Explaining rising caesarean section rates in urban Nepal: A mixed-methods study

RESEARCH ARTICLE Explaining rising caesarean section rates in urban Nepal: A mixed-methods study Sulochana Dhakal Rai 1*, Edwin van Teijlingen1, Pramod R. Regmi1, Juliet Wood1, Ganesh Dangal 1,2, Keshar Bahadur Dhakal3 1 Bournemouth University, Bournemouth, United Kingdom, 2 Kathmandu Model Hospital, Kathmandu, Nepal 3 Karnali Province Hospital, Surkhet, Nepal * , Abstract Introduction Caesarean section (CS) rates are rising in urban hospitals in Nepal. However, the reasons behind these rising rates are poorly understood. Therefore, this study explores factors contributing to rising CS rates in two urban hospitals as well as strategies to make rational use of CS. OPEN ACCESS Citation: Dhakal Rai S, van Teijlingen E, Regmi PR, Wood J, Dangal G, Dhakal KB (2025) Explaining rising caesarean section rates in urban Nepal: A mixed-methods study. PLoS ONE 20(2): e0318489. https://doi.org/10.1371/ journal.pone.0318489 Editor: Hlengani Lawrence Chauke, University of the Witwatersrand, SOUTH AFRICA Received: March 8, 2024 Accepted: January 16, 2025 Published: February 26, 2025 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal. pone.0318489 Copyright: © 2025 Dhakal Rai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Methods This cross-sectional mixed-methods study was conducted in 2021 in two hospitals, one public hospital and one private one in Kathmandu. The quantitative part included a record-based study of 661 births (private hospital = 276 and public hospital = 385) for the fiscal year 2018/19. The qualitative part included semi-structured interviews with 14 health professionals (doctors, nurses & midwives) and five key informants from relevant organisations and four focus group discussions with pregnant women in antenatal clinics in two hospitals. Quantitative data were analysed using SPSS v28. Qualitative data were organised through NVivo v12 and thematically analysed. Results The overall CS rate was high (50.2%). The CS rate in the private hospital was almost double than that in the public hospital (68.5% vs. 37.1%). Previous CS was the leading indication for performing CS. Non-medical indications were maternal request (2.7%) and CS for non-specified reasons (5.7%). The odds of CS were significantly higher in the private hospital; women aged 25 years and above; having four or more antenatal clinic visits; breech presentation; urban residency; high caste; gestational age 37-40 weeks; spontaneous labour and no labour. Robson group 5 (13.9%) was the largest contributor to overall CS rate, followed by group 1 (13.4%), 2 (8.8%), 3 (4.4%) and 6 (2.9%). Similarly, the risk of undergoing CS was high in Robson groups 2, 5, 6, 7 and 9. The qualitative analysis yielded five key themes affecting rising rates: (1) medical factors (repeated CS, complicated referral cases and breech presentation); (2) socio-demographic factors (advanced age mother, precious baby and defensive CS); (3) financial factors (income for private PLOS ONE | https://doi.org/10.1371/journal.pone.0318489 February 26, 2025 1 / 31 PLOS ONE Data availability statement: All relevant data are within the paper and its Supporting information files. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Caesarean section rates hospitals); (4) non-medical factors (maternal request); and (5) health service-related factors (lack of awareness/midwives/resources, urban centralised health facilities and lack of appropriate policies and protocols). Four main strategies were identified to stem the rise of CS rates: (1) provide adequate resources to support care in labour and birth (midwives/trained staff & birthing centres); (2) raise awareness on risks and benefits mode of childbirth (antenatal education/counselling and public awareness); (3) reform CS policies/ protocols; and (4) promote physiological birth. Conclusion The high CS rate in the private hospital reflects the medicalisation of childbirth, a public health issue which needs to be urgently addressed for the health benefits of both mother and baby. Multiple factors affecting rising CS rates were identified in urban hospitals. This study provides insights into factors affecting the rising CS rate and suggests that multiple strategies are required to stem the rise of CS rates and to make rational use of CS in urban hospitals. 1. Introduction Caesarean section (CS) is a lifesaving major surgical intervention in high-risk pregnancies to save mother and/or foetus, and the use of CS evolved throughout history [1]. In 1985, the World Health Organization (WHO) recommended a CS rate of 10-15% at population level [2]. More recently, it advocated that CS is only used when there are medical indications [3], since CS rates higher than 10% at population level do not result in lower maternal and newborn mortality rates [4,5]. However, CS rates are rising worldwide, although with regional and national disparity. Globally, rates in 2000 were double (21.1% vs 12.1%) that in 2015 [6]. It is predicted that the global CS rate will increase to 28.5% in 2030 with the lowest rate (7.1%) in Sub-Saharan Africa and highest (63.4%) in Eastern Asia [7]. There are many health consequences of CS to mother (increased mortality risk, severe morbidity and a higher risk for adverse outcomes in subsequent pregnancies) and child (altered immune development, allergy, atopy, asthma, and reduced diversity of gut microbiome) [8]. Moreover, CS is a financial burden for individuals, their family, and the health system/country [9]. The rates of CS are increasing rapidly in South Asia [10], as they are in Nepal [10,11]. The higher CS rates in urban and private hospitals are linked to “Too Much Too Soon” and the medicalisation of pregnancy and childbirth [11]. Although there is a disparity in rates between urban and rural, the overall rate of CS rose three-fold from 1996 to 2016 in Nepal. In private hospitals it rose from 8.9% in 1996 to 26.3% in 2016 [12]. However, the reasons behind the rising rates are not well understood. Hence, this study explores factors associated with rising rates of CS in two urban hospitals in Nepal. Specifically, this study has estimated the CS rate in study samples using the Robson groups; identified key factors contributing to a higher rate of CS and sought strategies to improve the rational use of CS. 2. Methods This mixed-methods cross-sectional study was conducted in 2021 in one public hospital: Paropakar Maternity & Women’ (...truncated)