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India’s institutional delivery rate has reached 90.6 per cent, but rising hospital births have not translated into equal access to emergency obstetric care.
Bihar’s overall Caesarean section rate of 13.2 per cent hides a deeper crisis in public health facilities, where the rate is just 2.7 per cent.
A very low public-sector C-section rate can indicate that women with obstructed labour, placental complications or other emergencies may not be receiving life-saving surgery in time.
India’s maternal health challenge is now split between excess surgical intervention in some private hospitals and inadequate emergency care in under-resourced public facilities.
A striking paradox has emerged in India’s maternal healthcare landscape. According to the National Family Health Survey-6 (NFHS-6), institutional deliveries have crossed a major milestone, reaching 90.6 per cent nationally. More women are giving birth in medical facilities than ever before.
Yet beneath this achievement lies a fractured reality. Nationally, Caesarean section rates have climbed steadily to 27.2 per cent, far above the World Health Organization’s reference range of 10 to 15 per cent. In affluent and highly medicalised private hospitals in parts of southern India, surgical deliveries have become the statistical norm, crossing 54 per cent.
Bihar, by contrast, reports an overall Caesarean section rate of just 13.2 per cent as per NFHS-6 (up from 9.7 per cent in NFHS-5). At first glance, this may look like a sign of low-intervention childbirth. But the statewide average hides the real crisis.
Bihar’s low C-section rate is not necessarily evidence of safe, natural births. It is also a warning sign of a severe structural gap in emergency obstetric care.
The true picture becomes clearer when the data is separated by type of facility. In Bihar’s public health facilities, where many low-income and rural women go to deliver, the Caesarean section rate is just 2.7 per cent.
In public health terms, a public-sector surgical rate below 5 per cent is widely treated as an indicator that many women who need emergency obstetric care may not be receiving it. It suggests that when a woman arrives at a rural health facility with obstructed labour, breech presentation, placental abruption or another obstetric emergency, the system may not be equipped to intervene in time.
If Bihar’s low surgical rate reflected safe and successful vaginal deliveries, the state’s maternal and infant survival indicators would tell a very different story. Instead, the data points to a more troubling reality.
When a health system cannot provide an emergency surgical delivery during a labour crisis, the result is not a successful natural birth. It can be a preventable tragedy.
In resource-limited parts of the state, public facilities often face shortages of blood banks to manage postpartum haemorrhage, a lack of round-the-clock anaesthetists and inadequately equipped operating theatres. These are not peripheral gaps. They are the difference between a facility that can conduct a normal delivery and one that can respond when childbirth becomes life-threatening.
When life-saving surgery cannot be performed, newborns may die in the womb or immediately after birth. Mothers may also die from complications that could have been managed with timely emergency care.
When life-saving surgery cannot be performed, the infant dies in the womb (stillbirth) or immediately after birth, driving elevated survival risks across the state—where the Infant Mortality Rate stands at 23 and the Neonatal Mortality Rate at 17 per 1,000 live births, as per 2022-24 Registrar General of India's Sample Registration System (SRS) bulletin.
Concurrently, the mother succumbs to preventable labor complications, keeping Bihar's Maternal Mortality Ratio at 96 per 100,000 live births as per the SRS bulletin — miles away from states such as Telangana, with an MMR of 48, and Kerala, with an MMR of 24.
What makes this failure especially painful is that India has, in many ways, succeeded in bringing women into hospitals. Public health campaigns, financial incentives and frontline workers have helped shift childbirth away from homes and towards institutions. In Bihar, more than 81 per cent of women now choose institutional delivery.
Women and families have responded to the message. They travel to health facilities because they have been told that a hospital birth is safer.
But reaching a facility is only the first step. The promise of institutional delivery depends on what happens after a woman reaches the delivery room.
If the facility can manage only routine births, and cannot respond to complications, institutional delivery becomes an incomplete public health success. Women may reach the delivery table, but when a medical emergency occurs, the public system may still fail to save them.
This is the disconnect at the heart of Bihar’s maternal health crisis. The demand for institutional care has risen. The capacity to provide comprehensive emergency care has not kept pace.
India’s maternal healthcare landscape now reflects two different but connected failures. In some private hospitals, especially in more urban and affluent regions, Caesarean sections appear to be overused. Healthy women may be pushed towards surgery even when it is not clinically necessary, driven by convenience, scheduling pressures, risk-averse medicine or commercial incentives.
In parts of the public health system, the opposite problem persists. Women who urgently need surgery may not get it because there is no surgeon, anaesthetist, blood bank or functioning operating theatre available when the emergency occurs.
Both situations are failures of healthcare. One is excess intervention. The other is absence of intervention. Both can harm women.
A single national C-section average cannot capture this reality. India does not have one Caesarean section problem. It has a distribution problem: too many surgeries where they may not be needed, and too few where they could save lives.
True health equity will require action on both fronts. Private-sector Caesarean rates need stronger clinical audits, transparent reporting and accountability to ensure that surgical births are performed when medically indicated, not when they are commercially convenient.
At the same time, states such as Bihar need urgent investment in emergency obstetric care. That means functional blood banks, round-the-clock specialists, trained anaesthetists, operating theatres, referral transport and public facilities capable of managing complications when they arise.
Safe motherhood cannot be measured only by whether a woman reaches a hospital. It must be measured by whether the system is ready when childbirth turns into an emergency. Bihar’s low public-sector C-section rate should therefore not be read as a quiet success. It should be read as an alarm. The challenge is not to raise surgical rates for their own sake, but to ensure that every woman who needs emergency care can receive it in time.
Gunjan Soni is a Homoeopathic Practitioner (BHMS) pursuing a Master of Public Health. Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth