3.6.1. Medical factors.

Medical factors included three sub-themes: (1) repeat CS and lack of VBAC (vaginal birth after CS); (2) complicated referral cases; and (3) breech presentation (S1 Fig).

Most interviewees said that repeat CS and lack of VBAC were the major factors for rising rates, because a repeat elective repeat CS is planned for women with a previous CS due lack of intensive monitoring as well as to avoid risk. Hospitals do not want to take the risk, but neither it seems, do the women and their families:

“We don’t provide the opportunity of VBAC because it needs intensive monitoring of patient as well as hospital do not want to take risk. Previous CS falls under indication plus patient also demand it, so we do repeat CS for previous CS.” (P9)

Another main medical factor was the complexity of cases referred from smaller units/hospitals elsewhere in Nepal. Many highlighted that both hospitals are referral centres, and many complicated cases who need CS were referred to these hospitals. Sometimes complicated cases arrived at urban hospitals from remote area by air ambulance:

“… the reason for the high caesarean section rate in this hospital is because this is a referral centre also and complications that arise in other places are referred to here through helicopter or nearby places. Since this is a main referral centre that is the reason for the high caesarean section rate.” (P2)

Elective CS for breech presentation is a reason for the rising rate of CS. Trial of labour was not planned for primigravida with breech unless the woman is admitted in active labour with fully dilated cervix and buttock of baby is visible. However, trial of labour is offered to multigravida if their condition is deemed favourable:

“Labour trial is not given for primigravida breech for first-time mom, but when they come from home if the dilation is over 10 centimetre and if the buttock of the baby is seen then we do not tell them to perform a caesarean section, but rest of the time on first-time mother receive a caesarean section. But if it is multigravida, and if they have normal condition then we try to perform normal delivery.” (P2)

3.6.2. Socio-demographic factors.

Three sub-themes were identified: (1) changing socio-demographic characteristics of women (pregnancy in advanced age and career-oriented rather than family); (2) precious baby; and (3) lack of security of service providers, legal issues and defensive CS (S1 Fig).

The socio-demographic characteristics of the obstetric population are changing. This study indicated that pregnancy at advanced age was a reason for the increasing rate of CS. Problems of infertility, diabetes and hypertension also increase with advanced age, and these are associated with CS:

“…the women who come to us are slightly older. We need to perform CS on elderly women and with many complications. So, because of this also CS rate is slightly high.” (P10)

Women focus on their education, work, and career rather than having children. They get pregnant at a later age, when subfertility and complications increase the likelihood of CS.

“…the main reason for the increase in CS is nowadays women are more concerned about their education and career. So, they do late marriage and plan baby late, there are also subfertility cases. All these factors lead to the complications, for which CS is needed.” (P12)

Pregnancies after infertility treatment, after many years of marriage and having a poor obstetric history may be viewed as particularly precious. Many interviewees emphasised that such babies are more likely to be delivered by CS:

“Precious babies are also more likely to be caesarean section. If they have had a baby by IUI (=intrauterine insemination), IVF (in-vitro fertilisation), have had a baby after years, have had a miscarriage, or have had a previous pregnancy loss, have had a bad experience such as stillbirth…they mostly demand CS.” (P7)

In Nepal, there is a lack of security and legal protection for doctors/service providers in case of unfortunate incidents. Doctors, nurses, and hospitals are criticised and may even attacked and punished if something goes wrong with the mother or baby due to vaginal birth rather than CS. Many thought that doctors perform defensive CS for self-protection to avoid verbal/physical assault and litigation:

“… If one baby dies because of conducting vaginal delivery rather than CS, Then, hospital is vandalised, and doctor is charged and court orders to both hospital and doctor. That is why doctors do not want to take risk…” (K4)

3.6.3. Financial factors.

Two sub-themes occurred under this theme: Income source for private hospitals and incentive for public hospitals (S1 Fig). Many interviewees highlighted that CS was a major operation which can be a good income source for private hospitals.

“It comes with the financial aspects of a private hospital. Because of these things, I think it is a challenge to conduct normal delivery.” (P8)

Financial benefit also includes an increased bed occupancy:

“…benefit of CS to the hospital is definitely in terms of money. After CS, hospital receives income from bed/room, income from medicine, income from OT (=operating theatre) charge, many benefits from CS... income source to the hospital, staff also get salary on time.” (P10)

CS is conducted in private hospitals to generate money as they charge a lot for a CS:

“…the intention is to earn money in a private hospital. If you do normal delivery, the money will not come. Intentionally, they want to cut women to generate the income…Private hospital charge approximately 1-2 lakh rupees (=625-1,250 US$) for a caesarean section.” (K3)

Public hospitals also receive some incentives from government. Some interviewees highlighted that the state provides some funding to hospitals to provide free CS:

