Assessing factors associated with rising caesarean section rates in urban Nepal: a hospital-based study.

Abstract

Background Caesarean section (CS) rates are rising in urban hospitals in Nepal. However, the reasons behind these rising CS rates are not well understood. Therefore, this PhD study explores contributing factors to rising CS rates in two urban hospitals and seeks strategies to make rational use of CS. Methods This cross-sectional mixed-methods study was conducted in 2021 in two hospitals: Paropakar Maternity and Women’s Hospital (PMWH) and Kathmandu Model Hospital (KMH) in Kathmandu. The quantitative part included a record-based study of 661 births (KMH=276 & PWMH=385) for the fiscal year 2018/19. The qualitative part included interviews with 14 health professionals (doctors, nurses & midwives) and five key informants (two hospital directors and one representative from Nepal Society of Obstetrics and Gynaecologists, one from Midwifery Society of Nepal and one from Ministry of Health and Population Nepal), and four focus group discussions with pregnant women in antenatal clinics. Quantitative data were analysed using SPSS v28. Qualitative data were organised through NVivo v12 and thematically analysed. Results The overall CS rate was very high (50.2%). CS rate was almost double in KMH than in PMWH (68.5% vs. 37.1%). Previous CS was the leading indication for performing CS. Non-medical indications for CS were maternal request (2.7%) and CS for non-specified reasons (5.7%). The odds of CS were significantly higher in KMH, women aged 25 years and above, four or more antenatal clinic visits, breech presentation, urban residency, high caste, gestational age 37- 40 weeks, spontaneous labour and no labour. Robson group five (13.9%) was found the largest contributor to overall CS rate followed by groups one (13.4%), two (8.8%), three (4.4%) and six (2.9%). Similarly, the risk of undergoing CS was significantly high in Robson group five, six, seven, nine and two. The qualitative analysis yielded five key themes affecting rising CS rates: (1) medical factors; (2) sociodemographic factors; (3) financial factors; (4) non-medical factors; and (5) health service-related factors. Four main strategies were identified to stem the rise of CS: (1) adequate resources (SBAs, midwives and birthing centres); (2) raising awareness on mode of childbirth (antenatal education and counselling); (3) reforming CS policies/protocols; and (4) promoting physiological birth. Conclusion The rate of CS was extremely high, particularly in the private hospital. It reflects the medicalisation of childbirth, a public health issue which needs urgent addressing. Multiple factors affecting rising CS rates were identified in urban hospitals. Therefore, a combination of multiple strategies is required to stem the rise of CS rates and to make rational use of CS. This thesis provides basic insights of both factors affecting the rising CS rate and strategies for rational use of CS in urban hospitals in Nepal.