Journal article

Why are C-section rates in private Indian health facilities unreasonably high? The providers’ view

by Dr Meenakshi Gautham and Dr Neil Spicer

published 6 December 2018

‘If I do 10–15 normal deliveries in a month I hardly ever sleep at home.’ This qualitative study looks at reasons given by health care providers for high rates of caesarean deliveries in private sector maternity care in Delhi, India.

Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. This paper, authored by Alison PeelAbhishek Bhartia, Neil Spicer and Meenakshi Gautham, and published in BMC Pregnancy and Childbirth presents providers’ perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend.

The authors conducted fourteen in-depth interviews with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad.

The results show that respondents were of the view that private sector caesarean rates were unreasonably high and perceived time and doctors’ convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more  support, from either well-trained midwives and junior staff or using a ‘shared practice’ model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers’ caesarean rates.

The paper concludes that commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the ‘safe’ option have re-defined caesareans as the new ‘normal’, even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates.

Authors

Dr Meenakshi Gautham

IDEAS India Country Coordinator and Research Fellow

Dr Neil Spicer

Assistant Professor