In this study, we examined trend of CS rates in Nepal and inequalities in its utilization by geography (Mountain, Hill Terai), place of residence (urban/rural, Province), population characteristics (educational status, income quintile, caste/ethnicity, occupational status) and place of delivery. The findings show more than three-fold increase (from 3.2% ;95% CI: 2.1–4.3 during 2002–2006 to 10.5%, 95% CI: 8.9–11.9 during 2012–2016) in age and parity adjusted CS rate over the decade. Women with higher educational level (21.2%;95% CI:14.7–27.8), those from the highest wealth quintile (25.1%;95% CI:20.2–30.1) and women delivering in private facility (37.1, 95% CI:30.5–43.7) have much higher CS rates than WHO's recommended level. Ever increasing CS rate above the recommended level among specific population groups indicates an alarming situation, although overall CS rate in Nepal is still within WHO's maximum limit of 15% and is much lower than in China (34.9%) (23, 24), Bangladesh(14)and Brazil(15).
The rising trend in CS section found in our study is consistent with the experience of other low and middle income countries(25, 26). This increase is largely due to increase in the proportion of institutional deliveries. Between 2006 and 2016, proportion of institutional deliveries (at public and private/NGO run facilities) in Nepal increased from 17.7–54%(16, 17). Similarly, expansion of 24 hour birthing centers and emergency obstetric care in selected facilities has eased identification of possible complications and referral to higher facilities(27). Furthermore, in the fiscal year 2016/17, CS service was expanded to 72 districts(5), which was available only in 45 districts until 2009/10(28). Additionally, GoN has implemented demand side financing scheme all over Nepal since 2009 to remove financial barriers to receive institutional deliveries, including CS when needed (27).While service expansion and demand side financing played a major role in increasing CS rate in Nepal, role of patients' preferences (choice of private facility over public facility, lower pain, choice of exact moment for delivery based on astrological belief) and provider preferences(save time, manage scheduling, increase earning, avoid litigation/ harassment)(25) cannot be overlooked. Moreover, increase in maternal age at first birth, growing proportion of pregnant women with the history of CS, and improvement in CS procedure were also found to be associated with increase in CS rates(29, 30).
Current analysis indicated that the most significant determinants of inequality in the use of caesarian section are ecological region, wealth index, maternal education and place of delivery. In Nepal, women from Mountain region and province 6, and those from poorest income quintile have CS rates below the recommended level of 5%.Furthermore, the absolute difference in age and parity adjusted CS rate between the poorest-fifth income quintile(2.4%) and richest income quintile(25.1%) is nearly 22.7% in 2016 and has increased compared to 2006 and 2011 .Furthermore, while CS rate among the richest quintile is ever increasing, it declined among women from the poorest income quintile after 2011 initially increasing from the level of 2006. These findings clearly show that significant barriers exist for women from the poorest income quintiles to access CS despite the existence of demand side financing scheme that cover transportation incentives and free delivery. To make things worse, unavailability/irregular functionality of birthing centers, and emergency obstetric services and geographical difficulties might have contributed to lower service utilization in Mountain region and province 6. A further analysis of Nepal Health Facility Survey data also showed that among hospitals and primary health care centers offering normal delivery services, province 6 had the lowest proportion of facilities offering CS(28.6%) which was much below the national average of 37%(31).
Anecdotal evidence suggests transportation incentive offered by the maternity incentive scheme is inadequate in case of complicated delivery for women from difficult geographical terrain, and remote areas. In such cases, women need to spend significant amount of indirect costs to access services. Lack of ready to use money, and lack of means of transportation often delays transportation to referral facilities. On the basis of current findings and anecdotal evidence, the maternity incentive program needs to be revised targeting poor women from remote areas /mountain region areas when maternity complications arise. Although, GoN has established emergency referral fund to airlift women from poor, Dalit, Janajati, geographically disadvantaged and from mountainous region to transport to a higher facility in case of life threatening maternity complications, the use of this fund is very low. Only nine women in FY 2017/2018 used this fund to be air lifted(27). There is a need of an in-depth study to understand barriers in the use of emergency referral funds.
There is growing concern on the rise of C-section in the private facilities. Age and parity adjusted C-section rate in private facilities more than doubled from 15.8% in 2006 to 37.1% in 2016 while it remained almost constant (12.3% in 2006 to 12.6% in 2016) in public facilities over ten years’ period. In 2016, women delivered in private/NGO-run facilities were nearly 4 times more likely to have CS (adjusted OR 3.6; 95%CI: 2.7–4.9) compared to women delivering in Public facilities. Such a high proportion of CS in these facilities suggest that non-medical factors (economic gain, manage scheduling or others) motivate health care providers to perform CS. In Brazil too, rise in CS was observed in the private sector (4).The rise in C-section in Brazil did not reflect upper and middle class women’s preferences for CS(4) .The authors deduced that it is driven by obstetrician's preferences and perceptions. Obstetricians might believe that CS is safer to vaginal delivery, or they might assume women in private facilities would prefer CS without exploring women's choices and expectations. Alternatively, it was suggested that given the staff constrains and workload issues, CS might be an easier option to manage schedules for managers and service provides(4)
It is beyond the scope of this study to determine the cause for high C-section in private facilities. However, such a high CS rate in private/NGO-run facilities in Nepal warrants an appropriately defined quality assurance mechanism (32). Appropriate government policies and clinical practice protocols should be enacted to achieve an optimal C-section rates. Increasing rates of C-section has created a huge financial burden for Bangladesh’s health care system (14). A study on an economic burden of CS in Nepal may be a starting point to understand it's significance. The findings can be used to develop advocacy tool, eventually to implement a contextual and validated standard clinical protocols such as Robson classification to support health workers to assess need and monitor the use of CS(33)..
Some studies have indicated that midwife led maternity care can reduce C-section rates including the maternity costs(34). In Nepal, maternity care in hospitals is obstetrician led and it is high time to consider promoting physiological birth through midwife led maternity care(35).There is a need to scale up current midwifery education to improve maternity care as well as to reduce over-burden of normal deliveries in tertiary care facilities.
Although the overall CS rates in Nepal is within WHO standard [15], due attention is necessary to monitor the increasing C-section rate (crude CS rate from 2.7% in 2006 to 9% in 2016) and appropriate measures should be in place to curb the increasing trend. More importantly, women from the poorest income quintiles with maternity complications need special targeting. Furthermore, there is a need to expand C-section in Mountain districts to reduce geographical inequality. Overall, considering rising trend and persisting inequalities, Nepal needs to adopt policies and strategies to increase access among women from the poorest income quintile and Mountain region and reduce CS rate among women from the richest income quintile, those with higher education and those delivering in private/NGO facilities.
Strengths and limitations
We used high quality nationally representative data to assess trend and inequalities in CS. However, DHS survey lacks clinical data to evaluate appropriateness of CS. However, it is unlikely that clinical factors drive these variations. Furthermore, supply side variables and variables related to socio-cultural norms and beliefs were not available.