“…the Ministry of Health provides the service free of cost from the Safe Motherhood programme and the patients do not have to pay money for it. We keep the statistics of how many surgeries we performed and send it to the Ministry of Health and the Ministry of Health provides 8000 Nepali rupees (= 50US$) per caesarean section.” (P4)

The reimbursement for doing CS is higher than for vaginal birth:

“Upon doing caesarean section the Government of Nepal provides incentive, which is even more than that provided to normal delivery…” (P2)

3.6.4. Non-medical factors.

Two sub-themes emerged here: Maternal request and service providers’ attitude towards CS (S1 Fig). All women in FGDs said that the preferred mode for their forthcoming birth is a normal delivery due to the benefits for both mother and baby:

“If normal delivery, it is good for both mother and baby because in caesarean section incision is done in abdomen which creates difficulty in sitting, walking. Normal delivery is natural, and caesarean section is difficult, and it is different. So, normal delivery is good for both mother and baby. Natural birth is better than incision in abdomen.” (FGD/P22)

However, CS performed at maternal request is also one of the main non-medical factors for the rising CS rates in urban hospitals in Nepal:

“…Some of the CS are done on demand of the pregnant mothers as they do not want to give normal delivery in any condition. So, because of this also CS rate is slightly high.” (P10)

Cord around the foetal neck (nuchal cord) is sometimes evident on ultrasound scans. It is not a standard indication for CS as it does not usually pose a threat to the foetus. If a pregnant woman learns that her baby has its cord around the neck, she may then request a CS to avoid perceived risks to baby. Doctors may consider the autonomy of women and respect their request when the cord is awkwardly positioned:

“…major reason is patient request. Even if there is no indication for example cord round neck is not indication for CS but while we explain patient about this, they themselves demand CS. I think caesarean delivery on maternal request is one of the major unnecessary CS, in that case we should also respect patient request, so we have to do it.” (P11)

Some indicated that service providers also perceive CS as the safest option to avoid risk. Normal birth is not promoted, and CS is performed by doctors ‘to be on the safe side’:

“…normal delivery is not encouraged as much as it used to be. In case of CS, baby is safe, mother is also safe which reduces the headache of the doctors.” (P7)

3.6.5. Health-services-related factors.

Four main sub-themes are identified here: (1) lack of awareness around mode of childbirth/risk and benefits of CS and vaginal birth; (2) lack of adequate resources; (3) the centralisation of health facilities in urban Nepal; and (4) lack of appropriate policies and protocols on CS (S1 Fig). Most of interviewees highlighted that women’s lack of awareness around mode of childbirth is one of the main factors for the rising CS rate. Interviewees described how most pregnant women were poorly informed about the risks and benefits of CS in ANC:

“…there is lack of awareness among the women themselves on the risk and complications of caesarean section, so they want to do it. Whether the caesarean section is required, or not. This type of awareness is lacking among the women as they are not well informed about it. In the hospital settings also, there is not any system to provide information on this while the women come for ANC visit. There is communication gap between the service providers and client. This is one of the main barriers to reduce CS.” (K3)

Furthermore, it is highlighted that health workers are not able to inform pregnant women nor teach them pain relief techniques:

“…we health workers do not provide full information to them from our side and do not make them aware about the complication of caesarean section and we do not tell them much about the techniques of pain relief. This is not quite practised in Nepal and therefore caesarean section is mostly done.”(P2)

Some interviewees highlighted that urban, educated and rich women are not aware of mode of childbirth:

“Urban educated women are not aware and informed about the physiological birth. I think, that’s why they think that birth is pathological condition. So that, they choose artificial way to bring their baby in this world... Even, women rights activists should be aware because those women who call themselves feminist or empowered women, they mostly do CS while giving birth to baby…” (K3)

Most interviewees emphasised that a lack of adequate resources, especially midwives or SBAs (skilled birth attendants) is another main factor for the rising CS rates, as some mentioned:

“Main challenge is proportion of doctor/nurses with proportion of patients, so if trained midwife, SBA trained personnel are mobilised in every remote as well as urban then this may help to reduce unnecessary CS rate.” (P7)

Some interviewees highlighted that midwives who are expert for handling physiological births are lacking in Nepal:

“…We don’t have experts (midwives) in handling natural births in Nepal. Recently our country has produced 28 midwives. It takes a minimum of 10 years for them to adopt a system-adjusted society because it is challenging for you to change the established practice to change the system...” (K3)

Some also noted the lack of medical skill in conducting vaginal and instrumental:

“…we called instrumental delivery like forceps, vacuum delivery nowadays their use is very low like when I was MD [medical] student about 25 years ago. At that time there was vacuum delivery 6% and forceps delivery 3% - total 9% of instrumental delivery. Now, this 9% is also added to caesarean section because today’s doctors are lacking the skills of instrumental delivery like vacuum, forceps...” (K4)

