C-Section Rates in Kathmandu: Why Are They So High?
"A new study reveals alarmingly high cesarean section rates in Kathmandu, Nepal. What's driving this trend, and what can be done?"
Cesarean section rates (CSR) are a significant public health concern globally. Over the past few decades, there's been a notable increase in C-sections, raising questions about the factors contributing to this trend. A recent study conducted at Kathmandu Medical College in Nepal sheds light on the local landscape of C-section deliveries.
While increased access to gynecological and obstetrical care has improved institutional deliveries in many developing countries, the rate of cesarean sections in Nepal remains relatively low compared to some nations. However, hospital-based data suggests a rapid increase in C-section deliveries, particularly in certain regions.
This article delves into the findings of the Kathmandu Medical College study, examining the C-section rate and the primary reasons behind these surgical births in their specific setting. Understanding these factors is crucial for implementing targeted measures to address the rising CSR and mitigate potential associated problems.
Accepted Methods and Their Limits
Cesarean birth is performed when it is believed to offer greater benefit to the mother or fetus than vaginal birth. The overall cesarean birth rate measures cesarean births per 100 live births, while the primary cesarean birth rate measures cesareans among live births without a previous cesarean. The NTSV cesarean rate, covering nulliparous, term, singleton, vertex births, can help compare obstetric performance across similar hospitals and regions. However, research has often focused on clinical indications while giving less attention to structural, systemic, and sociocultural drivers of rising rates.
From Rare Operation to Routine Procedure
Jane Eliot Sewell presented “Cesarean Section--A Brief History” in 1993 as a brochure for the National Library of Medicine’s history exhibit in Bethesda, Maryland. A cesarean section is a surgical procedure in which doctors deliver a fetus through an incision in the pregnant person’s abdomen. Historical reviews describe the procedure’s evolution from its origins in the 1500s to the present day. They characterize it as once a rare operation performed on dying mothers to save the unborn child, but now a typical part of childbirth.
Kathmandu's C-Section Profile: Key Findings
The study analyzed 1,172 deliveries at Kathmandu Medical College between June 2015 and January 2016. The overall cesarean section rate was a significant 45.81%. Here’s a breakdown of the key demographics and indications:
- Age: Most patients were between 25-29 years old (42.8%).
- Parity: A slight majority were first-time mothers (primigravida) at 51%.
- Type: Emergency C-sections accounted for 76.5% of cases, while elective C-sections were 23.4%. Multigravida patients (those with previous pregnancies) underwent elective procedures more often than primigravida patients (73.8% vs 25.39%).
Evidence from Nepal
Research from a district hospital in Eastern Nepal reports fetal distress, cephalopelvic disproportion, breech presentation, fetal distress or meconium-stained liquor, nonprogress of labor, and failed induction among reported cesarean indications. The cited studies give different distributions: Rajbhandary and Shrivastava reported fetal distress at 40.4%, cephalopelvic disproportion at 14.8%, and breech at 10.4%, while Dhakal et al. reported fetal distress or meconium-stained liquor at 37.8%, nonprogress of labor at 17.1%, and breech at 15.8%. Prasad et al. (2017) reported fetal distress or meconium-stained liquor at 29.15%, failed induction at 19.73%, cephalopelvic disproportion at 10.8%, and breech at 8.5%. A national Nepal study also reports that cesarean delivery rates were significantly higher in private than government hospitals among South and Southeast Asian women, with cost and rapid decisions identified as relevant factors.
Risks Beyond the Immediate Birth
A systematic review and meta-analysis examined long-term risks and benefits of cesarean delivery for mothers, babies, and subsequent pregnancies. Its author summary notes that cesarean rates are rising worldwide, particularly cesareans without medical indication. Cesarean delivery is also described as the most commonly performed surgical abdominal procedure in many countries. An integrative review argues that rates have increased beyond medically indicated limits and identifies structural, systemic, and sociocultural contributors as areas requiring attention.
Why Rates Are Difficult to Compare
The CDC reports the percentage of all live births that were cesarean deliveries for each U.S. state in map and table formats. International comparisons are complicated because cesarean trends vary substantially from region to region. The PLOS review notes that professional organizations have recommended modifying the Robson classification with criteria that enable comparison of cesarean rates and indications. A separate analysis describes cesarean section as one of the world’s most commonly performed operations while raising concern about rates reaching ‘epidemic’ proportions.
Addressing High C-Section Rates: A Call to Action
The study's conclusion highlights a C-section rate significantly higher than the 10-15% recommended by the World Health Organization (WHO). The predominance of emergency C-sections, with previous cesarean births being a leading factor, warrants further investigation.
A Multi-Part Reduction Strategy
A strategy described in the provided expert commentary combines four active ingredients for addressing cesarean use. These are opinion leaders who implement evidence-based clinical guidelines, cesarean audits and feedback to identify potentially avoidable procedures, a decision-analysis tool to support women’s choices about delivery mode, and implementation of WHO recommendations. The approach therefore links provider practice, measurement, patient decision-making, and international guidance rather than relying on a single intervention.
Tracking Rates Through 2030
Research on global and regional cesarean trends presents current rates, changes since 1990, and projections for 2030. The study obtained nationally representative cesarean-rate data from countries worldwide for 1990 through 2018. Its background states that cesarean rates continue to increase across high-income, middle-income, and low-income countries. A 2026 review likewise describes cesarean section as an essential intervention when medically justified while examining global projections and regional disparities.
Social and Economic Drivers
A review of socioeconomic risk factors describes increased cesarean rates as complex and multifactorial. It examines social and economic factors that may contribute to more cesarean births in the population. Another review argues that reducing cesarean rates could ultimately reduce healthcare expenditures and identifies intensive public health education as one possible response. A CDC systematic review adds that unnecessary cesarean births can increase risks for maternal death, long-term complications, and intergenerational health effects, contributing to chronic-disease burdens.
Kathmandu in a Global Pattern
A study titled “Profile of Caesarean Section at Kathmandu Medical College” describes the worldwide rise in cesarean rates over the last three decades as a cause for alarm requiring in-depth study. A global population-based study examined the association between cesarean-section rates and neonatal mortality rates. More recent clinical research emphasizes that pregnancy- and birth-related factors can help explain variability in cesarean likelihood. A 2025 review notes that cesarean delivery can save women’s and infants’ lives but has also been associated with immediate and long-term complications when used ineffectively.
Several factors could contribute to this elevated rate. These include fear of litigation, increased use of electronic fetal monitoring (potentially leading to over-diagnosis of fetal distress), and a higher proportion of breech deliveries performed via C-section. Limited access to techniques like fetal scalp blood pH estimation (to confirm fetal distress) and external cephalic version (to turn breech babies) may also play a role.
Addressing the high C-section rate in Kathmandu requires a multi-pronged approach. This includes promoting vaginal birth after cesarean (VBAC) when appropriate, refining fetal monitoring practices, exploring strategies to reduce failed inductions, and ensuring access to techniques that can minimize the need for surgical deliveries. By understanding the specific drivers in the local context, healthcare providers and policymakers can work together to optimize maternal and neonatal outcomes.