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On World Health Day 2025, India’s rising C-section rates highlight how financial incentives and cultural factors are turning childbirth into a commercial medical event
Image Source: Getty
This essay is part of the series: World Health Day 2025: Healthy Beginnings, Hopeful Futures
Childbirth in India presents a story of two worlds: private and public. In private hospitals, mothers can have a luxury setting with individualised attention but also a greater likelihood of surgical intervention. In public hospitals, the equipment and personnel may be lacking, but unwanted interventions are less frequent. During 2019-21, only 14.3 percent of public hospital institutional deliveries were by Caesarean section (C-Section), versus 47.4 percent of births in private hospitals. The latest National Family Health Survey (NFHS-5) also shows private hospitals in most states now performing C-sections for over half of all deliveries, while public hospital rates hover between 10 to 15 percent.
While C-section can be a life-saving procedure for high-risk cases, excessive use of these methods raises questions about whether the act of giving birth is being over-medicalised.
As the world commemorates World Health Day 2025, the theme "Healthy Beginnings, Hopeful Futures" highlights an important point in the lifecycle—motherhood. While C-section can be a life-saving procedure for high-risk cases, excessive use of these methods raises questions about whether the act of giving birth is being over-medicalised. Research shows that C-section rates, which are higher than 19 percent, may not be followed by the decline in maternal and neonatal mortality rates. Studies also indicate that women choose C-sections due to fear of labour pain, perceived security, negative past birth experiences, or even cultural beliefs, such as selecting delivery dates based on astrology. Educated women might also view C-sections as safer and less intrusive. Thus, promoting informed decision-making, driven by health needs rather than convenience or profit, is crucial to ensuring the well-being of both mothers and children.
Before exploring the causes of the C-section epidemic, it is crucial to understand that a C-section is a life-saving procedure and has rescued countless lives. The issue is not the procedure itself, though, but how it is being overused in uncomplicated, low-risk pregnancies.
Several financial and practical incentives in healthcare are skewed toward more C-sections. Hospital revenue models often make surgical deliveries far more lucrative than normal births. A C-section typically costs significantly more than a vaginal delivery, yet it can be completed on a scheduled timeline. Research confirms that “C-section delivery costs more than a normal delivery… and pays more”, which encourages private facilities to promote surgery for profit. In many private hospitals, performing a C-section is quicker and requires fewer hours of doctor/nurse time than waiting for labour—a perverse incentive that rewards intervention over patience. The result is an unregulated market of obstetric care where some clinics exploit the system for financial gain through needless C-sections.
In private practice, obstetricians may face pressure to meet performance targets or simply manage their schedules; scheduling a C-section during the day is more convenient than attending an unpredictable midnight labour.
Beyond hospital profit, doctor incentives and convenience also play a role. In private practice, obstetricians may face pressure to meet performance targets or simply manage their schedules; scheduling a C-section during the day is more convenient than attending an unpredictable midnight labour. C-section rates tend to spike on weekdays before evening, hinting at scheduling preferences. There is also a defensive medicine aspect—some doctors may pre-emptively choose surgery to avoid potential complications.
Health insurance may also be another contributor. C-Sections under government packages are usually for government facilities but can occur at private hospitals through referrals by government hospitals. Government schemes like Ayushman Bharat reimburse C-sections (~INR 11,500) at high fixed rates in comparison to normal deliveries which are not reimbursed in private facilities yet. This may reduce the out-of-pocket expenses (OOPE) for patients, but it may also incentivise private hospitals to opt for surgery over normal delivery to claim the higher payout. For insured patients, families may be less likely to question a recommended C-section (“insurance will cover it”), removing a financial brake on overuse. With an increase in sentiment about rising costs, the number of maternal and health insurance products will continue to increase as well. In essence, insurance can inadvertently underwrite unnecessary procedures. Unless monitored, such payment structures encourage maximising revenue per birth.
Demand-side factors in India’s society also fuel this C-section surge. One unique driver is the influence of astrology and numerology on birth timing. Many families hold strong beliefs in auspicious birth dates and times. It has become common for expecting parents to consult astrologers and schedule “mahurat” C-sections at exact moments deemed favourable. Another cultural phenomenon is the “Too Posh to Push” mindset among certain urban, affluent families. Here, the fear of labour pain or the desire for convenience leads women to elect C-sections without medical need.
Women who have had one C-section are often discouraged or outright refused a trial of labour in subsequent pregnancies.