The centralisation of comprehensive maternity health facilities in tertiary centres in cities is another reason for rising CS rates in urban Nepal. Many interviewees highlighted that big and/or private hospital are situated in urban areas:

“The trend of caesarean section in Nepal is increasing now especially in urban areas, in big hospitals of cites, corporate hospitals in comparison to rural and remote areas…” (K1)

Another key issue is the lack of written protocols and policies on CS, lack of models of maternity care and respectful maternity care, lack of policy on rewards for low CS or monitoring and supervision regarding high rate of CS, lack of political commitment to implementing international recommendations (Robson classification) and lack of appropriate auditing of CS. Most interviewees said there were no written policies and protocols for CS:

“There is no such a separate strategy/policy for CS in Nepal, we follow MD level book and according to the indication we do CS.” (K1)

Hospitals in Nepal mostly follow an obstetric model of maternity care. Some interviewees importantly stressed that the lack of a midwifery model and current practice of an obstetric model of care is also a reason of increasing the CS rate:

“…doctors are trained to handle pathological conditions while being professionally trained...where there is a midwife, the midwifery is called the social model of maternity care. Similarly, the midwifery model of maternity care, women are trained to be empowered…if professional midwives are very empowered in the country, the rate of CS is relatively low in that country.” (K3)

One participant indicated that the lack of respectful maternity care was also a reason for unnecessary CSs in Nepal. Performing unnecessary CS is obstetric violence. However, there was no complaints system and service users are scared to raise their voice:

“...There is lacking respectful maternity care…There is not any mechanism to handle consumer rights although there is legal right. There should be a system to complain, but even clients are very fearful even to raise their voice. Unnecessarily CS is obstetrics violence, which is what is happening in Nepal, first it was in Brazil. I am blaming the system for the mindset of the society which is the big drawback of the system that brought women up.” (K3)

The Government of Nepal has no policy to reward hospitals with lower CS rates or a system for monitoring and supervision to reduce high CS rates. Some interviewees raised the issue about lack of policy and protocol for awards to hospitals for low CS rates and monitoring of CS rate in hospitals:

“…Government has no policy to award the hospitals having caesarean section rate less than 15%. And another thing is there should be the monitoring and supervision of the hospitals in order to prevent the higher rate of caesarean section...” (P2)

A lack of political commitment to reduce CS rate was clear according to several interviewees:

“…national leader, you must be committed to implementing the standards set by the WHO.... from our Prime Minister it is impossible, then in the Ministry of Health, the ministers in the Ministry of Health also come from different backgrounds we cannot expect that from them…... For example, WHO says use the Robson classification, but if the director of the maternity hospital cannot get support from the Government than he/she could not implement it alone, that is what the system is all about we need system to support our work… NESOG doesn’t seem like to have taken any initiative to control... (K3)

Lack of appropriate monitoring and auditing systems can be a reason for rising CS rates. Most said that they do record CS in medical record and presented report on CS along with other maternal health statistics monthly and yearly basis:

“In our hospital, there is a monthly audit …for example, how many of the deliveries during the month are normal delivery, how many forceps, vacuum deliveries and how many caesarean sections are done, how many are done annually. We also provide this data to the Government of Nepal.” (K1)

However, a few said that they do audit CS according to Robson criteria:

“…there is a system for audit of CS. We do CS audit according to the Robson criteria.” (K2)

In contrast, some interviewees agreed that they would not do audit of CS and it would be better to do CS audit using Robson criteria:

“We do not have practice of audit of CS. If we move forward using Robson criteria, then it will be better.” (K3)

3.7.1. Adequate resources.

Three sub-themes yielded in this theme: (1) training and availability of SBA trained staff, (2) training, education and utilisation of midwives; and (3) the establishment of birthing centres (S2 Fig).

The Government of Nepal should focus on training and mobilising SBAs. All SBAs should be skilled in normal birth, and they should be placed at labour room and delivery room to support women for normal delivery as well as to facilitate birth. Most interviewees emphasised that providing SBA training to doctors and nurses and availability of adequately trained staff would be a strategy for reduction of the CS rate and the promotion of normal birth:

“Skilled birth attendants have to be mobilised in every part of the country. Likewise, the service providers should be trained and skilful to provide this type of services... Along with doctors, SBAs also should have a hand in normal delivery, so the government should focus on training and mobilising SBA. In the same way there should be skilled birth attendants at labour room, delivery room to perform the normal delivery. At the hospital level we need to influence the patients for the normal delivery as well as staff themselves should be skilful.” (P13)

