Archives of Gynecology and Obstetrics

, Volume 289, Issue 2, pp 421–427

Cesarean deliveries among Nepalese mothers: changes over time 2001–2011 and determinants

Authors

    • School of Health SciencesUniversity of Tampere
  • Subas Neupane
    • School of Health SciencesUniversity of Tampere
Reproductive Medicine

DOI: 10.1007/s00404-013-2976-8

Cite this article as:
Prakash, K.C. & Neupane, S. Arch Gynecol Obstet (2014) 289: 421. doi:10.1007/s00404-013-2976-8

Abstract

Objectives

To examine the most recent trends of cesarean delivery in Nepal and the association with socio-demographic characteristics of mothers.

Methods

Nationally representative cross-sectional data was used from three Demographic and Health Surveys conducted in Nepal in 2001 (N = 4,745), 2006 (N = 4,066) and 2011 (N = 4,148). Cesarean section delivery was measured in two categories with yes and no responses for the delivery in their latest pregnancy. Data on socio-demographic variables was obtained by interviewing the participants. The data was analysed using logistic regression models.

Results

The prevalence of cesarean section delivery was increased by more than 4 times from 2001 to 2011 both among rural and urban residents. After adjusting for mother’s age, number of births in last 5 years and mother’s education the prevalence of cesarean section delivery among all mothers was 1.71 times higher in 2006 (OR = 1.71, 95 % CI 1.23–2.37) and increased further in 2011 (OR = 2.42, 95 % CI 1.78–3.30) compared with year 2001. When adjusted for all the variables simultaneously, all variables except births in last 5 years remained significantly associated with cesarean section delivery of the mother. Older age, urban resident, being educated, having educated partners and being rich according to wealth index were associated with cesarean section delivery.

Conclusions

The prevalence of cesarean section delivery continues to rise but still lower than the World Health Organization recommended rates. More studies are needed to examine the non-medical reason of increasing rates of cesarean section deliveries and their effect in maternal and infant morbidity and mortality in Nepal.

Keywords

Cesarean ratesPregnancyTrendsDeterminantsNepal

Introduction

World Health Organization (WHO) estimates that a large number of countries are at most providing cesarean deliveries to meet demand, resulting in the death of thousands of mothers each year [1]. Cesarean delivery has been regarded as the safer option but indeed it has greater risks and complications than vaginal birth. In 1985, WHO stated that any specific geographic region with more than 10–15 % cesarean births would not be reasonable [2]. However, after 25 years a global survey conducted by WHO in 2010 showed that 25.7 % of all deliveries in the world are done through the cesarean section [1].

One of the recent studies indicate that in 137 countries in the world 18.5 million cesarean section deliveries were performed each year with the rate of <5 percent in 24 percent countries and >15 percent in 50 percent countries [3]. An analysis of nationally representative data of different countries of world showed the occurrence of 15 percent of cesarean births, among total deliveries in developed countries almost one-fourth was cesarean section and in least developed countries very minimal (2 percent) was cesarean section delivery [4]. Earlier studies show that inconclusive results with higher cesarean section rates were shown to be associated with lower maternal and child mortality rate in some countries whereas no association found in some countries with higher rates of cesarean section deliveries [5]. It shows from the earlier studies that married, educated and the women in their first delivery were the one to prefer cesarean section delivery without the medical need [1].

Cesarean section deliveries are usually made to ensure safety of the mother and the child under conditions of obstetric risk. Although rates of cesarean section in many countries have increased from the recommended level both in developed and many developing countries with increasing institutional deliveries and growing access to gynecological and obstetric care [2], the rate of delivery through cesarean section is relatively low in Nepal. However, some earlier studies from Nepal on hospital-based data shows that the cesarean section deliveries are increasing rapidly e.g., in eastern part of Nepal cesarean section delivery rate was 28.6 % in 2006 which raised to 33.7 % in 2007 with annual increment of 5 % [6] . In our understanding there are no previous studies examined the trends of cesarean section deliveries and their determinants from national sample of Nepal. The study of determinants of cesarean section deliveries makes it easier to see how different components play a role in the decision to perform this surgical intervention. This study presents the most recent trends of cesarean section delivery in Nepal and examines the association with socio-demographic characteristics of women using data from three latest Demographic and Health Surveys.

Methods

Data sources

The present study utilizes data from the third, fourth and fifth round of the Nepal Demographic and Health Survey (NDHS) carried out in 2001, 2006 and 2011. The surveys were conducted by the department of health services, Population Division of the Ministry of Health and Population and were implemented by New ERA, a local research organization. These surveys covers a nationally representative sample from sample household using a multistage stratified cluster sampling design and provide cross-sectional data on a wide range of indicators relating to population such as household and respondent’s characteristics, health such as maternal and child health and nutritional indicators such as breastfeeding, micronutrient intake, anemia, iron supplement, etc. Surveys included women aged 15–49 years, men aged 15–49 years, and children <5 years of age because the survey basically focused on reproductive age group and child health.

