DIMAPUR — A new study analysing data from the
National Family Health Survey-5 (NFHS-5) has revealed stark disparities in
access to Caesarean delivery (CD) across India, with Nagaland exhibiting the
lowest CD rate at 5.2%.
The study, published in The Lancet Regional Health—Southeast
Asia, examined state-wise variations in CD rates, considering geographical
location, wealth, and type of healthcare facility (public vs. private).
Researchers found substantial variation across states, with
the lowest rates concentrated in the Northeast, including Nagaland, Meghalaya
(8.2%) and Assam (9.7%). By contrast, southern states like Telangana have rates
as high as 60.7%, reflecting vast disparities across the country with a
national average of 21.5%.
The study highlighted that inequality in access to CDs in
states like Nagaland and Meghalaya is among the highest in India, with relative
inequality scores of 10.4 and 10.9, respectively. “In states like Nagaland and
Meghalaya, caesarean deliveries are primarily utilised by wealthier
populations, leaving the poorest at a severe disadvantage,” it noted.
This inequality is compounded by the lack of adequate
healthcare infrastructure and challenging geographic conditions that limit
access to facilities capable of performing CDs. Furthermore, cultural factors,
such as preferences for vaginal deliveries and mistrust of institutional
healthcare, exacerbate the problem, it suggested.
The study also pointed to challenges tied to the Rashtriya
Swasthya Bima Yojana (RSBY) insurance program—the primary health insurance
scheme for those below the poverty line—which negatively influenced CD access,
as beneficiaries had lower rates than non-beneficiaries in states like
Nagaland.
“High financial
constraints on patients and a lack of awareness about available schemes often
overshadow the benefits of insurance programs, like RSBY. As a result,
beneficiaries turn to paid services instead of utilising their insurance
benefits,” it stated.
Moreover, schemes like Ayushman Bharat Pradhan Mantri Jan
Arogya Yojana (AB PM-JAY), while enabling access to private healthcare, still
resulted in higher out-of-pocket expenses for economically disadvantaged
groups.
Nationally, the rate of caesarean deliveries is higher in
private healthcare facilities (47.5%) compared to public facilities (14.3%).
However, in states like Nagaland, where healthcare infrastructure is limited
and reliance on public services is high, these rates remain consistently low
across all income groups.
The study noted that “in states with uniformly low CD rates,
including Nagaland, access challenges persist across wealth groups, suggesting
that even the wealthiest quintile faces obstacles in accessing maternal care.”
The study, while using India’s most comprehensive publicly
available dataset on CD access, acknowledged potential biases due to sampling,
nonresponse, and recall issues inherent in the NFHS-5 data. Various mitigation
strategies were employed; however, as a descriptive cross-sectional analysis,
the study was limited in its ability to infer causality and could not fully
explain the observed disparities.
The researchers emphasised that policy failures often stem
from multiple factors, requiring further research using implementation
evaluation and policy analysis frameworks. Periodically assessing the
implementation and effectiveness of health policies can improve patient
outcomes, ensuring they align with intended goals.
While no single prescriptive solution exists, evidence-based
strategies in similar contexts can provide learning points to balance the
under- and overuse of CDs. To curb unnecessary CDs, they recommended adopting
and implementing WHO evidence-based non-clinical guidelines, including
mandatory second opinions, periodic audits, and physician education. The WHO
statement on caesarean section rates—“Every effort should be made to provide
caesarean sections to women in need, rather than striving to achieve a specific
rate”—underscores the importance of focusing on clinical need rather than
arbitrary thresholds, it said.
To bridge the identified gaps, the researchers recommended
strengthening public healthcare infrastructure, ensuring the availability of
skilled professionals in remote regions, and expanding insurance coverage under
schemes like Ayushman Bharat to alleviate the financial burden for economically
disadvantaged groups.
“There is a need for
tailored interventions that respect local cultural preferences while ensuring
the safety and accessibility of essential maternal healthcare services,” the
study emphasised.