Midwives should be posted in antenatal clinics, birthing centres, PNC (postnatal care) clinics, as well as in the community. Most interviewees also highlighted that education and appropriate utilisation of midwives must be the strategy for reasonable use of CS and physiological birth:

“First of all, midwives should be produced, and they have to be mobilised from ANC, birthing to PNC. Because of the lack of midwives normal physiological birth is not promoted. If we are able to produce more midwives and utilise them from community level to higher level than the rate of caesarean section can be decreased.” (P2)

Similarly, midwives who can promote and assist physiological birth should be trained in large numbers in Nepal:

“…if there is a midwife then they should promote women for the normal physiological birth until and unless there is an emergency otherwise you can have a normal birth, you are made with such a physiology type of counselling should be done among the mothers...Until and unless we don’t have a midwife who can assist the physiological birth, it would not happen. Human resources who can handle physiological birth need to be produced in large numbers; the government has already estimated that 9000 midwives should be produced and utilised...” (K3)

Birthing centres should be established in each hospital to promote physiological birth. Many interviewees stressed the importance of establishing birthing centres in each hospital which are run by midwives and where normal birth is promoted:

“In order to promote normal physiological birth, birthing centres should be established, well trained nurses should be utilised in every health facility.” (K2)

Furthermore, these birthing centres should be run by midwives

“Birthing centres should be established which are run by midwives…” (K4)

3.7.2. Raising awareness around mode of childbirth.

Three sub-themes were recognised under this theme: (1) counselling of pregnant women for normal birth, (2) increasing awareness of pregnant women around mode of childbirth, (3) increasing public awareness around mode of childbirth (S2 Fig).

Doctors should counsel women to motivate them to have normal births. Most interviewees stressed that counselling pregnant women about normal birth from the beginning of pregnancy can play a vital role in reducing CS rates:

“…If we have counselled properly during antenatal period, the client will be prepared mentally to give normal birth…Doctors should counsel that you have come to safe place, and you have a normal delivery. Counselling also convinces many patients, so, I think as a doctor he/she should also be a counsellor.” (P8)

Some interviewees also stressed importance of counselling women from their preconception period regarding the process and advantages of normal delivery to reduce fear of normal birth:

“…women should be counselled from their preconceptions. About how one can deliver normally then only we might be able to reduce their fear of the normal delivery by explaining to them about the benefits of normal birth. This way we might be able to reduce the rate of caesarean section.” (P1)

Many participants emphasised health education to pregnant women on mode of childbirth:

“Health education should be given to pregnant women by health workers and encouraging normal delivery.” (FGD/p1)

Furthermore, some stressed that childbirth education should be given during ANC visits:

“Education on mode of childbirth should be given to women during antenatal check-up. And their mental and physical aspect should be taken care of to prepare them. If you can do that then CS will decrease. Woman must be prepared for a normal delivery rather than CS.” (P2)

Some interviewees added that women should be made aware of the benefits of vaginal birth:

“…make pregnant women aware about the benefits of vaginal delivery during ANC visit. Monetary cost is also cheap, physical recovery is also quick, CS recovery takes time so normal delivery recovers quickly, all these things should be made aware during ANC visits.” (P10)

Many interviewees stressed that pregnant women should be empowered by providing service from midwives to help women make informed decisions around the mode of their childbirth:

“The first thing is that the women must be empowered themselves, there is not much human resource to empower the right of the woman and that is lacking for example the midwives… the main thing that can be done is the empowerment of the woman to reduce the rate of caesarean section. And the number of people performing elective caesarean section in the urban sector is increasing and women need to be aware that they must be empowered so that they can make decisions for themselves.” (P2)

Some interviewees highlighted that especially educated urban women should be made aware about the risks and benefits of different modes of childbirth – both risks and benefits of CS and normal birth:

“... All we need to do is to make aware and informed urban settings women about the consequences of CS…Likewise, women should be made aware and informed about the benefits of normal physiological birth.” (K3)

Many interviewees emphasised that public awareness around mode of childbirth should be increased using mass media such as displaying posters and pamphlets:

“Normal delivery has to be promoted via ANC by displaying posters, pamphlets and by counselling patients in the OPD about the benefits of normal delivery. This can be done by providing information in an understandable form in television.” (P3)

Some also emphasised the importance of educating family and the wider community:

“…family, community people should understand that CS should only be done in indicated cases...make the client aware from the very beginning to promote normal delivery.” (P9)

Some interviewees recommended increasing public awareness on CS, and how health education around childbirth could occur in high schools:

“Changes should be done only from education system. Health education should be provided in courses of +2 (=higher secondary) or medical course but basic general knowledge needs to be included from the beginning. Male and female both should know that this is the natural process, and it should be included in health education from school level.” (FDG/p12)

3.7.3. Reform policies and protocols for CS.

In this strategy, ten sub-themes were identified: (1) policies for avoiding CS for non-medical reasons and primigravidae/primary CS; (2) appropriate use of partograph for labour monitoring; (3) fixed service charge for CS; (4) rewards for, and investigations into hospitals in relation to CS rate; (5) monitoring of private hospitals; (6) use of Robson classification to enable proper comparison; (7) VBAC/trial of labour; (8) decision making around CS to be made by two consultants; (9) provision of security of service providers; and (10) commitment to implementation of international recommendations (including midwifery model of care and respectful maternity care) (S2 Fig).