Additionally, misinformation about Vaginal Birth After C-Section (VBAC) contributes to a cycle of repeat surgeries. There is a common belief in Indian families (and sadly, among many practitioners) that “once a C-section, always a C-section”. Women who have had one C-section are often discouraged or outright refused a trial of labour in subsequent pregnancies. Over time, this has eroded confidence in VBAC. In the mid-1990s, VBAC was relatively common, but today only 1 in 10 eligible even attempt a VBAC. Yet medically, a majority (around 75 percent) of those attempts succeed, with the risk of serious complications (like uterine rupture) well below 1 percent. Hospitals may also worry that if a VBAC attempt fails and causes harm, they will face litigation, so they would prefer the safety of a repeat C-section. The outcome is a self-fulfilling prophecy: fewer VBACs mean more women end up on a conveyor belt of serial C-sections.
Although C-sections may be commonplace now, they can be quite expensive in terms of hidden health costs. For the woman, a C-section is a significant abdominal surgery with its related risks. Short-term risks include increased risk of infection, blood loss, blood clots, and complications from anaesthesia. Routine postpartum problems such as breastfeeding complications or postpartum depression can be worsened by the longer recovery and pain. Vaginal birth has shorter hospitalisation and faster bounce-back. The World Health Organisation (WHO) alerts that there is no benefit to undergoing an unnecessary C-section and only increases maternal risk of morbidity and mortality over a natural delivery.
For the child, C-section birth changes early health patterns subtly. Caesarean section bypasses the normal squeezing of the birth canal, thus not being exposed to the mother's vaginal flora. Research in neonatal care now finds that C-section infants have dramatically different compositions of gut flora during early life, as they are first colonised by hospital/environmental microbes instead of the mother's flora. This disrupted “seeding” of the microbiome is believed to compromise early immune system development, making C-section infants more susceptible to a host of diseases.
Caesarean section bypasses the normal squeezing of the birth canal, thus not being exposed to the mother's vaginal flora.
Data from the NFHS also highlights that the average OOPE for a C-section in a private hospital is about US$ 498 (~INR 43,000, 1 US$ at 87.22 INR Rate as of March 2025), compared to US$ 99 (~INR 8,600) for a C-section in a public hospital. Normal deliveries cost much less, often a fraction of those amounts, especially in public facilities. For a normal vaginal birth, expenses in public hospitals are lower (NFHS-5 data noted a decline to ~INR 2,916 on average), whereas in private hospitals normal delivery might still run tens of thousands of rupees, but less than a surgical birth.
Private hospitals often charge separately for anaesthesia, surgical consumables, paediatrician attendance at birth, and post-operative care, all of which can inflate the final bill beyond the “package” price. If the baby requires Neonatal Intensive Care Unit (NICU) care (not uncommon with elective early C-sections), daily NICU charges can be astronomical. Moreover, unnecessary C-sections can create a cycle of expenditure where a woman who had a C-section will likely face another in her next pregnancy, meaning another big bill.
The choice of childbearing method should be guided by medical necessity and the well-being of the mother, not by profit margins and the convenience of scheduling. Practitioners and hospitals are acting knowingly or unknowingly, to market pressures such as additional revenues, time-saving, and even fear of malpractice lawsuits, pushing them towards surgery even when it is medically not required. Hospitals and physicians need to re-declare their commitment to the fundamental ethos of "primum non nocere" (first, do no harm).
Practitioners and hospitals are acting knowingly or unknowingly, to market pressures such as additional revenues, time-saving, and even fear of malpractice lawsuits, pushing them towards surgery even when it is medically not required.
Stepping up public education on the topics of increased vaginal birth, the safety of VBAC, and the avoidable harms of C-sections can reverse widespread misconceptions and fears. Hospital-wise C-section reporting openly, payment disincentives to unnecessary use, and insurance audits are all key steps which can prevent unnecessary interventions at a policy level. Mechanisms of public accountability, like occasional C-section audits and the provision of incentives for compulsory second opinions in low-risk situations, can promote balance.
Vilification of C-sections should not be the target; C-sections are a lifesaver and are still necessary for the majority. However, beyond a threshold, higher C-section rates do not boost maternal or newborn survival. Each percentage point of increase above the optimal level represents thousands of unnecessary procedures in terms of health outcomes and financial well-being. Delivering babies should always be a deeply personal health experience, and a system that respects this most basic value will not only ensure healthier beginnings but also pave the way for radiant, hopeful futures for generations of Indian mothers and newborns.
K. S. Uplabdh Gopal is an Associate Fellow with the Health Initiative at the Observer Research Foundation.
The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.
Dr. K. S. Uplabdh Gopal is an Associate Fellow within the Health Initiative at ORF. His focus lies in researching and advocating for policies that ...
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