Rising Cesarean Section Rates in India: Impact, Aftereffects, and Legal Complexities


This article is written by our intern Ms. Navita, who is a second year student, pursuing B.A. LLB (hons.) from Rajiv Gandhi National University of Law, Punjab.



The cesarean section (C-Section), a vital medical intervention, has witnessed a concerning rise in India, particularly within private healthcare settings. While crucial in mitigating childbirth risks, its overutilization beyond recommended thresholds poses significant health, economic, and legal challenges. This article examines the multifaceted factors driving this surge, its implications on maternal and neonatal health, and the legal complexities surrounding cesarean deliveries.


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Defining cesarean section

The C-section, stands as a pivotal medical intervention, safeguarding the lives of mothers and infants in precarious childbirth scenarios. This surgical procedure, warranted in instances of obstructed labor, fetal distress, or maternal complications, ensures the delivery of infants when vaginal birth poses substantial risks. However, its judicious application is imperative, aligned with the World Health Organization's (WHO) directive advocating for its usage solely in medically indicated circumstances.

In the context of India's healthcare landscape, a concerning trend has emerged within private hospitals—the escalating rates of cesarean sections have increased beyond the WHO's recommended threshold of 15%. This trajectory underscores the imperative to delve deeper into its ramifications on women's health, postoperative conditions, and the legal labyrinth enveloping childbirth practices.


Factors Contributing to the Surge in Cesarean Section Rates

The escalating prevalence of cesarean sections in India's private hospitals can be attributed to several intertwined factors, each exerting a significant influence on childbirth practices.

1. Rise in Institutional Births and Unregulated Health Facilities: A notable driver behind the surge in cesarean deliveries is the burgeoning trend of institutional births, particularly within private healthcare facilities. The proliferation of unregulated health institutions, has created an environment conducive to the overutilization of cesarean sections. In the absence of stringent oversight, profit motives often overshadow clinical considerations, leading to an unwarranted inclination toward surgical interventions.

2. Lifestyle Factors and Obesity Prevalence: Urbanization and shifting dietary patterns have increased a rise in sedentary lifestyles, contributing to an alarming increase in obesity rates among women. The confluence of this lifestyle predisposes women to complications during childbirth, rendering them more susceptible to cesarean deliveries. Obesity not only complicates the process of labor but also necessitates surgical interventions to mitigate associated risks, thereby exacerbating the prevalence of C-sections.

3. Fear of Childbirth Complications and Secondary Infertility: For women grappling with secondary infertility, the specter of childbirth complications looms large, instilling a pervasive fear of pursuing vaginal delivery. The desire to maximize the chances of a successful live birth often prompts these women to opt for cesarean sections, viewing it as a safer alternative despite potential risks. This fear-driven decision-making process further perpetuates the escalating rates of cesarean deliveries, particularly within the private healthcare domain.

4. Economic Considerations: The economic dimension also plays a pivotal role in fueling the surge in cesarean section rates. While cesarean deliveries entail higher costs compared to vaginal births, they offer healthcare providers a lucrative revenue stream. The expedited nature of cesarean sections translates to shorter hospital stays and reduced resource allocation, thereby maximizing profitability. This financial incentive, coupled with the perception of convenience and expediency associated with cesarean deliveries, incentivizes healthcare providers to favor surgical interventions over natural childbirth.

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Data Insights

In the Indian context, data from the National Family Health Survey (NFHS-4) reveals that 17% of live births in the five years preceding the survey were delivered via cesarean section, with a significant portion (45%) of these cesarean deliveries being planned after the onset of labor pains. Notably, the prevalence of cesarean sections has surged over time, with NFHS-3 reporting a rate of 8.5%, which escalated to 17.2% in NFHS-4 and further climbed to 21.5% in 2019-21. Disparities based on geographic and socioeconomic factors are apparent, as women residing in urban areas and those with higher levels of education exhibit higher likelihood of undergoing cesarean deliveries. Specifically, women with bachelor's degrees delivering in private facilities have been observed to have 11 times greater odds of delivering via cesarean.

