The National Family Health Survey (NFHS-6), conducted in 2023-24 and released in May 2026, has revealed a troubling paradox in India’s maternal healthcare story. While institutional deliveries have risen dramatically and maternal healthcare access has improved, the country is witnessing a sharp increase in Caesarean section (C-section) births – many of which may not be medically necessary.Twenty-two-year-old Suman (name changed) from a village near Rajasthan’s Dholpur delivered her first child at a private hospital earlier this year. She returned home with a healthy newborn, but also with a debt of nearly Rs 80,000 – equivalent to several months of her family’s income. Her husband, a daily-wage worker, borrowed money from relatives and local lenders to pay hospital bills. For the family, childbirth became not only a medical event but an economic crisis.Months later, the loan remains unpaid. Suman’s story raises a question that statistics alone cannot answer: when did surgery become such a common part of childbirth, and at what cost to women and their families?NFHS-6 shows that India’s C-section rate has risen from 21.5% in NFHS-5 (2019-21) to 27.2%. In private health facilities, the figure has reached 54%, meaning that more than one in every two deliveries is now surgical. Urban India has crossed 40%.Rajasthan mirrors this trend. The state’s overall C-section rate stands at 35%, while urban private hospitals report a rate of 49.4%, nearly one in every two births. The survey also points to a widening urban-rural divide, suggesting that districts with a stronger private healthcare presence are witnessing significantly higher rates than less urbanised regions.The World Health Organisation has long maintained that population-level C-section rates above 10-15% do not necessarily improve maternal or neonatal outcomes. While every pregnancy is different and many C-sections are lifesaving, rates far above this threshold raise concerns about unnecessary medical intervention.Not every increase in Caesarean deliveries is cause for alarm. Rising maternal age, diabetes, hypertension, delayed pregnancies and improved diagnosis of high-risk cases have contributed to higher C-section rates across the world. Modern obstetric care has saved countless lives because doctors have access to timely surgical intervention when complications arise.As one Jaipur-based obstetrician, speaking on condition of anonymity, observed, “A Caesarean is a life-saving procedure when medically indicated, but it should never become the default mode of childbirth.”The concern begins when surgery becomes routine rather than exceptional.In villages across Rajasthan’s Chambal region, where the Jagan Foundation works, I have repeatedly met women who describe a similar experience. They enter a private hospital expecting a normal delivery. A few hours later, anxious relatives are informed that surgery is urgently required. Most families are neither medically equipped nor emotionally prepared to challenge that advice. Faced with fear and uncertainty, they agree.The issue is whether women are being given enough information to make an informed decision.Many women report that they are told surgery is required but receive little explanation about alternatives, risks, benefits or possible outcomes. In a healthcare system marked by sharp inequalities of education and income, informed consent often remains more aspirational than real.This is also why the debate cannot be reduced to doctors versus patients. Several factors are driving the rise. Private hospitals earn more from surgical deliveries than normal births. Planned surgeries are easier to schedule than unpredictable labour. Fear of litigation encourages defensive medical practice. At the same time, many families actively seek C-sections because they fear labour pain, perceive surgery as safer, want to choose an auspicious birth date or simply place greater trust in private healthcare facilities.Yet complexity should not prevent scrutiny.Also read: Teen Pregnancy, Contraception and the Unequal Responsibility Placed on Rajasthan’s Marginalised WomenThe financial dimensions of childbirth deserve closer attention. Government-backed insurance programmes have expanded access to institutional care and undoubtedly helped many families. But some public health experts have raised concerns that package-based reimbursement systems may inadvertently encourage procedural interventions in private facilities. While insurance is not the cause of rising C-sections, it highlights the importance of monitoring how healthcare is delivered and paid for.The consequences of unnecessary surgery extend well beyond the delivery room. Compared with vaginal births, C-sections involve longer recovery periods and can increase the risk of complications in future pregnancies. For women in rural Rajasthan, where domestic responsibilities often resume almost immediately after childbirth, recovery can be physically exhausting.During one community meeting in Bharatpur district, a young mother described how she struggled to lift water containers and care for livestock for weeks after her surgery. There was no extended maternity leave, no domestic help and little access to follow-up care. For her, the operation did not end when she left the hospital.The economic impact can be equally severe. Families often take loans, mortgage jewellery or postpone essential household expenses to pay medical bills. The burden falls disproportionately on poorer households, who have fewer resources to absorb unexpected healthcare costs.Women from marginalised and low-income communities also frequently have less access to information and fewer opportunities to question medical decisions. In many cases, they rely entirely on healthcare providers to navigate childbirth, creating an imbalance of power that deserves greater attention.This raises broader questions about the commercialisation of maternity care in India.The remarkable success of institutional delivery programmes over the past two decades has saved countless lives. Rajasthan now reports institutional delivery rates above 96%, a significant public health achievement. But increasing access should not be confused with ensuring quality, transparency and dignity in care. The growing normalisation of surgical births reflects a larger shift in which women’s reproductive experiences are increasingly shaped by institutional authority rather than informed choice.Countries seeking to address rising Caesarean rates have relied on stronger monitoring systems, regular clinical audits and greater transparency. The World Health Organisation’s Robson Classification system, which categorises women into different obstetric groups to evaluate Caesarean rates, offers one useful framework for identifying patterns of overuse and underuse.Rajasthan and other states should consider mandatory audits of hospitals with unusually high C-section rates, transparent reporting of delivery data, second-opinion requirements for non-emergency surgeries and stronger oversight of private maternity care. Equally important is investment in respectful maternity care, labour support services and public awareness campaigns that help women understand their options.Women should receive accurate information throughout pregnancy, not only when labour begins. Childbirth decisions made under pressure and fear are rarely informed choices.India has made extraordinary progress in expanding maternal healthcare access. The next challenge is ensuring that childbirth remains guided by medical necessity and women’s choices – not by convenience, fear or financial incentives.Otherwise, the hidden costs will continue to be borne by the women least able to afford them.Malvika Mudgal is a social entrepreneur and founder of Jagan Foundation, working on women’s health, education and grassroots development in Rajasthan’s Chambal region.