Dr. Ruma Satwik still remembered the smell of the sugarcane fields outside the little primary health centre in rural Maharashtra. It was 2000. She was young, newly posted, and she delivered eighteen babies that year.

“Most of them never even came here,” she told a junior resident last week, stirring her tea in the staff room of a busy Delhi hospital. “The second NFHS survey confirmed it. Nine out of ten births in that area happened at home. We only saw the ones already going wrong.”

The resident looked up from her phone. “And now?”

“Now more than ninety percent of Indian women deliver in hospitals. Infant mortality has fallen from sixty-six to twenty-four. Neonatal deaths from forty-four to eighteen. Maternal deaths from four hundred to a hundred. We did that.” She paused. “We also started cutting a lot more.”

Nationally the caesarean rate had climbed from 7.1 percent in 1998 to 41 percent in 2024. In private hospitals it was touching 57 percent. The usual explanation was greed. Obstetricians slicing for convenience and cash.

Ruma no longer bought the simple version.

“The women walking into labour rooms today are not the same women who walked in twenty-five years ago,” she said. “They are older. Mean age here is 33.4. NFHS-6 shows women 35 to 49 are twice as likely to need a caesarean as the 15-to-24 group. They are heavier. Fifty-seven percent of Indian women now exceed the waist circumference that flags metabolic risk. An overweight woman is twice as likely to end up with a section. Hypertension and diabetes have shot up between NFHS-4 and NFHS-5. And more of them conceived with help.”

The resident frowned. “So we’re operating more because the patients are different?”

“Partly. And because we finally measure things we used to miss.” Ruma leaned forward. “WHO used to say once you go past 10–15 percent caesareans you stop saving lives. That number assumed you were looking at the same population and the same deaths. We weren’t. Perinatal mortality, stillbirths, very early neonatal deaths—our two big national datasets still disagree by a factor of two. NFHS-5 says 32 perinatal deaths per thousand. Sample Registration System says 18. When the yardstick itself is that wobbly, how do you decide what ‘too many’ cuts even means?”

She told the story of the Australian study that had stayed with her. Researchers matched more than 867,000 births. Public hospitals: 32 percent caesareans. Private obstetric-led care: 48 percent. The private group had substantially fewer stillbirths and neonatal deaths—roughly half—and one-third the neonatal ICU admissions. Caesarean birth was linked to a 70 percent drop in the odds of those worst outcomes.

“It doesn’t prove more sections are always better,” Ruma said quickly. “It proves the relationship is too messy for a single magic percentage. England is at 45 percent now. Even the Nordic countries everyone used to point at have crossed 20 percent. The old ‘keep it low’ story is looking thinner.”

Ten years earlier she had written an article titled Natural Births in the Age of Litigation. She had ended it with a cheerful line: keep calm and labour on.

She smiled at the memory, a little wry. “A decade later I am not so sure. Maybe we should start by asking a different question. Not ‘how many caesareans?’ but ‘which women, under what circumstances, and judged by which outcomes?’”

The resident was quiet for a moment. Then she said, “So the rising numbers… might not be all bad.”

Ruma picked up her cup. “That’s what I keep telling myself when I look at the board and see another section booked. The mothers are different. The measurements were never clean. And some of the extra cuts are catching babies who would have died quietly before anyone counted them.”

She stood to go back to the labour ward. “Doesn’t mean we stop asking hard questions. It just means the old answers stopped fitting.”