Furthermore, the odds of cesarean deliveries are markedly higher in private hospitals compared to public hospitals. District Level Household Survey-4 (DLHS-4) data indicate that while 13.7% of births occur in public hospitals, a staggering 37.9% of births in private facilities are through cesarean section. This trend is corroborated by findings from the NFHS, highlighting a decline in cesarean deliveries in public hospitals from 15.2% to 11.9% between 2005-06 and 2015-16 in cesarean deliveries in private healthcare providers during the same period.

The escalation in cesarean section rates raises concerns not only due to associated health risks but also due to manifold increases in healthcare expenditure, particularly in private healthcare settings in India. The costs associated with cesarean deliveries are substantially higher than those of non-cesarean deliveries, exacerbating financial burdens on families. Moreover, the discrepancy in costs between cesarean and non-cesarean deliveries perpetuates healthcare inequities, disproportionately affecting marginalized and economically disadvantaged populations who may already face barriers to accessing quality healthcare services.

Alarmingly, a substantial proportion of cesarean deliveries in India are deemed avoidable which reflects a systemic issues of over-medicalization and inappropriate utilization of surgical interventions. The potential cost savings of $320.60 million, as estimated if private sector facilities had adhered to the WHO's recommended threshold of 15% cesarean delivery rates, underscore the magnitude of this issue. These savings could have been redirected towards strengthening maternal and neonatal healthcare services, improving access to prenatal care, and implementing evidence-based interventions aimed at reducing maternal and infant mortality rates.

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High Cesarean Section Rates in Teaching Hospitals

The prevalence of cesarean sections (CS) in teaching hospitals is notably high, driven by several interrelated factors intrinsic to medical education and the broader healthcare landscape in India.

1. Training Imperatives and Learning Environment: In teaching hospitals the CS rate is generally high. To learn the caesarean technique, students particularly those doing post graduation in gynaecology and obstetrics may perform caesarean when it is not required. The imperative to impart practical experience in CS techniques may inadvertently lead to the performance of cesarean deliveries when not clinically warranted, as students seek to hone their skills under supervision.

2. Infrastructure Deficiencies and Population Pressure: India's burgeoning population exerts immense pressure on healthcare infrastructure, particularly in the realm of obstetric care. Many public and private healthcare institutions lack essential infrastructure for proper vaginal deliveries, including adequate beds, electronic fetal monitoring systems, skilled neonatal intensive care, and blood transfusion facilities. In such resource-constrained settings, healthcare providers may opt for CS as a perceived safer alternative to mitigate potential risks associated with vaginal delivery.

3. Demand from Affluent Urban Women: The rising demand for elective cesarean sections among highly educated, affluent urban women further contributes to escalating CS rates. Motivated by a desire to avoid labor pain and influenced by cultural perceptions and preferences, these women may opt for cesarean deliveries.

4. Doctor-Patient Dynamics and Reputation: Patient preferences, particularly the desire for a specific obstetrician with a reputed track record, can influence the decision-making process regarding childbirth methods. In instances where doctors maintain busy schedules or where patients express explicit preferences, elective cesarean sections may emerge as a favored option, aligning with both patient and provider expectations. Sometimes doctors recommend to opt CS owing to the fact that it takes lesser time than a normal delivery. This dynamics, thus, influence patient’s decisions as well.

5. Limited Access to Pain Management Options: Unlike developed countries where painless vaginal deliveries are commonplace, India faces a dearth of anesthesia services and infrastructure to support pain management during labor. The unavailability or lack of painless labor options, coupled with the time-consuming nature of such procedures for both doctors and patients, further exacerbates the inclination towards cesarean deliveries.


After effects of Cesarean Delivery

While cesarean delivery undoubtedly serves as a life-saving intervention in certain obstetric circumstances, its judicious utilization is paramount, given the documented adverse consequences for both maternal and neonatal health outcomes.

1. Neonatal Health Implications: Infants born via cesarean delivery are at heightened risk of various negative health outcomes, as evidenced by research findings. These include an increased likelihood of childhood obesity, respiratory disorders, type 1 diabetes, acute lymphoblastic leukemia, impaired cognitive development, and higher rates of autism and neurodevelopmental disorders. These aftereffects underscore the importance of cautious consideration when opting for cesarean delivery, particularly in cases where vaginal delivery is feasible.

