Profit over woman-centred care? A commentary on drivers of high rates of caesarean birth in Indonesia

Summary box.

• Caesarean section (CS) is a life-saving intervention but CS rates are rising globally beyond clinical need. Enhanced Recovery After Caesarean Section (ERACS), originally an evidence-based perioperative approach, is increasingly commercialised and marketed as a premium CS option.

• In Indonesia, ERACS promotion emphasises comfort, painless birth and rapid recovery, contributes to misinformation, disinformation and an infodemic shaping women’s perceptions of birth, downplays the risks of CS and may encourage women to choose CS more readily.

• Commercial framing of ERACS reinforces inequities, as access is largely limited to wealthier women in private hospitals and is not routinely covered by national insurance. This model risks increasing unnecessary CS use and placing additional strain on surgical capacity and essential health system resources.

• Stronger regulation, clear evidence-based guidelines and equitable financing are urgently needed to protect women’s rights to safe, informed and equitable maternity care.

Introduction

Globally, the rate of caesarean section (CS) has surged, from 5% in 1990 to 21% of all births in 2018, with future projections forecasting further increases to at least 28.5% in 2030.¹ In Indonesia, CS rates have dramatically increased from 17.6% in 1990 to 25.6% in 2023.^{2 3} Some major regions like Bali and Jakarta have reached CS rates of 40.8% and 53.2%, respectively, by 2023.³ While CS can be a life-saving intervention for a woman and/or baby, rates higher than 15% at a population level do not correlate with improvements in maternal and neonatal mortality.^{4 5} Instead, high CS rates introduce avoidable risks to women and babies and impose substantial costs on health systems.^{6 7} CS increases the risk of surgical injury, haemorrhage, infection, anaesthetic complications, longer-term placental abnormalities, uterine rupture and reduced fertility for women, and is associated with respiratory morbidity, NICU admission, allergies and potential neurodevelopmental effects for babies, particularly when performed before 39 weeks.⁶ At a systems level, rising CS rates increase demand for operating theatres, anaesthetic services and blood banks.

As CS rates continue to rise globally, attention has increasingly turned toward improving women’s experiences and recovery following the procedure. Several perioperative protocols and models of care approaches, such as the Charité Caesarean Section, Gentle Caesarean and Enhanced Recovery After Caesarean Section (ERACS), have been developed to humanise the surgical birth experience and promote better physical and emotional outcomes.^8–10 These protocols or models of care integrate elements often associated with physiological birth that are usually absent in CS births, including a birth companion, immediate skin-to-skin contact, early initiation of breastfeeding and limited mother-newborn separation.^8–10 While such approaches represent best practices in vaginal births and important progress in aligning surgical birth with women’s holistic needs, ‘ERACS’ has been particularly packaged as a ‘premium’ birth option in Indonesia, raising concerns about equity and the commodification of women’s bodies and birth experiences.

The birth of ERACS

ERACS is one of several perioperative care protocols that have gained popularity over the past 5 years. Originally developed for enhanced recovery protocols in colorectal surgery,¹¹ the idea has been adapted and adopted in maternity care and is increasingly being implemented as a standard practice in hospitals across high-income countries.¹¹ Systematic reviews have evaluated the components of ERACS and its effectiveness in improving maternal and neonatal outcomes.^{9 11} While there is no universally standardised ERACS protocol, it typically comprises a continuum of evidence-based interventions delivered before, during and after CS.^{9 11} These span preoperative preparation (patient education, shorter fasting period, optimised nutrition), intraoperative care (regional anaesthesia, delayed cord clamping, skin-to-skin contact) and postoperative recovery (early mobilisation, multimodal analgesia and early oral intake).^{9 11} Research has shown that ERACS implementation is associated with shorter hospital stays, improved maternal satisfaction, better pain control and reduced healthcare costs compared with conventional CS care.^{9 11}

