On September 29, 2015, a memo went out from Swasthya Bhawan, the West Bengal Health Department’s headquarters in Salt Lake, to every medical college principal and every district’s chief medical officer of health. Its subject was a concern the Union Health Ministry had raised about rising Caesarean sections rates, especially where the operation was not medically needed.
The memo enclosed a statement the World Health Organization (WHO) had issued that April. It suggested that chief medical officers, who license private clinics, carry out periodic “prescription audits” of Caesareans in private and government facilities.
At the time, the National Family Health Survey (NFHS-4, 2015-16) had found that about one in four births were Caesareans in West Bengal (23.8%). The latest sixth round (NFHS-6, 2023-24) puts the figure at 44.5%, close to double that level, against 27.2% for India. In Kolkata and North 24 Parganas it was found to be 67.5%, meaning about two of every three babies were born via a C-section.
Why the concern
A Caesarean section saves mothers and babies when labour goes wrong. It is also, however, major abdominal surgery, with slower recovery rates and higher risks of infection and bleeding, and it leaves a scar that can complicate later pregnancies.
The WHO statement said that across a population, Caesarean rates above 10% are not associated with fewer deaths of mothers or newborns. While the WHO does not recommend a specific rate, the increasing numbers of Caesarean births in West Bengal, and more widely in India, deserve attention.
The opening of the gap
The NFHS’s first three rounds, from 1992-93 to 2005-06, found West Bengal close to the national average when it came to C-sections, at 10.2% against 8.5% by the third NFHS round.
The State then pulled away. Its rate reached 32.6% in NFHS-5, for which West Bengal was surveyed in 2019-21, and by NFHS-6 (2023-24) the gap with India had widened from 1.7 percentage points in 2005-06 to 17.3.
The climb has also grown steeper. The rise of 13.6 points between 2005-06 and 2015-16 took a decade, while the latest 11.9 points came in four to five years.
The data cannot reveal how many of West Bengal’s operations were necessary, though it does show when and where the rise happened.
Prevalence of C-section delivery, West Bengal
| Survey Round | West Bengal (%) | India (%) | Difference (% points) | Change in WB (% points)) | Change in India (% points) |
| NFHS-1 (1992–93) | 3.3 | 2.5 | +0.8 | — | — |
| NFHS-2 (1998–99) | 10.3 | 7.1 | +3.2 | +7.0 | +4.6 |
| NFHS-3 (2005–06) | 10.2 | 8.5 | +1.7 | −0.1 | +1.4 |
| NFHS-4 (2015–16) | 23.8 | 17.2 | +6.6 | +13.6 | +8.7 |
| NFHS-5 (2019–21) | 32.6 | 21.5 | +11.1 | +8.8 | +4.3 |
| NFHS-6 (2023–24) | 44.5 | 27.2 | +17.3 | +11.9 | +5.7 |
Source: NFHS reports
Private vs. government
Of every 10 women who give birth in a private facility in West Bengal, 9 nine now have a C-section (87.7%). In 2015-16, the year of the memo, the figure was 70.9%. West Bengal’s numbers are also significantly higher than current the national private-sector rate, 54.1%.
While numbers in the government sector are lower, they are also on the rise: government facilities performed C-sections in 28.8% of the births they handled, up from 18.8% in 2015-16 and 1.7 times the national public-sector figure of 16.9%. In Kolkata, the share of births in government facilities delivered by C-section rose from 32.4% in NFHS-5 to 59.1% in NFHS-6.
The move to private care
Births are also increasingly moving to private facilities. Between NFHS-5 and NFHS-6 their share of the total rose from about 19% to about 29%, even as the public share fell from 72.4% to 65.8%.
These private facilities now perform almost 6 in 10 of the State’s Caesareans (57%). Had births stayed where they were at NFHS-5, the same arithmetic would give a rate of about 38%. The move into private care accounts for more than half of the 11.9-point rise, about 6.6 points, and higher rates in government facilities for most of the rest, about 4.1 points.
The pattern holds outside cities as well. In rural West Bengal, 88.1% of births in private facilities are Caesareans, slightly more than the urban figure of 86.8%.
