Motherhood under the knife

Srinagar, Dec 22: An analysis of India’s Caesarean Section (CS) deliveries published in the January 2025 issue of The Lancet reveals a striking feature of Jammu and Kashmir: the state’s high CS rates are consistent across all wealth quintiles, with only a 2 to 3 percent disparity between the richest and poorest households.

This contrasts with most other Indian states, where socioeconomic factors heavily influence access to CS deliveries.

According to the National Family Health Survey (NFHS-5), 82.1 percent of deliveries in private hospitals in J&K are conducted via CS.

In public facilities, the figure is 42.7 percent, both significantly above the World Health Organisation’s (WHO) recommendation of 10 to 15 percent.

Unlike in many states, these high rates in J&K are not driven by wealth disparities but appear to stem from broader, region-wide factors, an analysis of NFHS-5 CS data (state-wise variation and inequalities in caesarean delivery rates in India: analysis of the National Family Health Survey-5 (2019-2021 data) published in January 2025 issue of The Lancet reveals.

Greater Kashmir spoke to a number of gynaecologists working in Kashmir to understand the reasons behind the disproportionate CS deliveries.

Gynaecologists and maternal health experts pointed to a combination of medical, cultural, and societal factors that spiked the J&K CS rates to one of the highest in India.

J&K has one of the highest proportions of the population that is unmarried at 29 years as per available data.

Many women in J&K marry later and have pregnancies in their 30s or 40s.

Advanced maternal age is often associated with complications, reduced fertility, and a higher likelihood of medical interventions, including CS.

“Older maternal age brings risks that make vaginal deliveries more challenging,” says Prof Farhat Jabeen, one of the best-known gynaecologists in Kashmir.

Infertility is increasingly common, and many pregnancies result from prolonged medical treatments, making them highly valued or “precious.”

Families and expectant mothers are often unwilling to take any risks, opting for CS as a perceived safer alternative, what is referred to as CS on demand.

Prof Jabeen says, “When families invest emotionally and financially in achieving a pregnancy, they prefer to eliminate any uncertainties during delivery.”

Conditions like polycystic ovary syndrome (PCOS), obesity, and hypertension are widespread among women in the region, increasing the likelihood of complications that necessitate CS.

These health issues, compounded by late pregnancies, make vaginal deliveries more challenging and risky.

Families often perceive CS as a more controlled and less painful option compared to vaginal delivery. “There is a misconception that CS ensures better outcomes for both mother and child,” says Prof Shahnaz Taing, a trusted infertility expert in J&K.

Moreover, there is limited awareness about the benefits of vaginal deliveries and the potential risks of unnecessary CS procedures.

“Most women think that CS is painless, without any complications. This notion needs to change, and our grassroots healthcare system as well as the levels above need to work actively on this,” Prof Taing says.

Both public and private healthcare providers in J&K tend to lean towards CS deliveries, figures show.

In private facilities, financial incentives often play a role.

Public hospitals too may lack the resources or staff needed to manage complex vaginal deliveries, further contributing to high CS rates.

J&K Private Hospitals and Dialysis Centers Association President, Faizan Mir said that in the private hospitals in the private sector, there are no full-time gynaecologists, who can plan and wait for a patient to go into labour and monitor till delivery.

“Plus couples have a preference for CS, believing that to be better for their lives. The high CS rates are a result of several factors, it is not like private hospitals push for it,” he said.

Over the last decade, the percentage of institutional deliveries in J&K has risen dramatically from just over 50 percent.

According to gynaecologists, many women now associate delivering in a hospital with the expectation of medical intervention, often equating it with surgical procedures.

“A large number of women believe that giving birth in a healthcare facility means a doctor must intervene in the natural birth process,” says Prof Taing.

This intervention, for many, translates to a CS, with women expecting a pain-free and controlled birthing experience.

Prof Jabeen says unnecessary CS deliveries increase risks such as infections, blood loss, and longer recovery times.

Repeated CS deliveries can lead to complications like uterine rupture and placenta accreta in future pregnancies.

“In addition, babies delivered via CS face higher risks of respiratory issues and miss out on the beneficial microbial exposure associated with vaginal births,” Prof Jabeen says.

Prof Taing says the prevalence of CS deliveries places financial strain on families and healthcare facilities. “We have seen how often tertiary care facilities, like Lal Ded Hospital, get overburdened due to the high demand of CS, and how patients are unnecessarily referred from many hospitals,” she says.