Most interviewees stressed that policy should be reformed to avoid conducting CS on non-medical grounds. CS must only be done to avoid mortality and/or significant morbidity. Some interviewees also highlighted that primary CS should be avoided wherever possible:

“…you should not perform the operation during the first delivery, because if the CS was performed at the primigravida, if VBAC was not performed, then again, the caesarean section will be performed at second time.” (K4)

Furthermore, many stressed that hospitals should avoid doing CS on request of the mother:

“In private institutions we should reduce maternal requests…” (P11)

Some emphasized that policy for reducing unnecessary CS such as CS for non-medical reasons and primary CS should be reformed and strictly monitor it.

“The first step to reducing unwanted CS is to make strict protocol… Secondly, strict monitoring of whether the protocol has been strictly followed or not. The main thing is to reduce the unwanted CS, one had to make a protocol and strict monitoring of it…The current policy has everything, but we do not have a system of strict monitoring. If the government alone can’t monitor, it is better to have a separate body…In addition, there is policy which need to be strictly implemented, there is system to provide allowances to the mother who give birth through normal delivery.” (K1)

Compulsory use of a partograph to monitor labour in each hospital was emphasised as a strategy. Some interviewees stressed that labour in hospital should be monitored around their use of the partograph, although there was a notion that some private hospitals did not use them:

“Our hospital has its own protocol. We complete partograph but I don’t think private hospital use partograph, at least partograph should be filled.” (P6)

Some interviewees recommended that the government should create policy to reward hospitals with high normal birth, to investigate reasons for high CS rates, to run programmes to increase morale of doctors and to promote audits to reduce unnecessary CS. Such policy reform could encourage more normal deliveries in hospitals:

“…create protocol/guideline to be followed to reduce unwanted CS... programs to increase morale of the physicians, encouraging strategy. The hospital that has more normal delivery had to be awarded. If it is encouraging there will be competition in the hospital, so more vaginal delivery can be done or in a hospital where most of the CS are done, the government should investigate the cause of more CS. Auditing can also reduce CS because when there is inquiry, then people become aware that unnecessary CS should not be done…” (P10)

Several stressed that the Government of Nepal should monitor private hospitals regarding high CS rates as CS should only be conducted based on indications:

“Government should advocate that CS should be done only in indicated cases…Government should also monitor the private sector and need to strengthen for doing CS in indicated cases only.” (K5)

Some interviewees highlighted that the government should not blame private hospitals because doing a CS is an easy option to generate income for these hospitals:

“Private hospitals are there for making money unless and until government sector they do not themselves question and monitor them, nothing is going to happen. That is why it is useless to blame private hospital, because we are pretty much sure they are for profit making and they don’t get any money from government to run hospital and to run hospital they must generate fund, and to generate the fund CS is best option…” (K3)

Some interviewees emphasised that fees for CS must be fixed in private hospitals. The current fee for CS in the private hospitals is high but also varies across hospitals. Poor families cannot afford CS in private hospitals. Therefore, the government should set a fixed CS rate at a reasonable price and should monitor it:

“… financial aspects like in government sector CS is free, likewise if there are certain rules like only CS service fee can be charged up to that amount this will help patient to get service easily. The fee in a private hospital is very expensive for CS…It is cheaper in some places. Doing CS for some of our poor family or lower/middle-class family is expensive. So, even if they need to do CS, they try for normal delivery. At the same time, the lives of both mother and baby may be at risk, so if the Government of Nepal makes fixed rate available to the public at a very reasonable price along with strict monitoring... those who need a CS will get CS.” (K1)

A few interviewees suggested that the Robson criteria must be applied in all hospitals. This would enable better identification of the reasons for CS and allows cross comparison locally, regionally and internationally:

“By taking the Robson protocol and analysing all the hospitals indication for CS. This should be applied in private as well. Going private is the individual choice of the patient but Robson criteria is universally accepted and approved by WHO. Now there is also a necessary to know why the CS rate is high. The root cause also comes from the criteria and if the main cause of CS is found then we can reduce the unwanted CS.” (P9)

Many interviewees discussed the provision of protocols for VBAC and trial of labour for breech presentation. It would not only reduce CS rates, but also reduce the cost:

“…we should give a chance of trial of labour to previous CS, and this must be kept in every hospital protocol. Usually, doctors are distressed while the baby takes long time to deliver in order to be on the safe side, we want to do CS. So, it would be better if doctors try to keep calm and manage their distress and not perform unnecessary CS.” (P11)

One interviewee highlighted the need for intensive monitoring in a trial of labour in breech presentation to reduce CS:

“…it would be better if hospital could provide intensive monitoring for the trial of labour in the case of breech and previous CS. If we do all this, then normal physiological birth can be promoted.” (P9)

Many interviewees highlighted the provision of a safe working environment by protecting staff’s safety and morale to help reduce defensive CS:

“…Providers also should have confidence and safety. In case of any problem during delivery, safety of the provider should be ensured. The society should also be aware if anything happens blaming doctors, attacking them should not be done. Government should provide guarantee of security and conduct different workshops to increase the morale… This is the responsibility of the hospital as well as of government to provide safe environment for health worker to work.” (P10)

Some interviewees also emphasised the need for the law to protect health workers if they followed protocol even in case of bad outcomes as patients’ family are often seeking revenge:

“There should be a provision for safety of the doctor. If the system has followed well there, the judge does not have to make a hasty decision. If you have not followed the system, you must be punished if you have made a mistake, but even after following the system, sometimes bad results come, it does not mean that we know everything about the child inside... There should be strict law for the sake of doctors in what condition do they get exemption and punishment if any complications arise even if precaution is taken as protocol.” (K4)

Implementing international maternity recommendations was also mentioned as a strategy by interviewees. Some emphasised that government policy should aim to reduce CS by following the WHO protocol on the provision of Respectful Maternity Care with the midwifery model of care:

“The maternity department head is obstetrician, he/she should commit first to reduce unnecessary CS, they should commit that their institution CS rate should not be more than WHO standard... Department of Health Services, Family Welfare Division Head all should be committed collaboratively to reduce unnecessary CS… from national level WHO criteria should be strictly followed. Similarly, local level government should also commit for respectful maternity care... The Ministry of Health should be conceptually clear which model exists for maternity care in the country... This should be applied in the private sector as well.” (K3)

3.7.4. Promotion of physiological birth.

In this strategy, eight sub-themes were explored: (1) promote midwifery model of maternity care; (2) manage low-risk cases by midwives in birthing centres; (3) provide VBAC and trial of labour; (4) promote instrumental delivery; (5) provide painless delivery; (6) involve husbands; (7) improve care during pregnancy; and (8) improve care in public hospitals (S2 Fig).

Most interviewees emphasised that physiological birth should be promoted by employing midwives to avoid certain interventions, such as using oxytocin unnecessarily.

“…the approach to delivery should be midwifery model by promoting physiological birth, then the rate of caesarean section might be lowered... Because midwives have more knowledge about physiological birth and how to perform normal delivery. And the way in which the oxytocin is being used randomly and the misoprostol an induction is increasing. After the induction fails, the next option is caesarean section. So, we have to promote physiological birth giving process by producing more midwives and utilising them...” (P1)

There is a birthing centre in the public hospital where low-risk cases are managed by SBA nurses and midwives. Similar birthing centres should be established in other hospitals. Some interviewees emphasised that low-risk cases should be looked after by midwives and trained nurses in birthing centres to promote physiological birth, as in their maternity hospital:

“…should promote the system of delivery like in our maternity hospital, low risk cases are there in birthing centre where nurses and midwives manage delivery. The caesarean section rate over there is less than 10%. Therefore, birthing centres should be established in all the places in the country where there are more than 5000 deliveries in a year, but that birthing centre should not be like which is there in the health post. There should be a birthing centre having obstetric unit where nurses, midwives can do normal physiological delivery…” (K3)

Moreover, intensive monitoring of labour for VBAC and trial of labour for breech presentation can promote physiological birth:

“…hospital could provide intensive monitoring for the trial of labour in the case of previous CS and breech presentation. If we do all this, then normal physiological can be promoted.” (P9)

Some interviewees suggested that more instrumental deliveries could reduce CS rates:

“We also do vacuum, forceps, instrument delivery we need to keep both mother and baby healthy…instrumental/vacuum delivery should be performed like previously if these things are done then we can reduce CS rate.” (P6)

Several indicated that provision of pain relief in labour can help reduce maternal request CS. However, there is still a challenge due to shortage of staff such as anaesthetists:

“…if epidural anaesthesia is provided to relieve the labour of pain. then normal delivery can be increased. Many patients are demanding painless delivery but to get painless delivery there should be good backup of anaesthetic doctors because pain management is not the scope of work of the obstetrician. However, there is a shortage of anaesthesia doctors in Nepal. Therefore, if the doctor of anaesthesia can produce and utilise it well, and then, painless delivery can be done in Nepal.” (K4)

Some interviewees emphasised that husbands should be involved during pregnancy and childbirth, to help them understand when and how to encourage partners to go to hospital in good time:

“Husbands should be involved in the time of birth as they can’t do anything during pregnancy... in our country they don’t have any clue about that as they know only if their wife is pregnant. So, I think change needs to start from our society as well.” (FGD/p12)

Quality care during pregnancy can have a huge influence on the pregnant woman. Interviewees emphasised the importance of such care, including regular exercise, mental preparation and family support in promoting physiological birth.