A belt around Kolkata
On a district map, the highest rates form one contiguous belt in the south of the State. Kolkata and North 24 Parganas are at 67.5% each, Hooghly at 66.6%, Nadia at 62.9%, Purba Medinipur at 59.1% and Howrah at 58.5%.
Urbanisation alone does not account for the belt. Purba Medinipur, a coastal district where 11.6% of people lived in towns at the 2011 Census, has a higher rate than industrial Paschim Bardhaman (48.1%), where 81.6% did.
Purulia, on the Chota Nagpur plateau in the West, has the State’s lowest rate at 21.6%, followed by Jhargram (27.4%), South 24 Parganas (28.5%), Maldah (29.9%) and Bankura (30.1%). Every district except Purulia is above the national average of 27.2%.
A low district average, however, can also obfuscate women in remote blocks who need an emergency Caesarean and cannot get one. Almost every birth in the two districts with the lowest C-section rates now takes place in a health facility (95.7% in Purulia and 97.7% in Jhargram, against 94.9% for the State), so what matters here, is whether those facilities can perform a Caesarean when one is needed. Block-level hospital records would show how often they do.
Behind the rise
Explanations for the rise need records the survey does not hold. The first concerns money.
Swasthya Sathi, the State’s health insurance scheme, was launched in 2016 and opened to every resident on December 1, 2020. It covers up to ₹5 lakh per family a year in government and empanelled private hospitals. Between NFHS-5 and NFHS-6, the share of households with at least one member covered by a health insurance or financing scheme rose from 33.7% to 88.2%.
The timing matches the shift to private care. West Bengal was surveyed for NFHS-5 before the scheme became universal, and the births counted in NFHS-6 straddle the change. A scheme that pays for care in private hospitals would be expected to move births into them. The same years brought the COVID-19 pandemic. By May 2020 the State had set aside 69 hospitals for COVID-19 patients, 16 government-run and 53 privates. The disruption fell on both sectors, and the survey cannot separate its effect from the scheme’s.
Whether the scheme’s payments also tilt private hospitals towards surgery is a question its claims records could settle. They would show what share of delivery claims are Caesareans and how package rates for normal and Caesarean births compare.
Another explanation feeds on itself. A woman with a previous Caesarean can safely try labour only where an emergency operation can follow at once, which most district hospitals in India cannot promise. Each first operation therefore tends to bring a second, and the rate keeps rising over years.
Additionally, more women of childbearing age today are overweight or obese (34.6%, up from 22.7%), and more have 10 or more years of schooling (40%, up from 32.9%). An analysis of NFHS-5 data links both to higher odds of a Caesarean.
What the memo asked for
The 2015 memo already proposed periodic audits by the officials who license private clinics. The WHO statement it enclosed put forward a common method for such audits, the Robson classification. It sorts women into 10 groups by details such as how labour began and the baby’s position, so that hospitals can be compared fairly.
Published for each hospital, including every private hospital empanelled under Swasthya Sathi, the results would show where Caesareans are common among low-risk women, the group most likely to have unnecessary operations.
Fewer unneeded operations also require labour wards that can manage a normal birth safely at any hour, and protocols that let suitable women attempt a vaginal birth after a Caesarean. In Purulia and Jhargram the task would have to run the other way, to keep emergency surgery within reach.
What is needed now
The first step is for the State to say whether the audits suggested in 2015 were ever carried out, and what they found. Caesarean audits must then become routine in government and private hospitals alike, under the health department’s supervision. Swasthya Sathi can check each Caesarean claim against the medical reason recorded for it and devise methods to ensure hospitals are given no reason to prefer surgery.
Every woman who needs a Caesarean should get one without delay, and no woman should have one when there is no compelling medical reason behind it.
(Dr. Margubur Rahaman is a public health researcher with the MAMTA Health Institute for Mother and Child, New Delhi. margubur48@gmail.com Ankit Mishra is an ICSSR Doctoral Fellow at the Govind Ballabh Pant Social Science Institute, Prayagraj. ankitmishrakoraon@gmail.com)