Somewhere in Tamil Nadu, a woman emerging from a pregnancy already burdened by physical and mental distress is forced into an extra surgery, paying twice: with her health and her finances.
This is not just an anecdote but a glaring reality check for one of the country’s most robust health systems, which has proven to be a model state in community health check-ups, immunisation, and institutional delivery. This data challenges one of Tamil Nadu’s foundational maternal health metrics.
Data from the National Family Health Survey (NFHS-6) covering 6.79 lakh households reveals a worrying trend in Tamil Nadu: Caesarean (C-section) deliveries accounted for an alarming 46.9% of all births in the state. This is not a random spike, but a steady surge from 34.1% a decade ago, pointing to a systemic normalisation of surgical pregnancies.
While a C-section is a lifesaver in emergencies, it carries risks like infection and uterine rupture. The World Health Organisation notes that rates exceeding 10% yield no additional maternal benefits, creating a paradox in Tamil Nadu where nearly half of all births are surgical.
Both prominent Dravidian parties, the AIADMK and the DMK, have been active in the public health space. While the former rolled out schemes such as the Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS) and the Amma Baby Care Kit, the latter provided the Dr Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS) and the Kalaignar Magalir Urimai Thittam.
Tamil Nadu has achieved an impressive health profile, reflecting a Maternal Mortality Ratio of 35 deaths per 1,00,000 live births, a 90% facility delivery rate, and 95% childhood immunisation. This success stems from a unique community health model heavily driven by senior Village Health Nurses (VHNs) who bridge the gap between communities and formal healthcare without relying heavily on ASHA workers.
For most other states, the core issue lies in access and a lack of facilities, which is why C-section rates there are lower and less of a concern. In Tamil Nadu, the role of ASHAs, VHNs, or Anganwadi workers is concentrated in the prenatal and postnatal phases, while the actual delivery is entirely managed by the hospital. Consequently, a first-generation woman delivering at a health facility might consent to a C-section without fully understanding the procedure. This is not the fault of any individual, but rather a reflection of a robust system’s limitations.
This dynamic potentially explains why impressive performance in maternal health metrics and high C-section rates go hand in hand. The state can effectively link public and community health systems, yet the information available at the exact time of birth remains the crucial factor determining the type of delivery.
In 2022, the Centre for Economic Data & Analysis (CEDA), Ashoka University, used national-level data to find that Tamil Nadu had the highest out-of-pocket expenditure (OOPE) for deliveries in private hospitals, averaging Rs 36,909. Further, NFHS-6 shows that the public share of institutional births has declined from 70.2% to 66.9% — a considerable decrease over a single cycle. This reflects that a growing number of individuals are using private facilities and are willing to pay for them.
Another issue lies in the divergence between C-section delivery rates in the public and private sectors. In public facilities, 39.6% of all births were delivered via C-section, representing a 3.6% increase from NFHS-5. Meanwhile, the number was 60.3% for private facilities, a reduction of 2.5% compared to the previous round. These statistics show how deeply rooted C-sections remain in the private sector, given that the majority of pregnant mothers there undergo the surgery.
The problem stems not just from changing individual preferences, but from the very structure of one of Tamil Nadu’s key initiatives: the Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS), which provides financial support for surgical treatments to approximately 1.48 crore people.
Operating on a fixed-package reimbursement model, the insurance company pays the hospital a predetermined fee for the surgery. From the hospital's perspective, a C-section offers a higher financial return while being relatively less time-consuming. This model has been used in multiple countries, such as Brazil, South Korea, and China, and may explain the systemic tendency to favour C-sections.
A consequence of this is demonstrated by a peer-reviewed journal article published in BMC Pregnancy and Childbirth. The data show that 73% of individuals who self-reported as poor had C-section deliveries in private hospitals, compared to 64% for the non-poor. This contradicts national trends. For Tamil Nadu, C-section deliveries follow a regressive structure, placing the heaviest burden on poorer individuals.
This is an understated yet vital aspect to discuss in the context of C-section deliveries. A 2016 study of 95,000 judgments from district consumer courts across South India found that Tamil Nadu accounted for the highest share (36%) of medical negligence rulings. Out of these, gynaecology and obstetrics cases topped the list. High-profile cases have continued to emerge in Chennai, Coimbatore, and Krishnagiri.
What does this mean for medical practice? Individual doctors may view C-sections as a defensive measure to avoid legal trouble, given the procedure's predictable timing and relatively uncomplicated routine. When surgery is performed, the public perception is often that the medical system did everything it possibly could to help. Pointing this out is not a deflection of the issue, but a reality check of the complex legal environment in which doctors operate. Ultimately, however, the financial and health burden is borne entirely by the woman who undergoes it.
(Dr Maya K is Assistant Professor, Department of Economics, CHRIST University, Bengaluru; Ashwin Krishna is PhD Scholar, Department of Economics, CHRIST University, Bengaluru)