“…Women should be mentally strong enough to give normal delivery. Normal exercise should be done regularly from the beginning. Nowadays, there is a lack of exercise among pregnant women. They start bed resting from 2-3 months of pregnancy. Resting in bed only will make body stiff and weak. So, regular exercise is important.” (FGD/P22)

Similarly, emotional and mental support from family was important

“…Family support for normal delivery. Pregnant mother should be mentally prepared. … Emotional and mental support from family as well. Positive thoughts in mother.” (FGD/P18)

Some referred to quality of care in public hospitals other mentioned attitudes of staff:

“Hospital should be more concerned about the patient. Behaviour of nurses in public hospital should be good. Stiches should be done properly in the public hospitals in case of normal delivery. Before giving baby to the mother baby should be examined thoroughly and should be given to the parents.” (FGD/P21)

Moreover: “…Health workers should speak calmly and softly without harsh words…” (FGD/6)

4.4.1. Medical factors.

In this study, repeat CS was the key factor influencing the rising CS rate, as all women with a history of previous CS underwent a further CS. The incidence of repeat CS was equally high (30%) in Kathmandu Medical College [48]. Some have argued that the lack of resources means that VBAC may not be the best alternative in a low-resource country like Nepal [49], as there are several factors associated with successful VBAC [50]. Although the chance of uterine rupture is low [51], staff and women may perceive repeat CS as the best option. The high proportion of repeat CS reflects the idea of ‘Once a caesarean section, always a caesarean section’ similar to other countries [52].

CS for a breech presentation was another medical factor contributing to the rising CS. Both Robson groups 6 (primigravida breech) and 7 (multigravida breech) had a 100% CS. Management of breech presentation is still debateable. External cephalic version for breech presentation may not common in Nepal, although it can promote vaginal birth [53].

Both hospitals are tertiary care hospitals and many complicated high-risk pregnancy cases are referred from other parts of the country. These women may need CS due to pregnancy and childbirth complications for medical indications. Both in India and Bangladesh, high-risk pregnancy is a reason for high rates of CS [54,55].

Gestation was associated with mode of childbirth; gestational age of 30-36 weeks was 0.78 times less likely to have a CS compared to full-term (37-40 weeks) in this study. Similar results have been reported in other studies [28,38]. Planned elective CS (for breech presentation, previous CS, pregnancy after IUI/IVF) is usually reserved for term pregnancies which may explain why CS rates at term are higher. Also, preterm labours may be much shorter, with less time to decide about mode of birth.

This study suggests that induction of labour in low-risk pregnancy can reduce the rate of unnecessary CS as reported by other studies [28,56], however, the rate of induction was low in our sample (11.5%). The shortage of SBAs limits the use of induction of labour because constant monitoring of labour is vital [57]. In contrast, a US study reported that the CS rate is significantly higher among women who had induced labour than those with spontaneous onset of labour [58].

4.4.2. Sociodemographic factors.

The increasing age of first-time pregnant women is a factor in the rising CS rate. Most interviewees described how modern urban Nepalese women are getting married/starting their family later, as observed elsewhere [27,28,54]. In addition, advanced maternal age also associated with reduced success of VBAC [59], complications which are associated with an increased risk of CS [60]. Moreover, CS is viewed as a prestigious delivery for educated, wealthy urban women [61], as in Bangladesh [54,62], and elsewhere in South Asia [27]. The study showed that women from higher caste had significantly higher odds (OR: 1.14) of CS, as was found in India [63]. Whilst so-called ‘precious baby’, those conceived after long-term subfertility or infertility treatment, are more likely to end up as a CS [27,64].

Legislation on violence against the healthcare providers was passed in 2022 in Nepal to provide a safe working environment for all health workers [65,66]. However, violent repercussions and demands for compensation still exist in Nepal [67] when a vaginal birth goes wrong. This situation has resulted in doctors carrying out defensive CS due to fear of physical assaults and litigation [9], and a similar situation exists in Iran [61].