Misinformation, disinformation and the ERACS infodemic

Findings from our two recent studies highlighted the concerning misinformation, disinformation and infodemic of ERACS in Indonesia.^{12 13} While ERACS presents a perioperative model for improving maternal recovery, its promotion in Indonesia has taken on a commercial perspective that raises significant ethical and policy questions.¹³ Our previous mixed-methods social media analysis demonstrated that ERACS has been increasingly promoted by private hospitals and obstetricians on Instagram, portraying it as an ‘advanced surgical technique’ that enables women to have a painless, comfortable birth and faster recovery after CS (figure 1).¹³ Although our empirical analysis focused on Instagram, similar promotional content is also readily observable across other publicly accessible social media platforms, including TikTok and YouTube, suggesting that the commercialisation of ERACS extends beyond a single platform. Complementing these findings, our longitudinal qualitative research found that although most women initially preferred vaginal birth, many first learnt about ERACS through social media and perceived it as a modern and comfortable alternative to vaginal birth, suggesting that commercial messaging may shape women’s expectations and preferences regarding mode of birth.¹²

Figure 1. Temporal trends in selected Instagram hashtags related to Enhanced Recovery After Caesarean Section (ERACS) promotion in Indonesia (adapted from Zahroh et al¹³).

Promotional content on social media commonly claims that ERACS helps women return to normal activities within 6 hours post-surgery.^{12 13} This messaging is further amplified by social media influencers who document their ERACS experiences in highly curated, overly positive narratives, often featuring endorsements of specific hospitals or doctors.^{12 13} Hospitals likewise advertise ERACS through their official social media accounts, commonly accompanied by promotional discounts (see figure 2).¹³ Collectively, these narratives exemplify an ERACS infodemic: an overabundance of information, both accurate and misleading, that blurs the line between clinical evidence and commercial promotion. This has the potential to shape women’s perceptions, expectations and preferences regarding mode of birth, and ultimately may influence whether women have a vaginal birth or CS and may contribute to increasing rates of non-medically indicated CS.

Figure 2. Example of caesarean section disinformation in social media. This figure is a synthetic pseudonymous image recreated to protect the anonymity of the original social media poster. ERACS, Enhanced Recovery After Caesarean Section.

Within this infodemic, misinformation circulates through oversimplified claims shared by well-intentioned health workers and influencers (eg, describing ERACS as ‘painless’ or ‘like a normal birth’).^{12 13} Moreover, disinformation is also observed, involving deliberate exaggeration or fabrication to attract potential patients, such as advertising ERACS as involving a ‘smaller knife’ or ‘smaller incision’ that minimises scarring and pain,¹² neither of which is a documented component of evidence-based ERACS protocols.¹¹ Our qualitative study further showed that exposure to ERACS promotion through social media, healthcare providers, and hospital materials shaped women’s expectations of childbirth.¹² Several women described ERACS as ‘like vaginal birth, but better’, because it avoided labour pain; however, some women later reported that ERACS did not meet the expectations created by promotional messaging and expressed a desire for more balanced, evidence-based information from healthcare providers to support informed decision-making.¹²

ERACS promotion has become widespread despite clear prohibitions under the Indonesian Medical Code of Ethics, issued by the Indonesian Medical Association and the Ministry of Health’s regulations on health service advertisement and publication.^{14 15} These regulations explicitly forbid health workers from promoting specific services, products or techniques for profit, including offering discounts on medical procedures, with sanctions ranging from administrative warnings to the revocation of practice licences. However, such promotional activities continue to occur across hospitals and social media platforms, indicating weak enforcement and persistent commercial incentives within the health system.

ERACS fosters inequitable access to and provision of care

Access to ERACS is highly inequitable in Indonesia. Despite existing evidence showing reduced costs of CS with ERACS,^{9 11} its cost in Indonesia is substantially higher than ‘conventional’ CS, and it is often not covered by health insurance, including Indonesia’s national health insurance scheme.¹² Women reported out-of-pocket payments as a major barrier, noting that ERACS is more expensive than a conventional CS.¹² This commercialisation not only restricts access to wealthier women, but also reinforces a two-tiered system of maternity care, where dignity, comfort and recovery support become privileges rather than universal rights.

