NFHS-5: Share of Institutional Births & C-Sections increase in most States
Sai Krishna Muthyanolla
December 24, 2020
NFHS-5 data on delivery care indicates that the share of institutional births & C-Sections has increased in most states. It is also observed that the share of births in public health facilities has also increased in multiple states.
Recently, the key findings of the first phase of the National Family Health Survey-5  (NFHS-5) covering 17 states and 5 union territories were released. The survey collects extensive information on population, health, nutrition, etc. emphasizing on women and children. Estimates of 131 indicators are provided in the survey’s findings.
A separate section on delivery care is part of these findings where information pertaining to the type of birth like a cesarean section, dependence on public and private health facilities, and presence of skilled health personnel for delivery are provided for each of the 22 states/UTs parts of the first phase of the survey. Births in the five years before the survey are covered. In this story, we look at the data related to these indicators and compare it with NFHS-4.
Appropriate delivery care is essential for maternal health and perinatal health. Delivery care has a considerable influence on various health indicators like maternal mortality and infant mortality under the UN Sustainable Goal 3: ‘Ensure healthy lives and promote wellbeing for all at all ages.’
Institutional births were comparatively lower in northeastern states
In the states of Kerala and Goa, and the union territories of Lakshadweep and Andaman & Nicobar Islands, the percentage of institutional births is above 99% as per the NFHS-5 findings. That is, of all the births that have been registered in the state/UT for the last five years, more than 99% have taken place in an institution. Less than 1% have taken place outside health institutions in these places. In Bihar, only about 76% of the births were institutional- the least among states excluding the northeastern states. Except for Sikkim, all the remaining northeastern states reported less than 90% institutional deliveries. The percentage of institutional births was only 45% in Nagaland and about 58% in Meghalaya. This could be attributed to the lack of basic health amenities and the socio-cultural practices prevalent in the northeast.
Urban-Rural divide observed in the share of Institutional births across States
From the data provided in NFHS-5, it is observed that the percentage of institutional births in urban parts of Mizoram was 98.8% whereas in the rural areas it was 72.5% which is among the lowest. Meanwhile, in Nagaland, the only state with less than 80% institutional births, the share of such births in urban areas is 65% compared to just 38.8% in rural areas. Kerala, Goa, Lakshadweep, Sikkim, and Dadra & Nager Haveli were the only places where the share of institutional births in rural areas was higher than in urban. The difference in the share of institutional births between urban & rural areas is high in the northeastern states. In Meghalaya, the difference was as high as 28% while in Mizoram and Nagaland it was more than 26%. In most of the other large states, the difference is less than 5%.
There is an overall improvement in percentage of institutional births over the years
There has been an improvement in the share of institutional deliveries over the years. Sikkim has witnessed an increase of more than 90% in the past decade. Assam and Bihar too have recorded an improvement of more than 50% as compared to NFHS-3.
Institutional births at public facilities is below 50% in five states
Despite Kerala reporting more than 99% institutional births, it is observed that the state is at the bottom of the list when the percentage of institutional births at public health facilities is considered. Only about 34% of the institutional births in Kerala were at public health as per NFHS-5. Similarly, the states of Nagaland, Gujarat, Telangana, and Meghalaya too had less than 50% of institutional births in public health facilities. Ladakh had the highest, with more than 90% institutional deliveries in public health facilities.
Share of births at public facilities increased in 18 states/UTs since 2015-16
Compared to NFHS-4, the share of institutional births in public health facilities has dropped in four states/UTs- Andaman and Nicobar Islands, Kerala, Goa, and Sikkim.  Kerala is the only state where there has been a drop in this parameter in the last 10 years. Among the remaining 18 states/UTs where there has been an increase in the share of institutional births, Telangana has recorded the highest increase by more than 19% followed by West Bengal with close to a 16% increase. Assam and Andhra Pradesh have also recorded an improvement by more than 12% each. If one compares with NFHS-3, Assam has witnessed an improvement of more than 61% and Bihar by over 53%.
