Trends and correlates of cesarean section rates over two decades in Nepal.

Background: Cesarean section (CS) is a major component of emergency obstetric care. There has been a substantial rise in the rate of CS in private institutions in Nepal which might reflect the successful implementation of delivery schemes introduced by the government extended to the private organizations alternatively, it may also reflect the need for more public health care facilities to provide maternal and child health care services. Hence, the objective of this study was to examine the trends in institutional-based CS rates in Nepal along with its correlates over time.

Methods: We used the National Demographic and Health Survey (NDHS) data collected every 5 years, from 1996 to 2016. The trend in CS rates based on five waves of NDHS data along with its correlates were examined using multivariable logistic regression models after adjusting for socio-demographics and pregnancy-related variables.

Results: We included 20,824 reproductive-aged women who had a history of delivery within the past 5 years. The population-based CS rate increased from 0.9% in 1996 [95% CI: (0.6-1.2) %] to 10.2% in 2016 [95% CI: (8.9-11.6) %, p < 0.01] whereas the institutional-based CS rate increased from 10.4% in 1996 [95% CI: (8.3-12.9) %] to 16.4% in 2016 [95% CI: (14.5-18.5) %, p < 0.01]. Private institutions had a nearly 3-fold increase in CS rate (8.9% in 1996 [95% CI: (4.8-16.0) %] vs. 26.3% in 2016[95% CI: (21.9-31.3) %]. This was also evident in the trend analysis where the odds of having CS was 3.58 times higher [95% CI: (1.83-7.00), p < 0.01] in 2016 than in 1996 in the private sectors, while there was no evidence of an increase in public hospitals (10.9% in 1996 to 12.9% in 2016; p for trend > 0.05). Education of women, residence, wealth index, parity and place of delivery were significantly associated with the CS rate.

Conclusion: Nepal has observed a substantial increase in cesarean delivery over the 20 years, which might indicate a successful implementation of the safe motherhood program in addressing the Millennium Development Goals and Universal Health Care agenda on maternal and child health. However, the Nepal government should examine existing disparities in accessibility of emergency obstetric care services, such as differences in CS between public and private sectors, and promote equity in maternal and child health care services accessibility and utilization.