Doctors at a private hospital in Lalitpur five months ago told Prem Kala Gharti that she had an anterior placenta and that she needed to undergo a caesarean delivery.

The 29-year-old woman from Pyuthan district, now a mother of two, said she did not have enough money for a caesarean section.

“I told the doctors that my first son was delivered normally. So I wanted a normal delivery for the second baby,” Gharti told the Post. “But the doctor would not listen; she insisted that I undergo a caesarean section.”

Gharti’s labour pain started four days ahead of the date suggested by the doctor. Her in-laws rushed her to Patan Hospital where she gave birth to a baby boy without surgery. Gharti’s second child is now five months old and both the mother and the son are healthy. “If I had been taken to the private hospital, the doctor would have performed a surgery,” she said.

Gharti represents pregnant women who are often pressed into going for the caesarean section even when there is no medical need for it. The practice is so rampant that the C-section rate in Nepal is increasing, which experts say is alarming.

The Family Welfare Division of the Department of Health Services admits that the caesarean delivery rate at private hospitals has increased sharply in recent years.

“In some private hospitals, 95 percent of the deliveries are caesarean,” Dr Punya Poudel, a focal person at the Family Welfare Division, told the Post.

The World Health Organisation says the ideal rate for C-section delivery is between 10 and 15 percent.

“If the rate of caesarean deliveries is too high, there is enough ground to question why it is increasing at such an alarming rate,” said Dr Silu Aryal, a gynecologist. “Doctors often give their own reasons for performing caesarean sections.”

Caesarean section is one of the most common surgeries and it is a procedure that can save women’s and babies’ lives in the event of complications during pregnancy or birth. But caesarean section is oftentimes performed without medical need, “which can put the mothers and babies at risk of short- and long-term health problems”, the UN health agency says.

Nepal, however, is not the only country wherecaesarean delivery rate is alarmingly high. Three studies report in The Lancet, a weekly peer-reviewed general medical journal, last year suggested that caesarean sections around the world have more than tripled since the 1990s—from six percent to all births to 21 percent.

In Nepal, a web of factors is contributing to the rising rate of C-sections.

“Some women who do not want to go through the labour pain also go for a caesarean section. Late marriage, late pregnancy and preference for a single child have also contributed to the rise in the number of caesarean deliveries,” said Dr Poudel.

An official at the Family Health Division, who did not want to be named, said medical colleges also tend to perform C-sections when they are not medically required as part of instruction on how the surgery is performed.

Likewise, most private hospitals do not have trained and skilled birth attendants and deliveries are usually carried out by gynecologists who often press for a C-section, the official said.

The Journal of Gynecology and Women’s Health in its November 2017 issue said caesarean section rate in Nepal was way above the World Health Organisation guidelines.

Experts say private hospitals often press pregnant women and their families to go for caesarean section because surgery means more money.

“Private hospitals are conducting more caesarean sections, as they can charge more money from their clients than in a normal delivery,” said Om Khanal, public health administrator at the Family Welfare Division.

But gynecologists have their own reasons.

“A lot of working class women come to my clinic and say that they do not want another child—and any risk—and they seek caesarean delivery,” Dr Rangina Laikangbam, a gynecologist at Alka Hospital, told the Post. She said the number of women who do not want to go through labour pain is also high, hence the caesarean delivery rate is high.

On why the hospital—or she—does not advise women to not undergo surgery when there is no medical need, Laikangbam said if her hospital does not provide the service, they will go to another health facility for a C-section.

The caesarean delivery rate, according to estimates and some studies, is far higher in private health facilities than in government hospitals.

Nonetheless, government hospitals—Paropakar Maternity Hospital, Tribhuvan University Teaching Hospital, and Patan Hospital—also have high caesarean delivery rates. The division said doctors from across the country send complicated cases to these hospitals, as they are national referral centres, and caesarean delivery in these hospitals is carried out for medical reasons.

Though the authorities know C-section rate is high in private hospitals, officials said they have not been able to do anything to bring it down.

An official, who chose to remain anonymous, said the Family Health Division stopped carrying out inspection as the credibility of reports came into question after private hospitals started using different techniques to influence inspection teams to prepare reports that suited them.

“The division had taken initiatives to initiate action against some private hospitals for involving in unethical practices, but the plan had to be aborted after intense pressure from ‘higher-ups’,” the official said.

Experts say misuse of a life-saving procedure not only raises questions about the integrity of obstetric practice but can also increase the chances of diseases later in life and that introduction of proper mechanisms can only bring the caesarean delivery rate down.

Dr Poudel said there is no rule regarding normal and caesarean deliveries in the country, but the decision to perform caesarean section should be taken only when it can be medically justified.

“The Family Health Division is responsible for monitoring deliveries in hospital but it has not done inspection for the last one and a half years due to a staff crunch,” said Poudel. “We used to monitor hospitals and their records and give instructions and even sought clarifications when needed in the past,” said Poudel. “Neither our office nor the Health Ministry has been conducting inspection for quite some time now.”

Experts say caesarean section should not be made a must-do surgery, it may be necessary when vaginal delivery could pose a risk to the mother and baby. Caesarean section may be required when there is prolonged labour or foetal distress.

"Caesarean section delivery should not be performed unless it is absolutely necessary," gynecologist Aryal told the Post. "The government must introduce a strong mechanism to monitor caesarean sections in hospitals. Or it should entrust an independent agency with the task of monitoring."

Dr Sushil Nath Pyakurel, chief specialist at the Ministry of Health and Population, said his ministry was working to set up an independent body to monitor both public and private hospitals on the matter. “We have proposed formation of a monitoring mechanism. Once it is formed, most of the existing problems will most probably be sorted out,” said Pyakurel.