In the past 10 years, the number of babies born in India through Caesarean section has doubled.

In 2005-6, the country recorded 9% births via C-section; by 2015-16, the rate had increased to 18%, according to a series of papers published recently in The Lancet. The global C-section rate doubled in the same time period, too, the papers state.

Researchers point out that while the surgery remains largely unavailable for women in low-income countries and regions, the procedure is overused in many middle- and high-income settings.

Until 2010, C-sections made up only 8.5% of all deliveries in India, just under the recommended level of 10-15%, according to a World Health Organization (WHO) report. The WHO guidelines do note that for some women and newborns, C-sections can be a life-saving intervention when complications such as bleeding, fetal distress, hypertensive disease and babies being in abnormal positions occur.

In the case of Ayesha Baig, 35, who delivered a baby girl last year, a C-section was a medical necessity because her uterine fibroids were actually causing complications. However, Baig’s OB/GYN, Dr Nozer Sheriar, says some doctors do go overboard with promoting C-sections.

It’s a widespread problem; in at least 15 countries, C-sections are used in more than 40% of deliveries, The Lancet reports.

“Given the increasing use of C-section, even when medically not required, there is a crucial need to understand the health effects on women and children,” said one of the papers’ authors, Jane Sandall, from King’s College London who has a clinical background in nursing, health visiting and midwifery and an academic background in social science.

Experts suspect various reasons for the rise in number of C-section procedures.

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In India, like in the US or China, doctors can be paid much more for a surgical procedure, than for a vaginal delivery; some doctors and patients say this drives hospitals to recommend C-sections in cases where they are not medically required.

However, many doctors decide their fee in the third or fourth month of a patient’s pregnancy, which will remain the same even if the doctor waits while the woman labors for eight to 10 hours or performs a C-section. But even for these doctors, a C-section recommendation might be driven by targets that some hospitals have for number of deliveries to be done; C-sections allow hospitals to schedule births and thus maximize deliveries — and money.

“That could be a factor, too, for some doctors,” says Dr Alka Kumar, consultant gynecologist at Mumbai’s Fortis Hospital.

At the same time, “making an informed decision is the responsibility of the couple as much as the doctor’s,” Dr Sheriar says. “I have seen a rising number of women asking for a C-section even though there are no medical complications.”

This is often because some couples want the baby to be born at an auspicious time or a specific date, according to Dr Shilpa Agarwal, a consultant in high-risk pregnancy and fetal medicine at Mumbai’s Jaslok Hospital. Additionally, some pregnant women request C-sections after hearing friends recount the pain of a vaginal birth, or myths about how vaginal deliveries damage the mother’s pelvic floor and injure the baby, “none of which is medically accurate,” she says.

There’s little discussion of the common complications that follow a C-section — long recovery time, limited movement, and, if the incision pain is bad, difficulty holding or feeding the baby.

Amid misleading advice from all sides, the line between choice and necessity is thin. And some women are fighting hard for everybody to recognize it.

“I was cut open to deliver my baby. It was long, painful and depressing recovery for me,” says Subarna Ghosh, who was advised by her OB/GYN to opt for a C-section, though it was not medically needed. “Like me, lakhs of women in India are misled and manipulated so hospitals and clinics can make more money from surgical deliveries.”

Last year, Ghosh started an online petition urging the Union Minister for Women and Child Development, Maneka Gandhi, and Union Health Minister, JP Nadda, to require all doctors and hospitals to declare to patients their C-section delivery rate, conduct inquiries against those clinics and hospitals with abnormally high C-section rates, and frame clear guidelines for conducting C-sections to safeguard the health and rights of women and children.

On last count, she had amassed close to 1,600,000 signatories. And it did seem to have made some impact. According to one DNA report, it was announced that private hospitals participating in the Central Government Health Scheme (CGHS) would have to declare their rate of C-section deliveries. A few months later, Livemint also reported that the health ministry suggested equalizing the cost of normal delivery and C-sections as an attempt to curb hospitals from overusing the procedure.

Yet, it’s unclear how effective these mandates and plans have been; in September last year, the Central Government Health Schemes was threatening to drop private hospitals that don’t display their C-section rates prominently at the front desk, because so many had failed to comply with its mandate.

Until regulation on how medical institutions approach deliveries takes effect, the onus is on women to access to accurate birthing information and establish family support for childbirth decisions.

As 34-year-old Chhavi Panchal, who underwent a C-section delivery in 2016, says: “All my friends have had C-sections, too, in the name of [unexplained] ‘last-minute complications.’ Doctors know that will instill fear in us and we won’t argue.” Who would?