The present analysis was based on a sample of ever-married women (2001) and all women (2006 and 2011) and for this analysis the data was restricted to those who have had at least one delivery during last 5 years. The total data of 12,959 women were analysed from all three surveys (2001: N = 4,745, 2006: N = 4,066 and 2011: N = 4,148). The total number of subjects excluded from all three surveys for this analysis was N = 3,992 in 2003, N = 6,728 in 2006 and N = 8,530 in 2011.

Measurement of variables

Outcome variable

Cesarean section delivery was measured in a binary response: yes and no, question was asked if the respondent had the cesarean section method for delivery in their latest pregnancy. If the respondents had used cesarean section they replied as yes and if not then they replied as no.

Socio-demographic variables

Socio-demographic variables in this study included age (15–19, 20–24, 25–29, 30–34 and 35 or more years), parity (one, two and three or more), place of residence (rural and urban), region (Eastern, Central, Western, Mid-western and Far-western), mother’s educational level (no education, primary, secondary and higher), father’s educational level (no education, primary, secondary and higher), and wealth index. The wealth index was calculated using easy-to-collect data on a household’s ownership of selected assets, such as televisions and bicycles, materials used for housing construction and types of water access and sanitation facilities. The wealth index was generated by DHS staffs using three step principal components analysis. The first step comprised a common subset of indicators for urban and rural areas which was used for the households of both areas to create wealth scores. Then the transformation of categorical variables used into the separate dichotomous indicators (0–1) was performed and the common factor score was produced for each household. With the use of area-specific indicators, second step created the separate factor scores for urban and rural households. The separate area-specific factor score was combined in the third step to create a combined wealth index by performing regression analysis (adjusting area-specific scores through a regression on common factor scores) which places individual households on a continuous scale of relative wealth. It was then categorized into five (poorest, poorer, middle, richer and richest).

Statistical analysis

Descriptive statistics was calculated and presented as numbers and percentages by the year of the survey. The prevalence of cesarean section delivery in each category of age, births in last 5 years, region, mother’s education, partner’s education and wealth index was compared by the year of the survey using the Chi square test. Binary logistic regression models were used to calculate the odds ratios (OR) and 95 % confidence intervals (CI) for cesarean section delivery, using the first survey as the reference. The analyses were first done among all mothers and later stratified by the place of residence (rural and urban). Model I provided crude odd ratios and Model II was adjusted for mother’s age, number of births in last 5 years, and mother’s education. P value for the trend was calculated in each model using the year of survey as a continuous variable. Binary logistic regression analyses were also used to study the associations between the socio-demographic characteristics (age of mother, births in last 5 years, place of residence, region, mother’s education, partner’s education, and wealth index) and cesarean section delivery for the last survey. Crude odd ratios are presented in Model I and Model II was simultaneously adjusted for all socio-demographic variables in relation to outcome variable by enter method. Data were analysed using the SPSS statistical software package version 20. All the analyses in the tables were based on weighted data (using sampling weights) except for the regression analysis in Table 4.

Results

There were more mothers in the age group 20–24 years in each survey followed by age group 25–29 years. The fewest numbers of mothers were in the youngest category (15–19 years) of age with 8 % in each survey year (Table 1). Almost 60 % of the mother had one birth in last 5 years of the survey in 2001 whereas the number was higher in 2006 (67 %) and even higher in 2011 (73 %). The majority of the women (87–93 %) lived in rural areas. About one-third of the mothers were residing in the Central region of the country in each survey whereas the least number of mothers lived in far-western region (9–14 %). The number of mothers with no education was the highest (72.4 %) in 2001 but decreased to 58 % by 2006 and to almost 44 % by 2011. Similarly partner’s with no education were the highest (37 %) in 2006 but decreased to 24 % by 2006 and to 21.6 % by 2011. Educational status of the mother and their partners was increased by year in overall. The proportion of mother in the poorest quintile of the wealth index has also decreased slightly and the richest quintile of the wealth index had increased over time.
Table 1

Background characteristics of the participating women by year, weighted numbers (%)

Variables

Year of survey

2001

2006

2011

N = 4,745

%

N = 4,066

%

N = 4,148

%

Age (year)

