Rising trends and persisting inequalities in cesarean section rates in Nepal: evidence from demographic and health surveys 2006-2016

Abstract Background Sustainable development goals require member countries to reduce maternal mortality ratio below 70 per 100,000 live births by 2030. Addressing inequalities in accessing emergency obstetric care is crucial for reducing the maternal mortality ratio. This study was undertaken to examine the time trends and socio-demographic inequalities in the utilization of cesarean section (CS) in Nepal during the period of 2006 and 2016.Methods Data from the Nepal Demographic and Health Surveys (NDHS) 2006, 2011 and2016 were sourced for this study. Women who had a live birth in the last five years of the survey (most recent birth if there were two or more childbirths) were the unit of analysis for this study. Absolute and relative inequalities in CS rates were expressed in-terms of rate difference and rate ratios, respectively. We used binary logistic regression models to assess the rate of cesarean sections by background socio-demographic characteristics of women. Results Age and parity adjusted CS rates were found to have increased almost three-fold (from 3.2%,95% CI:2.1-4.3 in 2006 to 10.5%;95% CI:8.9-11.9 in 2016) over the decade. In 2016, women from Mountain region (3.0%;95% CI:1.1-4.9), those from poorest wealth quintile (2.4%,95% CI:(1.2-3.7) and those living in province 6(2.4%,95% CI:1.3-3.5) had CS rate below 5%. Whereas, women from the richest income quintile (25.1%,95% CI :20.2-30.1), with higher education (21.2%,95% CI:14.7-27.8) and those delivering in private facilities (37.1%,95% CI:30.5-43.7) had CS rate above 15%. Women from the richest income quintile (OR-3.3,95% CI: 1.6-7.0) and those delivered in private/NGO-run facilities (OR-3.6;95% CI:2.7-4.9) were more than three times more likely to deliver by CS compared to women from the poorest income quintile and those delivering in public facilities, respectively. Conclusion To improve maternal and newborn health, strategies need to be revised to address the underuse of C-section in poor, mountain region and province 2, province 5, province 6 and province 7 so that universal access to comprehensive sexual and reproductive health care services is ensured. Simultaneously, there is a pressing need for policies, guidelines and continuous monitoring of CS rates to reduce overuse in rich women, women with higher education and those delivered in private facilities.