Why women in Telangana have more C-sections than Nagaland

Picture this: In a bustling hospital in Telangana, a new mother holds her baby after a scheduled caesarean delivery, her decision shaped by a desire for convenience and precision. Thousands of miles away in Nagaland, another mother labors at home, unable to afford or access the procedure that could save her and her baby’s life. These two women live in the same country but face vastly different realities.A new study published in Lancet Regional Health-Southeast Asia, which is based on a cross-sectional analysis of C-section delivery rate data published in National Family Health Survey-5 (2019-21) report, shows that the state you live in, the kind of hospital you go to, and how much money you make largely determines whether or not you’ll have a cesarean delivery. A caesarean section (C-section) delivery is a surgical technique that involves making an incision in the belly to deliver a baby. When medically justified, the procedure can be lifesaving. However, when not strictly necessary, it can cause adverse health outcomes, lead to unnecessary expenditure, and place a strain on scarce public health resources.The study notes that 21% of women give birth by C-sections globally, and this is expected to rise to 28% by 2030. It’s not clear whether this growth in the number of C-sections is directly proportional to reducing maternal and perinatal mortality since “at the population level, a rate above 10–19% has not been linked to a decrease in maternal and perinatal mortality rates,” notes the study.C-section rates being too low or too high are equally problematic. “Low rates indicate that women requiring the procedure may not have adequate access, resulting in maternal and newborn mortality and morbidity,” the study says. “On the other hand, high rates are suggestive of overuse without medical necessity, which is associated with higher rates of adverse outcomes such as infection, haemorrhage, surgical complications, and misallocation of resources.” medium nocaption116257134Globally, however, a higher number of C-sections is usually associated with growing financial capacity. In India, the caesarean delivery rate has steadily increased. It went from 8.5% in 2005-2006, to 17.2% in 2015-2016, to 21.5% in 2019-2021. But when the researchers dug deeper into the geographies and economies where C-sections thrive in the country, they found significant disparities.The great state divideThe national average masks dramatic state-level differences. In Telangana, a staggering 60.7% of births occur via caesarean delivery, while in Nagaland, the rate is just 5.2%. The southern states —Tamil Nadu, Kerala, and Andhra Pradesh — dominate the high end of the spectrum, with robust healthcare infrastructure and cultural acceptance of C-sections. In contrast, northeastern and eastern states like Meghalaya and Bihar struggle with low rates, reflecting inadequate access to surgical care. medium nocaption116257621There are several reasons for this state-wise disparity. The researchers conducted a qualitative study in Arunachal Pradesh, which highlighted women’s preference for vaginal deliveries because of a perceived fear of long-term health issues, higher risks and costs associated with C-sections.But in Tamil Nadu and Telangana, the study notes that uniform access to healthcare, high literacy, and a higher GDP are some factors that aid in raising the rate of C-sections. “Cultural and social factors such as fear of normal childbirth, the desire to deliver on an auspicious day, and a preference for painless deliveries and smaller families, also potentially contribute to higher C-section rates.”In Bihar, since a large part of the population is engaged in daily wage work, vaginal deliveries are preferred because they’re both affordable and have a shorter recovery.Why money mattersMore women from high-income quintiles are undergoing delivery through C-sections, says the study. A wealth quintile is a statistical value that divides a population into five equally sized groups based on wealth, with each quintile representing 20% of the population. Only about 6% women belonging to the lowest wealth quintile, or the poorest, underwent C-section delivery in public hospitals across India. The rest went for normal delivery. The percentage of women undergoing C-section delivery at public hospitals in the poorer, middle, richer and the richest categories stood at 11%, 18%, 21% and 25%, of total births in the respective wealth quintile, says the study. medium nocaption116257647Dr Anita Gadgil, co-corresponding author of the study, told TOI+ that one of the major reasons for lower rate of C-section delivery among the poor even in public health facilities, where the procedure is carried out free of cost, could be lack of awareness. “Also, sometimes the poorer women aren’t able to reach higher centres in time where C-section delivery is available, or they don’t have money and wherewithal to reach there. These people are often also least aware of government schemes to provide financial support in such cases,” Dr Gadgil said.The study adds that while southern states like Kerala, Tamil Nadu and Andhra Pradesh have high C-section delivery rates, states with a predominantly poor quintile population like Bihar, Assam and Chhattisgarh have lower C-section rates. In 75% of the states, C-section rates in the poorest quintile are below 10%, indicating underuse.Even within states, the difference in C-section rates between the rich and poor are stark. This relative inequality measures the likelihood of accessing C-sections between the wealthiest and poorest populations within a given area. For example, if the richest quintile in a state has a C-section rate of 40% while the poorest has a rate of 10%, the relative inequality would be 4. Or, the richest are four times more likely to get a C-section than the poorest.In Assam, for instance, the C-section rate for the richest is 76.7%, compared to 0% for the poorest. Across India, the wealthiest are five times more likely to have a C-section compared to the poorest. medium nocaption116257680 A private affairNationally, the average C-section rate in private hospitals is 47.5%, significantly higher than the 14.3% observed in public hospitals. This trend persists across wealth quintiles, with the wealthiest women accessing C-sections at disproportionately high rates in private hospitals. In the richest quintile, private hospitals show a median C-section rate of 50%, compared to 33% in public hospitals. Even in the poorest quintile, where access is most limited, private hospitals exhibit higher C-section rates (25%) compared to public facilities (7.7%).This disparity can be attributed to several factors. Private hospitals often provide more immediate and accessible services, attracting wealthier populations who can afford the higher costs. Additionally, financial incentives and preferences for elective surgeries in private settings contribute to the higher C-section rates, sometimes even without clear medical necessity. Public hospitals, on the other hand, face infrastructural and resource limitations, restricting their ability to provide timely C-sections, especially for economically disadvantaged populations. medium nocaption116257699Researchers found better-educated women living in urban areas were more likely to deliver by C-section, suggesting that greater autonomy and better access to healthcare facilities play a role in the increase in prevalence of C-sections.With inputs from Rajesh Sharma