, around 97 per cent of births are institutional, according to NFHS-5, and several other states have comparable levels. This is a major public health success, but it also means hospital norms now decisively shape how Indian women give birth. And those norms are influenced by incentives, staffing, perceptions of risk and the availability of labour support.

On the supply side, the differences between public and private hospitals remain striking. Public facilities, though stretched, tend to stay closer to evidence-based practice. Many private hospitals show much higher surgical rates. Naidu’s allegation of a 90 per cent C-section share in private hospitals was not independently verified across the state, but it captures a real pattern: across India, private-facility births are significantly more likely to end in surgery than public-facility births. Financial incentives matter here. If surgery attracts higher reimbursement, hospitals receive a clear economic nudge. Scheduled surgeries are also easier to manage than long, unpredictable labours, especially in facilities with limited staff. Add the pressure of litigation, and the drift towards surgery becomes more understandable.

But focusing only on the supply side misses the complexity of how women and families make decisions. Demand-side factors are also fuelling the rise.

Fear of unmanaged labour pain is perhaps the most influential. In many hospitals, particularly smaller ones, reliable labour analgesia is not guaranteed. For women unsure whether they will receive adequate support through labour, a planned C-section can feel safer and more controlled.

There’s also a widespread perception that caesareans are cleaner, modern and more predictable. Antenatal counselling often happens in rushed consultations, leaving families with incomplete information about risks and benefits. Personal experience matters too: previous traumatic labours or stories within families shape expectations.

For working women, scheduling convenience plays a role. With limited maternity leave or childcare constraints, the ability to plan a delivery date can feel practical. And doctor influence carries enormous weight. When a clinician, facing time pressures or uncertain labour-room support, suggests that surgery is the safer option, most families will follow that advice.

The result is a feedback loop: women who fear poorly supported labour lean towards surgery; hospitals, shaped by incentives and staffing constraints, lean towards recommending surgery; and as surgery becomes routine, families assume it is the norm rather than an exception. Demand and supply reinforce each other within this environment.

This is where WHO’s position is instructive. Contrary to old shorthand, WHO does not recommend a fixed “15 per cent” target. Its evidence shows population-level maternal and neonatal mortality benefits plateau at around 10 per cent, after which additional increases do not improve outcomes. The emphasis is on ensuring every woman who needs a C-section gets one — and avoiding unnecessary surgery where it does not add clinical value. India’s rising rates, especially in private settings, can’t be explained by rising medical need alone.

The consequences of unnecessary C-sections remain under-acknowledged. Surgery increases maternal risks, including infection, haemorrhage and complications in subsequent pregnancies. Babies delivered by C-section face higher chances of respiratory distress. And for the health system, unnecessary surgery absorbs scarce resources. Naidu claimed that 4.2 per cent of Andhra Pradesh’s health-scheme expenditure went towards C-sections, a figure the state should publish for verification.

If India wants to correct its trajectory, reforms have to address both the environment that shapes women’s preferences and the incentives that shape provider behaviour.

The first step is data transparency. States should publish hospital-wise C-section rates monthly, distinguishing between emergency and non-emergency procedures. Andhra Pradesh has already ordered monthly reviews; making them public would create accountability and enable families to make informed choices.

Second, payment reform is essential. Public insurance schemes — whether state or centrally supported — must reimburse vaginal and surgical births at the same rate unless clinical documentation justifies the higher cost. As long as surgery yields higher pay-outs, the system will continue producing more of it.

Third, India urgently needs to invest in midwifery-led care. Kerala has piloted this model, and international experience shows that midwives offering continuous intra-partum support significantly reduce unnecessary surgical escalation. A robust midwifery workforce would make labour support more reliable and reduce patient anxiety.

Fourth, labour analgesia must be treated as a basic service. Ensuring that public hospitals have dependable anaesthesia staffing, and that private hospitals meet minimum pain-relief standards, directly addresses one of the key demand-side drivers of C-section preference.

Fifth, states should adopt a second-opinion protocol for non-emergency C-sections. A rapid digital review by an independent obstetrician would not slow care but would protect patients from unnecessary surgery and support clinicians making balanced decisions.

Finally, clinicians need clearer legal protection when acting in good faith. Defensive medicine is a real driver of surgery, and legal clarity would allow doctors to manage labour more confidently without defaulting to surgical intervention.

These reforms do not undermine clinical judgement or restrict women’s choices; they create an environment where those choices are genuinely informed and supported. Naidu’s remarks may have been prompted by Andhra Pradesh’s alarming numbers, but they illuminate a national challenge. India’s rising C-section rate is not inevitable. It is the outcome of incentives, anxieties and institutional habits — and because it is systemic, it can be corrected.

India has the institutional capacity to tackle this. What it needs now is the resolve to ensure that C-sections occur for clinical reasons, not because the system offers no credible alternative.

The author is a health and science journalist