The Cesarean Delivery Trend in South Asian Countries

by Eva Martin, MD of Elm Tree Medical Inc.

We all came into the world the same way: childbirth. Well, almost the same way. Some of us were delivered vaginally and others were delivered by a cesarean section. Looking at two adults, you’d never know who was born which way. So, does it matter?

The short answer is, yes, it matters a lot. Cesarean sections can save lives. Some babies are too large to fit through the pelvis and a cesarean is their only way out.

Across the globe, the percentage of births by cesarean section has been growing. At first, you may think this is a great thing. But medically unnecessary cesarean sections are dangerous. They can increase the risk of bleeding, infection, and severe complications in later pregnancies that can lead to the infant’s or mother’s death.

Here’s the rub: many women who need cesareans don’t have access to them. And, many women who don’t need them are getting them anyway. South Asia is a particularly interesting place to examine cesarean delivery rates. Like most places in the world, the cesarean section rate is increasing, but where? And for whom?

How many c-sections is too many c-sections?

In the United States, about one-third of infants are born via cesarean section (1). Most experts agree that this number is too high. The World Health Organization estimated that 15% is a reasonable upper threshold for a nation’s cesarean delivery rate. At 15%, there is a reasonable balance between saving lives with cesareans and causing women and babies more harm than good.

What is the lower limit?

Experts estimate that at least 5% of births absolutely require a cesarean delivery, although this estimate is pretty rough (2). Suffice it to say, less than 5% is definitely not the safest level for laboring moms.

So, where do South Asian countries stand?

A 2013 study collected data from household surveys from four countries in South Asia: Bangladesh, India, Nepal, and Pakistan (3). All four countries showed significant increases in the rate of births by cesarean section from the 1990’s to the present.

For instance, the cesarean rate in India in 1992 was 2.4% and rose to 8.4% in 2006. Of the four countries, Nepal was the only country whose most recent c-section rate (in 2011) was less than 5%, at 4.6%. Overall, these rates are heading in the right direction.

Unlike the United States, where the big push is to decrease unnecessary cesarean sections, in South Asia, the big push is to give women who need cesarean sections access to them. The increasing c-section rate provides hope that this is happening.

Are c-sections becoming more available for all women?

Or just the richest women? The authors divided everyone up by their wealth. For the poorest women, the most recent cesarean delivery rate was less than 2% for all four countries. The richest women had a much higher cesarean delivery rate than the poorest women in all countries, and they have shown huge gains in the past few decades.

In India, the wealthiest women had a c-section rate of 8.2% in 1992, which rose to 25.5% in 2006. The poorest Indian women had a c-section rate of 0.4% which rose only to 1.5% over the same time period. In this case, the wealthiest women may actually get too many cesarean sections, while the poorest women do not have access to enough. In both cases, the mother’s health is at risk.

None of us remember our very first birthday—the day we were born. But, often, the events that day shaped the rest of our lives. Was a c-section necessary? If so, was it available to us? Was a vaginal delivery possible? Did we end up with a cesarean section anyway? Location and wealth, it seems, are two of the biggest factors in answering these important questions. The most important question is still unanswered: how can we find a balance between too many and too few cesarean deliveries to save the most lives?


1. Hamilton BE, Martin JA, Osterman MJ, Curtain SC. Births: preliminary data for 2014. Natl Vital Stat Rep. 2015;64:1–19.
2. Cavallaro FL, Cresswell JA, Franca GVA, Victora CG, Barros AJD, Rosmans C. Trends in ceasarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013;91:914-922D.

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EvaMartinDr. Eva Martin is the CEO and Founder of Elm Tree Medical, Inc., a medical device company devoted to innovating in the field of women’s health. They are currently developing a device to increase the accuracy of cervical dilation measurements. Eva blogs regularly about women’s health on the Women’s Health Review blog. To learn more, please visit their website or connect with her on Twitter or Facebook.

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