India has witnessed a steady and concerning rise in Caesarean section births (C-section) rates over the past decade. According to the National Family Health Survey-5, the C-birth rates in India stand at 21.5 per cent of all births, a significant increase from 17.2 per cent in NFHS-4 and just 8.5 per cent in NFHS-3. Growing evidence suggests that maternal nutrition is an important, though often overlooked, determinant of pregnancy and childbirth outcomes.
Micronutrient deficiencies or hidden hunger, maternal anaemia and the dual burden of malnutrition increase the risk of obstetric complications that often necessitate Caesarean births. The rise in C-births is therefore not solely a surgical or systemic challenge. While this is often discussed as a health-system issue driven by private sector practices, provider preferences, institutional delivery policies, and even medico-legal concerns, it is also, and perhaps more fundamentally, a nutrition issue.
The biological link between nutrition and childbirth
The pathways connecting poor maternal nutrition to operative delivery are clear and interconnected. Understanding them is essential for designing effective interventions.
First, maternal anaemia, which affects over 57 per cent of women in India, according to NFHS-5, reduces the blood’s oxygen-carrying capacity. During labour, this physiological deficit can lead to foetal distress, uterine inertia, and maternal exhaustion, conditions that frequently necessitate emergency C-sections. The evidence linking maternal anaemia with Caesarean births is compelling. A recent systematic review and meta-analysis involving 336,128 pregnant women across 14 studies found that women with anaemia had a 63 per cent higher likelihood of Caesarean births (OR 1.63; 95 per cent CI 1.23–2.17) than non-anaemic women.
Anaemia also significantly increased the risks of prolonged labour, foetal distress and maternal complications that frequently necessitate emergency surgical delivery. These findings are reinforced by prospective hospital-based studies from South Asia, which show that anaemic mothers experience significantly higher rates of Caesarean births, postpartum blood transfusion, foetal distress and poorer neonatal outcomes compared with non-anaemic mothers. Together, these studies suggest that preventing iron deficiency anaemia is likely to reduce both maternal morbidity and the need for emergency operative intervention.
Beyond anaemia, calcium status during pregnancy deserves attention. India’s dietary calcium intake is significantly below recommended levels. The World Health Organisation recommends calcium supplementation during pregnancy for prevention of pre-eclampsia, a condition that often necessitates emergency C-sections. This evolving evidence underscores the importance of robust, continuously updated research to guide India’s maternal health policies.
Second, childhood undernutrition casts a long shadow into adulthood. Women who experienced chronic undernutrition during childhood, manifesting as stunting, often grow into shorter adults with smaller pelvic dimensions. During childbirth, this anatomical reality can result in cephalopelvic disproportion and obstructed labour, making C-sections medically necessary. A landmark Indian study published in 2023 found that short women, reflecting childhood undernutrition, and those who were overweight or obese had the highest risk of C-section. The study further estimated that changes in maternal nutritional status explained nearly 18 per cent of the increase in Caesarean deliveries observed in India over a decade, demonstrating that nutritional deprivation across the life course, not merely during pregnancy, substantially influences childbirth outcomes
Third, India faces a dual burden of malnutrition, where deficiencies of iron, folate, vitamin B12 and zinc coexist with overweight and obesity. Analysis of nationally representative Indian data shows that women who were both short (reflecting childhood undernutrition) and overweight or obese had the highest probability of Caesarean birth, suggesting that the interaction between early-life undernutrition and adult overnutrition significantly increases obstetric risk
Finally, micronutrient deficiencies impair maternal health and well-being, placental function, and foetal development. Deficiencies in vitamin D, vitamin A, zinc, and B vitamins weaken the body’s ability to maintain a healthy pregnancy, increasing the likelihood of complications that require operative intervention.
What this means for maternal health policy
The public health implication of this evidence is clear and actionable. Improving women’s nutrition before conception, during adolescence, and throughout pregnancy could reduce avoidable obstetric complications and some Caesarean deliveries. This requires a multi-pronged, life-course approach.
First, preventing iron deficiency anaemia must remain a national priority. While the Anaemia Mukt Bharat programme has made strides, adherence to supplementation remains a challenge. Addressing the root causes of anaemia, including dietary inadequacy, parasitic infections, and menstrual health, needs sustained focus.
Second, addressing hidden hunger requires concerted action on dietary diversification, behaviour change, micronutrient supplementation and appropriately fortified staples. Staple food fortification with essential vitamins and micronutrients offers an effective population-level strategy to improve dietary quality, particularly among vulnerable households with limited dietary diversity. Fortification complements supplementation and food-based approaches by helping close persistent micronutrient gaps.
Third, improving adolescent nutrition is critical. Many girls enter pregnancy already undernourished. Interventions that address stunting, micronutrient deficiencies, and dietary diversity during adolescence can break the intergenerational cycle of malnutrition.
Fourth, ensuring adequate antenatal supplementation and nutrition counselling for pregnant women must be strengthened. This includes iron and folic acid supplements, calcium, and dietary guidance that is culturally appropriate and locally relevant.
A shared responsibility for safer births
Caesarean section is a life-saving intervention when medically indicated and should never be discouraged where clinically necessary. However, the growing body of evidence suggests that improving women’s nutrition across the life course can reduce many of the preventable complications that lead to emergency operative delivery.
Hidden hunger is therefore not merely a nutrition challenge; it is a maternal health challenge. Placing nutrition at the centre of maternal health policy will help improve pregnancy outcomes, support safer childbirth and contribute to healthier mothers, healthier newborns and a healthier India.