4.4.3. Financial factors.

The study revealed that conducting CS is a lucrative income-stream for non-governmental or private hospitals. CS is a major operation so a high price can be charged, not only for the operation but also for the hospital bed, medications and service charges. Those who can afford the cost and are keen to give birth by CS often go to private hospitals [68]. Financial gain can lead to private hospitals conduct more CS [9,54,61], fulfilling patients’ demands [69]. Whilst in public hospitals in Nepal are receiving financial incentives from the government to enable them to conducting free CS [70], perhaps the higher rate of incentive for a CS encourages doctors to conduct more CS in public hospitals.

4.4.4. Non-medical factors.

Only 2.7% of all CSs were conducted for maternal request, however, these only occurred in the private hospital, representing 4.8% of all is births. It may reflect that private hospitals would accept the maternal request for financial reasons. The proportion of CS conducted at maternal request was slightly lower than reported by an earlier study (6%) in the same hospital [18].

This is very interesting since all pregnant women in the FGDs preferred to give birth vaginally. The women understood the benefits of physiological birth, but poor ANC education and a lack of respectful maternity care possibly encourages CS. Perceiving CS as a safer option is another possible reason for opting for CS. Regular consultations with doctors antenatally and trusting in their advice, may lead to women changing their choice of mode of childbirth. The main reason for requesting CS was labour pain as reported by another study in Nepal [31] and studies elsewhere [9,54,61]. Pregnant women hear horror stories about labour pain from relatives and friends. Women may also request CS during labour due to not coping with pain [71]. The interviews revealed that there are few pain relief methods (e.g., use of nitrous oxide), whilst the provision of regional analgesia is uncommon in Nepal in many hospitals due to a lack of resources such as anaesthetists, facilities and awareness [72,73]. Moreover, an epidural seldom makes birth painless. The scoping review on non-medical reasons for CS suggested similar reasons for requesting a CS [9]. In 5.7% of cases in this study the reason for CS was not specified, similar to several South Asian countries [27]. Some doctors also perceive CS as safer [61].

4.5.5. Health service-related factors.

Several health service-related factors contribute to rising CS rates in urban hospital in Nepal. The study showed that lack of appropriate antenatal counselling for pregnant mothers was a health service-related factor for rising rates of CS in urban hospitals in Nepal. They may have a lack of information or misinformation regarding childbirth [61] due to poor counselling antenatally on the mode of childbirth [74] or poor communication between doctors and women [46]. Inadequate knowledge (i.e., health consequences of CS) may lead to a preference for a CS [75], and an inability to make an informed choice about birth [61,76].

The study showed that the probability of undergoing CS was significantly higher among women who had four or more ANC visits (OR: 1.26; AOR: 1.26) than those with fewer visits as reported elsewhere [54,63,77]. On the one hand, more ANC might be needed due to pregnancy complications that need a CS. On the other hand, more ANC visits reflect the higher educational and socio-economic status of women; both are associated with an increased risk of CS.

Properly trained midwives who can advocate for the rights of the woman, counsel and motivate for normal birth are scarce in Nepal [78,79]. In urban hospitals, vaginal birth may not be promoted because this mode of delivery time consuming and there is insufficient staff [69]. In addition, lack of skills in instrumental and vaginal breech birth adds to higher CS rates [80]. Tertiary and private hospitals offering comprehensive obstetric care are mostly centralised in cities [81], and women who prefer a CS may self-refer to these [82]. The probability of having a CS was higher in private and charitable facilities than in public facilities in Nepal [83].

A written protocol for CS (currently lacking in both hospitals), following international guidelines, could encourage evidence-based practice as would the reliable use of the Robson categories which force recording of reasons for each CS and therefore enable proper audit [84].

The current adherence to the obstetric model of care in hospital and a lack of policy promoting maternity care is adding to the rise in CS. Political commitment with evidence-based international guidelines to the midwifery model of maternity care would be a vital not only for the development of the midwifery profession in Nepal [85], but also, for the reduction of unnecessary CS and promotion of physiological birth [86].

The lack of respectful maternity care is also a reason for unnecessary CS in Nepal, the preferences and choices of pregnant women may be ignored by health professionals [87]. Respectful maternity care is recommended by the WHO [88], but disrespectful maternity care was witnessed in hospitals in Nepal [89]. Therefore, lack of respectful maternity care and disrespectful maternity care would encourage women to either request CS or accept advice from a doctor and opt for CS despite them preferring vaginal birth. [61]. In addition, there is no monitoring system of the CS rate by the government as private hospitals run almost autonomously, this creates a lack of accountability for private hospitals [90].

The study emphasised that a system for auditing CS is lacking. A systematic review highlighted that audit and feedback using the Robson classification can reduce CS rates [91]. However, it seems to be far behind in auditing CS by using Robson classification in hospitals in Nepal.