21.5% of all births in India are through C-section, far above WHO-ideal of 10-15%, shows NFHS

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Representative image : Pixabay
Representative image : Pixabay


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New Delhi: The latest National Family Health Survey (NFHS) may have brought the long awaited good news of population stabilisation, but it also shows that while there have been fewer births than before, a higher proportion of those being born are being delivered through caesarean section (C-section).

The fifth NFHS — done in two phases between June 2019 and January 2020, and January 2020 and April 2021, and released by the health ministry Wednesday — showed that the national C-section rate is 21.5 per cent, higher than what the World Health Organization terms “ideal”, 10-15 per cent. The number has has also gone up since NFHS 4 (conducted in 2015-16), when the percentage stood at 17.2.

Far more worrying, however, is the growing disparity in the number of C-section births at government and private sector facilities. At the national level, 47.4 per cent babies born in the private sector are being delivered by surgical methods, as compared to just 14.3 per cent in the government sector.

The disparity in the two numbers has deepened since the last family health survey. In the NFHS 4, the proportion of C-sections was 40.9 per cent in the private sector against 11.9 per cent in the government sector. Experts say there could be several reasons for the growing disparity, among them, the increased health insurance coverage in India since the launch of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in September 2018.

The PMJAY provides an annual health coverage of Rs 5 lakh to eligible families. C-sections are what are known in insurance parlance as “moral hazard” procedures — one that’s often done without medical reasons as the payment is assured for an insured person.


Also read: Financial burden of child births is rising in India – even in free public health facilities


Variation between states

The gap is even wider than the national figure in some states, with 95.7 per cent births in the private sector in urban areas in Tripura happening through C-sections, compared to 54.7 per cent in rural parts of the state. Among births in the government sector in the state, 40.4 per cent in the urban areas and 17.6 per cent in the rural areas happened through C-section.

Graphic: Ramandeep Kaur | ThePrint
Graphic: Ramandeep Kaur | ThePrint

In Andhra Pradesh, 63 per cent births in the private sector and 26.6 per cent in the public sector happened through C-section, including 61.4 per cent in the private sector in rural areas, and 66.1 per cent in urban areas.

In Chhattisgarh, 57 per cent births in the private sector and 8.9 per cent in the public sector were through C-Section. The figures for rural and urban in the private sector stood at 54.5 per cent and 60.4 per cent, respectively. The rural-urban numbers in the public sector were 7.1 per cent and 17.8 per cent, respectively.

The disparity is particularly high in Bihar, with 39.6 per cent deliveries in the private sector and just 3.6 per cent in the public sector happening through C-section. According to people aware of ground realities in the state, the lack of access and poor quality of healthcare in the public sector in the state is among the reasons for this. Those who need or want C-section deliveries are going to private sector hospitals.

According to the World Health Organization, “since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10-15 per cent. Since then, caesarean sections have become increasingly common in both developed and developing countries”.

The WHO adds: “When medically necessary, a caesarean section can effectively prevent maternal and newborn mortality. Two new HRP (human resource planning) studies show that when caesarean section rates rise towards 10 per cent across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10 per cent, there is no evidence that mortality rates improve.”


Also read: No big impact of childbirth on women’s job prospects, says UN study on rural Indian women


Role of Ayushman Bharat

An interesting change between NFHS 4 and NFHS 5 is the large jump in households with health insurance coverage — from 28.7 per cent to 41 per cent. That, government officials say, is a direct fallout of the Modi government’s Ayushman Bharat PMJAY.

“It is not surprising that proportion of C-section delivery has increased. Evidence from around the world shows that the proportion increases as incomes increase,” said former National Health Authority CEO Indu Bhushan, during whose tenure the PMJAY was launched.

“In the US, for example, the proportion increased from 4.5 per cent in 1970 to more than 30 per cent in 2009. It continues to stay at that level even now. In China, the proportion is close to 50 per cent. Nonetheless, studies show that the proportion beyond 15 per cent has little health benefits,” he illustrated.

“There can be at least three possible reasons for increase in proportion of C-sections conducted in private hospitals. First, institutional births in public hospitals have increased (from 52 per cent to 62 per cent), while the numbers have remained constant in private hospitals. It is possible that the more high-risk births are happening in the private sector because of better facilities,” Bhushan continued.

“The second possibility is that with the decline in fertility, more first-order births are happening, and since these are more complicated, could need C-section. The third reason could be the increase in insurance coverage, much of it would be because of Ayushman Bharat,” he added.

Other domain experts point out that there is a need to address the disparity in C-section rates between states, as that could indicate deficient access to quality and affordable care.

“States in the north and the east show very low C-section rates while those in the south and the west show very high rates, indicating a high degree of geographical variation in access to critical surgical care, especially in the public health facilities,” said Poonam Muttreja, executive director of Population Foundation of India.

“Often a shortage of specialists in public hospitals, especially in rural areas in the northern and eastern states, drive the private sector to cater to riskier pregnancies, and hence they have a higher proportion of C-sections,” she explained.

“Although caesarean delivery can be a life-saving surgery, this procedure should be performed only when medically indicated… Unnecessary caesarean deliveries may be associated with higher health care costs. Given that private sector facilities were associated with increases in the rate of caesarean deliveries; it is important that policy makers address the increasing number of avoidable caesarean deliveries in India,” Muttreja added.

(Edited by Poulomi Banerjee)


Also read: Indians didn’t make babies during lockdown, but abortion numbers higher, doctors say


 

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