Commercial promotion of ERACS further blurs the boundaries between medical necessity and consumerism in healthcare. By portraying ERACS as a modern, desirable and comfortable birth experience, advertising and influencer campaigns risk accelerating the normalisation of CS birth as a lifestyle choice rather than a medical intervention. This raises important concerns about informed decision-making, unnecessary CS and health equity. Discussions surrounding ERACS should therefore extend beyond maternal recovery alone to consider both maternal and neonatal outcomes. Balanced counselling should provide women with evidence-based information on the benefits and risks of different modes of birth for both themselves and their babies. While ERACS may improve recovery following medically indicated CS, it does not eliminate the potential risks associated with unnecessary CS for women and newborns. If ERACS is indeed shown to improve maternal outcomes and postoperative recovery, its evidence-based components should be integrated into routine perioperative care for all medically indicated CS births rather than marketed as premium packages available primarily in private hospitals. Normalising ERACS as a standard of care, rather than a premium, high-cost elective package, would ensure its benefits are distributed equitably and that CS use remains guided by clinical necessity rather than market-driven incentives.

Furthermore, commercial promotion of ERACS may obscure possible adverse consequences of unnecessary CS. Although no studies have directly established a causal relationship between ERACS promotion and rising CS rates, the widespread misinformation, disinformation and infodemic surrounding ERACS may contribute to further medicalisation of birth and unnecessary exposure of women and babies to avoidable harms. This trend is particularly troubling in low-resource settings, where limited access to essential obstetric care, including safe anaesthesia, blood transfusion and infection management, can turn even routine CS into life-threatening procedures. If CS continues to be portrayed as the preferred or modern way to give birth, women in such contexts may be encouraged to seek surgical birth in facilities unequipped to provide comprehensive perioperative support, compounding inequities and clinical risks.

Our call to action

There is an urgent need for coordinated action to challenge and reshape prevailing narratives that promote CS and ERACS in Indonesia and other countries experiencing similar trends. Regulatory leadership from the Ministry of Health, alongside clear guidance from professional associations including the Indonesian Medical Association, the Indonesian Obstetrics and Gynaecology Association, and the Indonesian Midwives Association, is essential to curb misleading promotional practices. Governments, health authorities and professional bodies must act now to ensure ERACS develops as an equitable, evidence-based standard of care rather than a market-driven innovation.

First, national and international guidelines are urgently needed to distinguish evidence-based perioperative CS practices that should be universally adopted from those that lack proven benefit or are driven by profit. These guidelines must be paired with transparent, evidence-based communication so women receive accurate, balanced information about the benefits and risks of CS. Second, mechanisms are needed to counter misinformation and biased promotion of CS, including regulation of misleading advertising and proactive dissemination of credible information by public health authorities. Governments and professional organisations must take a central role in delivering neutral, evidence-informed messages about birth options, enabling women to make informed choices and participate meaningfully in their care. Third, financing mechanisms must guarantee equitable access to effective ERACS components that improve maternal recovery and well-being. Integrating these interventions into national health insurance schemes would ensure that access to high-quality perioperative care is determined by clinical need rather than ability to pay. Finally, stronger regulatory oversight and professional accountability in Indonesia are needed to monitor and sanction the misleading promotion of ERACS and CS. Public communication about surgical birth must be accurate, transparent and ethically grounded to protect women from pervasive online misinformation and commercial influence. Collectively, these actions can reframe CS and ERACS within it as clinical interventions guided by evidence, ethics and equity, rather than commodified services shaped by market incentives.

The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

Data availability statement

All data relevant to this study are available in the published articles that form the basis of this commentary. These two articles are cited as references 12 and 13.