2. Maternal Health Risks: The aftermath of cesarean delivery extends beyond neonatal health implications, encompassing elevated risks for maternal health. Studies indicate that cesarean delivery is associated with approximately a four-fold increase in the risk of maternal death compared to vaginal delivery. This heightened risk underscores the imperative for careful assessment of maternal indications for cesarean delivery and the provision of appropriate preoperative and postoperative care to mitigate adverse outcomes.

3. Economic Burden: Beyond the health consequences, unnecessary cesarean deliveries impose a significant economic burden, particularly in low-income settings. The increased healthcare costs associated with cesarean sections, coupled with the potential for adverse health outcomes, underscore the importance of judicious utilization of this surgical intervention. Initiatives aimed at optimizing childbirth practices and promoting evidence-based decision-making can help alleviate the economic strain associated with unnecessary cesarean deliveries while ensuring optimal maternal and neonatal outcomes.

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Legal Consequences of Increasing C-Section Deliveries in Private Hospitals

The legal framework surrounding C-sections in India is a work in progress. While there are no specific laws directly regulating C-section rates, existing legal principles can be applied to address concerns about informed consent and potential misconduct by medical professionals. The "Code of Medical Ethics Regulations, 2002" underscores the primary objective of the medical profession as serving humanity, with financial gain being a secondary concern (Clause 1). Additionally, Clause 2.3 emphasizes the importance of providing accurate prognoses, prohibiting physicians from either exaggerating or downplaying the severity of a patient's condition.

1.       Uninformed Consent: No Consent, Potential Offense

Hospitals and medical practitioners have a duty to ensure that patients understand the risks and benefits of different delivery options and are given the opportunity to make informed choices about their care. Performing unnecessary c-sections without proper consent undermines patient autonomy and may constitute medical negligence.

If a patient gives consent for a normal vaginal delivery, hospitals should not perform a c-section without the patient's explicit consent or unless there is a clear medical indication necessitating the procedure. Citing potential risks associated with pregnancy, such as fetal distress or maternal complications, as grounds for performing a c-section when they are not imminent or unavoidable could be considered a violation of the patient's right to informed consent.

In Samira Kohli v. Dr. Prabha Manchanda, the Supreme Court ruled that consent given for a diagnostic procedure or surgery does not automatically extend to therapeutic surgery unless there is an immediate threat to the patient's life or health. The court emphasized the importance of obtaining "real and valid" consent from patients, ensuring that they are provided with adequate information to make informed decisions about their treatment.

In the case of the Indian Medical Association vs. V.P. Shanta and Ors., the Supreme Court clarified that the medical profession falls within the scope of the Consumer Protection Act, 1986. This landmark decision removed ambiguity and established that all patients, including those receiving free treatment, are considered consumers. This decision is relevant in cases of medical malpractice in c-section deliveries, particularly when the procedure is performed unnecessarily. If a doctor performs a c-section without a valid medical reason, it constitutes negligence and can lead to legal action under consumer protection laws.

2. Violation of Doctor's Duty: More Than Just a Procedure

Doctors have a professional and ethical duty to act in the best interest of their patients. Performing unnecessary C-sections can be seen as a violation of this noble duty. Medical councils in India have the authority to take disciplinary action against doctors who engage in practices detrimental to patient welfare. Performing unnecessary C-sections purely for financial gain or convenience could be considered professional misconduct.

In the case of Dr. Laxman Balkrishna Joshi vs. Dr. Trimbark Babu Godbole and Anr., and A.S.Mittal v. State of U.P., the Supreme Court established that doctors owe certain duties to their patients, including the duty of care in deciding whether to take on a case, the duty of care in determining treatment, and the duty of care in administering that treatment. Failure to fulfill any of these duties may result in a cause of action for negligence, allowing the patient to seek damages.



In light of these legal principles, the healthcare sector must prioritize patient well-being over financial incentives, adhering to professional codes and constitutional mandates to uphold the right to health and dignity for all individuals. Any deviation from these principles, such as undue financial incentives leading to unnecessary C-sections or misinformation provided to patients, would not only contravene medical ethics but also undermine the fundamental rights enshrined in the Indian Constitution. Effective regulation and oversight are imperative to uphold these standards and protect the health and dignity of individuals seeking healthcare services in private hospitals.

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