India
India is the leading example among a growing number of
countries where there is simultaneous overuse and underuse of
interventions. India has 27 million annual births, about one in
every fi ve births worldwide. Although India has a relatively large
number of midwives, they are not consistently educated to
international standards, and they attend fewer than one in six
births,23 with doctors attending most births in urban areas and
one fourth in rural areas. The UNICEF 2009 Coverage Evaluation
Survey165 reported an Indian caesarean section rate of 15·1%,
almost within the WHO recommended range. However, that
overall rate masks enormous disparities within the country. Data
from an earlier DHS survey (2005–2006),166 which reported an
8·5% overall rate, showed mothers in the poorest rural areas had
a caesarean rate of 1·5%; and mothers in the wealthiest urban
areas had a caesarean rate of 32·1%. Regionally, almost a third of
mothers in Kerala (31%) gave birth by caesarean section
compared with 2·3% of mothers in Nagaland.167 The Coverage
Evaluation Survey165 noted a caesarean section rate of 34·6% in
private hospitals compared with 12·4% in government hospitals.
India has lost what was once a strong tradition of
midwifery-based practice168 and has been slow to reintroduce it.
Midwives have a restricted scope of practice and, over time,
experience the associated loss of skills.169 India is already showing
signs of following the model of China and Brazil, with high
caesarean rates in wealthy mothers in urban areas, leading to a
culture of non-medically indicated caesarean sections. As a
rapidly emerging economy, with an improving health
infrastructure and reliance on private obstetrical providers, India
has obvious parallels to Brazil and China. Whether India will also
follow a path of high levels of medical interventions followed by a
re-emphasis on midwifery remains to be seen.