According to the Sample Registration System (SRS) Statistical Report 2024, 95.4% of all live births in India now take place in a medical institution, whereas in 2019, the figure was 82.8%. The National Health Mission, Janani Suraksha Yojana, and other public health programmes and incentives have evidently delivered results. In India, deliveries take place in both government and private healthcare institutions. This choice of where to give birth, however, is not equitable: it depends on income, geography, and the quality of accessible public health services nearby.

Geography of childbirth

The national split is sharp, with 71.7% of all births taking place in government hospitals, and 23.7% in private hospitals. In rural India, government hospitals account for 76.6% of all deliveries; while in urban India, that share drops to 56.9%, and private hospitals record 41% of urban births.

State-wise, Jammu & Kashmir records 95.5% of its births in government hospitals, with private facilities handling only 3.9%. Other States that have a high percentage of births in government facilities are Madhya Pradesh at 91.3% and Rajasthan, at 90.9%. At the other extreme, Kerala has only 30.4% of its births in government hospitals, while 69.6% are at private hospitals, making it the State with the highest rates of birth in the private sector nationally.

The urban-rural data breakdown further sharpens this divide. Urban Karnataka has 52.2% of births at private hospitals. In urban Tamil Nadu, the figure is 46.5%. and in urban Uttar Pradesh, it is 45.3%. What this means is that in the cities of India, the middle classes have quietly exited the public healthcare system for childbirth.

What the choices signify

It’s easy to assume that the choice is primarily driven by finances, that those who can afford to do so, choose a private healthcare institution to give birth in. But this ignores the larger reality of how choices are shaped for a significant section of the population: research has found that women don’t use public healthcare facilities due to reasons including inadequate infrastructure and long waiting times. Doctors and staff being unavailable as well as overcrowding are other common, country-wide issues, resulting in even those from poor socio-economic backgrounds having to choose a private health facility. Considering that median private hospital delivery costs are estimated to be nearly nine times higher than their public equivalents, this means that the shift to private hospitals in urban India, driven by issues in the public healthcare system, could often push families, especially those without adequate insurance coverage, into financial distress.

Does private guarantee better outcomes?

With the highest private birth share nationally, Kerala simultaneously records the country’s lowest Infant Mortality Rate (IMR) of just 8 per 1,000 live births in 2024, against a national figure of 24. This apparent paradox invites the conclusion that private care is simply better and that the policy goal should be to channel more births toward it. That conclusion would be misguided, as Kerala’s outcomes are the product of decades of investment into public health literacy, strong healthcare infrastructure, and a more literate population.

In contrast, Bihar records 72.9% of births in government hospitals and an IMR of 23; Madhya Pradesh and Uttar Pradesh each log an IMR of 35, each with public healthcare facilities as the dominant system. A simple correlation between public hospital births and poor outcomes however, cannot be made: several other variables, including, critically, the quality of healthcare facilities, matter here.

Reproductive health data has also been captured in the National Family Health Survey-6, 2023-24. One data point that made headlines was the effect of private dominance on surgical intervention rates during childbirth. As per NFHS-6, nationally, C-sections account for 54.1% of births in private facilities compared to just 16.9% in public hospitals.

When a woman in India delivers through Caesarean section in a private hospital at a rate three times the national threshold, the problem is not that she chose private care; the problem is that there is no monitoring system or regulatory mechanism to check if a C-section was warranted. The World Health Organization notes that the international healthcare community has considered the ideal rate for Caesarean sections to be between 10-15%. When medically necessary, a Caesarean section can effectively prevent maternal and newborn mortality it states, adding however that studies have shown that when C-section rates go above 10%, there is no evidence that mortality rates improve.

Regulatory gaps

This, perhaps is an area that calls for regulation and monitoring to determine whether private hospitals are monetising a medical procedure. India’s policies for childbirth are structured almost entirely around access, incentivising, and increasingly mandating institutional delivery, without adequate regulation of what occurs within institutions.

The Clinical Establishments (Registration and Regulation) Act, 2010, was enacted to provide for the registration and regulation of clinical establishments in the country. However, the Act has been adopted by only 19 States and Union Territories and even in States where it has been adopted, implementation remains poor.

What needs to change

The Clinical Establishments Act must be made uniformly applicable with a dedicated maternity care annexure prescribing equipment standards and mandatory C-section disclosures. Any facility recording a C-section rate above 15% should be required to submit auditable clinical justifications to the State health authority as a condition of continuing registration.

Ayushman Bharat’s empaneled private hospitals must also be made more accountable. Maternity-empaneled facilities should report C-section rates data quarterly, with delisting as a real consequence for the outliers. Insurance without accountability is a subsidy without safeguards.

The LaQshya (Labour Room Quality Improvement Initiative) quality certification programme, for public facilities, should be given statutory weight. It was launched in 2017 to improve the quality of care in labour rooms (LR) and maternity operation theatres (MOT). As of February 2026, 1,244 LRs and 917 MOTs in public facilities have been certified under LaQshya.

If we want women to have real choices about where and how they deliver babies, improving the country’s public health infrastructure, ensuring regulation is in place and is implemented and holding healthcare institutions accountable can go some way towards ensuring this.

(Yashweer Singh is a final-year student at Gujarat National Law University, Gandhinagar. yashweerr@gmail.com)