Last month, a friend in Bombay told me his sister had just delivered her first baby.

She was 28 years old, healthy, first pregnancy, with no complications anyone had flagged across nine months of check-ups, and her hospital had set the delivery date a month before her due date.

She was brought in at 6am on a Tuesday. By 9am, she was in the OT for a C-section.

The reason on the consent form, signed minutes before the surgery, was "previous failed trial of labour."

She had never been in labour.

The grandmothers were waiting outside, the car was decorated for the drive home and the hospital handed over a gift hamper as they left.

When my friend asked the doctor afterwards why the surgery had been needed, the doctor said it would just have been safer this way. 

He didn't push back, and most people don't.

Stories like this are now the most common way a baby gets delivered in urban India, and most of us have no idea it is happening.

In Indian private hospitals, 47.4% of all births during 2019-21 were caesarean sections, according to NFHS-5 data analysed by ORF in April 2025.

In Indian government hospitals, the same number is 14.3%.

That's almost one in two private deliveries becoming surgery, against one in seven on the government side, in the same country, with the same patient pool, often with the same.

The WHO has been saying since 1985 that the medically necessary C-section rate sits between 10% and 15%, and that anything above that does not save more babies or mothers.

In Andhra Pradesh, the private hospital figure is now 67.71%.

Two in every three babies, cut out instead of born.

This is what made the AP government approve a scheme on 22 July 2025 to train 1,264 midwives across 86 government hospitals just to bring normal childbirth back.

When I first read these numbers, my reaction was the obvious one. Private hospitals are greedy, C-sections pay more, doctors push surgery for profit.

But that explanation cracks the moment you push on it. 

The same gynaecologist who would deliver your baby normally on a Tuesday morning shift at a government hospital is performing a C-section on you on a Tuesday evening in their private practice, with the same training and the same patient, but a different decision. 

The only thing that changed between the morning shift and the evening shift was who the customer was.

Indian private maternity has done something stranger than just creating an agent with bad incentives.

It has split the principal in two.

The mother is the principal of the medical event, but the husband and the in-laws are the principal of the family event, and the family event is the one that gets paid for. 

They pick the hospital, sign the cheque, and tell the relatives afterwards.

The hospital knows exactly which of these two it is selling to.

A scheduled C-section is what the family event looks like when you write it down on paper.

You can fly the grandmother in from Indore on time, call the astrologer to pick a muhurat, and have flowers arranged in the room before the mother is wheeled out of the OT. 

A normal delivery cannot deliver any of this, because it starts at 3am on a Tuesday and nobody is ready.

Step three of one chain's checklist for prospective parents reads: "Align your childbirth philosophy and hospitals policy on family's involvement."

The premium package page on the same chain's website promises: "a specially designed [...] gift hamper and, what has now become our signature, your car decoration to announce your joy to the world!"

This reads more like a wedding planner. 

None of it is illegal, and every major Indian private maternity chain is selling some version of the same product, because they have all figured out who their buyer is.

A private hospital C-section in India costs ₹43,000 out-of-pocket on average, against ₹8,600 in a government hospital, and a Tier-1 metro package routinely runs ₹1.5 to ₹2.5 lakh. 

Most middle-class Indian families do not have ₹2 lakh sitting around for a surgery they may not have needed.

A 2023 BMC Pregnancy and Childbirth study by Goli and colleagues found that 27% of families paying for a private C-section ended up in what researchers call "distress financing," meaning they sold assets, took loans, or pawned jewellery to pay the bill. 

A 2020 LSE paper by M. Bhatia found that the odds of a private C-section were 4.2 times higher than a public one, even after every clinical risk factor was controlled for, and that roughly 21% of all private-sector C-sections in India cannot be explained by medical need at all.

A separate IIM-Ahmedabad study on NFHS-4 data put the absolute number at roughly 9 lakh unnecessary C-sections in private hospitals in a single year, and the figure is almost certainly higher today.

If you have already had a C-section, this is not about you. 

You did what you were told the safest thing was to do. The system is designed to make that decision feel inevitable.

But if a delivery is coming up in your family, you have three things you can ask for that will tell you almost everything.

The private maternity sector in India is full of smart people responding rationally to the demand they are paid to serve.

None of this changes until families start asking different questions before the consent form gets signed.

Hit reply and tell me: who decided the way your baby was delivered? Was it ever explained to you in writing?

I read every email.

Until next week,
Ritesh