Average out of pocket expenditure per delivery in public facilities has reduced in some states
The average out of pocket expenditure per delivery in public health facilities has been provided in the report. In West Bengal, the expenditure has come down by Rs. 5236 as compared to NFHS-4 which may have resulted in the increase in institutional births in public facilities in the state. Likewise, in Telangana, Gujarat, Nagaland, and Maharashtra, the share of institutional births in public health facilities has increased and the average out-of-pocket expenditure per birth has decreased. However, this is not the case with all the states. In some states, this expenditure has increased compared to NFHS-4. It has increased by more than Rs. 1000 in Assam & Bihar.
Proportion of births in public facilities is higher in rural areas in most states
In 16 of the states/UTs part of the first phase,  the proportion of institutional births in public health facilities is higher in rural areas than in urban areas. The six states/UTs where the trend is reversed are Ladakh, Jammu and Kashmir, Mizoram, Manipur, Meghalaya, and Nagaland. Here, the proportion of institutional births in public health facilities is higher in urban areas than in rural parts. The urban-rural divide was the most prominent in Lakshadweep where this is 92% in rural areas and 56.3% in urban areas.
Births by C sections is on a rise
Not only are institutional births rising, but the percentage of births by Caesarean Section (C- Section) is also increasing. C- sections are typically performed if there are complications from pregnancy which puts the health of the mother or child at risk since it is major surgery. According to WHO, 10% to 15% is the ideal cesarean rate. If the percentage of births by C-Section is below 10%, it is considered to be underused and if the same is above 15%, it means that the procedure is being overused. Only Mizoram’s rate of births by C-Section falls in this ideal category.
C-Sections are being overused in most states
Almost 61% of the deliveries in Telangana were through C-Section. Even according to the previous NFHS survey, the state had topped the list with over 57% births by C-Section. Andhra Pradesh is next in line with more than 42% of births by C-Section. Going by the WHO’s standards, 18 States/UTs are overusing C-Section. In Bihar, Meghalaya, and Nagaland, C-Sections are being underused. In Nagaland, it is seen that the rate has dropped further as compared to NFHS-4. Mizoram and Lakshadweep are two other states/UTs where the rates have dropped.
The share of C-Sections has increased by over 20% in Jammu & Kashmir, Sikkim, and West Bengal as compared to NFHS-3. Delivery by C-Section is more prevalent in rural areas than in urban areas only in Goa and Lakshadweep while it was reverse in the other states. The difference was the least in Kerala and highest in Tripura.
Private facilities across all states are overusing C Sections
The least share of births by C-section in private health facilities was recorded in Nagaland, about 23%, which implies that C-Sections were being overused by private health facilities across all states/UTs.  Births by C-Section were more than 50% in 12 of the 22 states/UTs, three of which had recorded more than 80% births by C-Section. In Tripura and Jammu & Kashmir, C-Section births were more than 90% in private health facilities. Public health facilities recorded a relatively smaller percentage of births by C-Section. The highest share of C-Sections in public health facilities was recorded in Telangana at 44.5% whereas the lowest was 3.9% in Bihar. Public facilities overused C-Sections in 16 states/UTs and were below 10% in four states/UTs including Mizoram, Meghalaya, Nagaland, and Bihar where the share of institutional births was on the lower side. The three northeastern states had also witnessed a drop in C-Section births compared to NFHS-4. Ladakh, Sikkim, and Goa reported an increase of more than 10% in C-Section births at public health facilities compared to NFHS-4.
Multiple reasons can be attributed to increasing C-Sections
One of the major reasons for the increase in C-Sections could be the push by private health facilities since it is costlier than normal delivery. Further, more women may be opting for C-Section as it is considered a safe procedure and can also help avoid the pain that comes with normal delivery. Whatever may be the cause, the increase in C-Sections is something that the government needs to focus on and reduce its share.
Featured Image: Share of Institutional Births.