Childbirth is a physiological phenomenon. It seems like a simple process, but even now 239 women in 100,000 in Nepal die due to complications during pregnancy, childbirth and the post-natal period. The mode of childbirth or labour may be vaginal, which is the most natural: The baby descends through the vaginal canal. This is popularly known as normal delivery. It may be instrumented, that is assisted vaginal delivery with the help of vacuum or forceps; or it may be a caesarean section (C-section), that is delivery of the foetus through incisions in the anterior abdominal (laparotomy) and the uterine wall (hysterectomy). According to the Nepal Demographic and Health Survey 2016, only 57 percent of the children born in Nepal are born in health centres and hospitals.

C-section is the last option for childbirth. Common causes include cephalopelvic disproportion (the foetal head is bigger than the maternal pelvis), prior caesarean, failed progression in labour, abnormal foetal heart rate, mal-presentations, multiple gestations, suspected foetal macrosomia, foetal distress, meconium stained, severe oligohydramnios and non-progression of labour. Besides medical causes, social causes or maternal issues like fear of pain or intolerance to labour pain, birth on specific date and time, intolerance to long-lasting deliveries, misconception about genital damage after vaginal delivery and lower tolerance to any complications or outcomes other than the perfect baby also lead to C-section on demand. These C-sections on demand usually occur in private hospitals only.

The rate of C-section is increasing globally. In 2014, the caesarean section rate in the United States was 32.2 percent, up from 20.7 percent in 1996. According to a 2015 World Health Organisation statement, the C-section rate was 40.5 percent in Latin America, 25 percent in Europe, 19.2 percent in Asia and 7.3 percent in Africa. In 2016, Japan conducted a retrospective study at 125 institutions and concluded that the overall C-section rate was found to be 37.3 percent. In Nepal, the proportion of caesarean sections increased slightly in 2016-17 to 10.1 percent of expected live births from 7.6  percent in 2013-14. According to the Nepal Demography and Health Survey 2016, the caesarean section rate was 35 percent in private hospitals and 12 percent in public institutions.

In Nepal, the health of pregnant women and maternity services are accorded high priority. The state has given high importance to pregnant women and made efforts to provide maternity services. The state, undoubtedly, has expanded maternity services effectively to control pregnancy deaths. The Safe Mother Package including cash gifts for having regular health check-ups to ensure a safe pregnancy, free delivery (including caesarean) at health institutions and transport allowance from the government shows that the country has given high priority to safe motherhood.

According to the 2015-16 annual report of the then Ministry of Health and Environment, there are a total of 2,018 health institutions in Nepal that have normal delivery facilities including birthing centres, Basic Essential Obstetric Care and Comprehensive Essential Obstetric and Neonatal Care. Among them, there are 104 Comprehensive Essential Obstetric and Neonatal Care units including tertiary level hospitals which have the facility of caesarean service. Only 5.1 percent of the public health institutions have the facility of caesarean service which has compelled pregnant women to go to private hospitals. Moreover, most labour cases in private hospitals are referred from public hospitals. C-section on demand only occurs in private hospitals as public health institutions are overcrowded and unable to address social and maternal (non-medical) indications.

Caesarean section is safe and available and can be planned, even though it is the last option for childbirth. C-section increases the duration of hospital stay and has higher chances of infection and other complications in comparison to vaginal delivery. This increases the unit cost and burden of childbirth. But if the service is available, neither health service providers nor patients will want the risk of vaginal delivery, resulting in a higher C-section rate where the service is available.

 Dr Shah is an obstetrician/gynaecologist at Morang Cooperative Hospital, Biratnagar.