 15–19

379

8.0

325

8.0

333

8.0

 20–24

1,370

28.9

1,355

33.3

1,329

32.0

 25–29

1,354

28.5

1,231

30.3

1,310

31.6

 30–34

850

17.9

592

14.5

670

16.1

 35 or more

793

16.7

562

13.8

507

12.2

Births in last 5 years

 1

2,785

58.7

2,722

67.0

3,021

72.8

 2

1,701

35.8

1,209

29.7

1,020

24.6

 3 or more

259

5.4

134

3.3

108

2.7

Place of residence

 Urban

332

7.0

536

13.2

418

10.1

 Rural

4,414

93.0

3,530

86.8

3,730

89.9

Region

 Eastern

1,102

23.2

884

21.7

999

24.1

 Central

1,535

32.3

1,329

32.7

1,293

31.2

 Western

914

19.3

755

18.6

973

23.4

 Mid-western

693

14.6

514

12.6

513

12.4

 Far-western

502

10.6

584

14.4

371

8.9

Mother’s education

 No education

3,437

72.4

2,357

58.0

1,822

43.9

 Primary

684

14.4

743

18.3

835

20.1

 Secondary

571

12.0

858

21.1

1,229

29.6

 Higher

53

1.1

108

2.7

263

6.3

Partner’s education

 No education

1,755

37.0

978

24.0

894

21.6

 Primary

1,170

24.7

1,170

28.8

984

23.7

 Secondary

1,539

32.4

1,598

39.3

1,809

43.6

 Higher

282

5.9

321

7.9

461

11.1

Wealth index

 Poorest

1,154

24.5

811

19.9

661

15.9

 Poorer

1,086

23.1

769

18.9

756

18.2

 Middle

1,037

22.0

762

18.7

672

16.2

 Richer

865

18.4

817

20.1

910

21.9

 Richest

569

12.1

906

22.3

1,150

27.7

Table 2 shows the demographic characteristics of the women who had cesarean section delivery by year of the survey. Mothers of the age group 25–29 had the highest rate of cesarean section delivery and which has increased almost by 9 % by 2011. The prevalence rate increased in each category of age (except first two and last categories), those with one birth in last 5 years (increased from 2003 to 2006), each region except Eastern, each category of mother’s education except the mothers with no education, mother whose partner’s education was secondary and mothers with the richest category of wealth index.
Table 2

Categorical demographic characteristics of women who had cesarean section deliveries by the year of survey, weighted crude percentages

 

Cesarean section delivery (%)

2001

P value

2006

P value

2011

P value

Age

 

0.696

 

0.013

 

0.011

 15–19

5.6

 

11.7

 

4.9

 

 20–24

29.6

 

30.7

 

24.7

 

 25–29

31.5

 

37.2

 

39.9

 

 30–34

14.8

 

11.7

 

19.7

 

 35 or more

18.6

 

8.8

 

10.7

 

Births in last 5 years

 

0.079

 

0.001

 

0.013

 1

77.8

 

84.6

 

82.5

 

 2

20.4

 

14.0

 

17.0

 

 3 or more

1.9

 

1.5

 

0.4

 

Region

 

0.006

 

<0.001

 

<0.001

 Eastern

27.8

 

15.6

 

5.2

 

 Central

50.0

 

52.6

 

58.1

 

 Western

16.7

 

20.0

 

23.4

 

 Mid-western

1.9

 

6.7

 

7.1

 

 Far-western

3.7

 

5.2

 

6.2

 

Mother’s education

 

<0.001

 

<0.001

 

<0.001

 No education

40.7

 

24.8

 

17.4

 

 Primary

14.8

 

18.2

 

18.8

 

 Secondary

37.0

 

38.7

 

42.0

 

 Higher

7.4

 

18.2

 

21.9

 

Partner’s education

 

<0.001

 

<0.001

 

<0.001

 No education

12.7

 

5.9

 

7.2

 

 Primary

14.5

 

14.0

 

10.4

 

 Secondary

36.4

 

43.4

 

51.8

 

 Higher

36.4

 

36.8

 

30.6

 

Wealth index

 

0.955

 

0.854

 

0.614

 Poorest

20.4

 

22.1

 

14.8

 

 Poorer

24.1

 

15.4

 

18.4

 

 Middle

24.1

 

18.4

 

17.5

 

 Richer

20.4

 

21.3

 

18.4

 

 Richest

11.1

 

22.8

 

30.9

 

P values tested from Chi square test

The overall prevalence of cesarean section delivery in each year is presented in Table 3. The prevalence was increased by more than 4 times from 2001 to 2011 both among rural and urban residents. After adjusting for mother’s age, number of births in last 5 years and mother’s education the prevalence of cesarean section delivery among mothers was 1.71 times higher in 2006 (OR = 1.71, 95 % CI 1.23–2.37) and increased further in 2011 (OR = 2.42, 95 % CI 1.78–3.30) compared with year 2001. However, when the analyses was stratified by the place of the residence the upward trend in the prevalence of cesarean section delivery among rural residents was similar to all population but a bit weaker among urban residents for whom the increase in the prevalence was observed only in 2011. Moreover, the trend shows that the increase in prevalence was highly significant among all population and also when stratified by the place of residence.
Table 3

Prevalence of cesarean section deliveries by year of survey, stratified by place of residence, weighted numbers (%) and odd ratios OR (95 % confidence intervals, CI)

 

Year of survey

P value for trend

2001

2006

2011

All

 C-section delivery, N (%)

55 (1.2)

136 (3.3)

223 (5.4)

 

 Model I, OR (95 % CI)

1.00

2.33 (1.69–3.23)

4.73 (3.52–6.37)

<0.001

 Model II, OR (95 % CI)

1.00

1.71 (1.23–2.37)

2.42 (1.78–3.30)

<0.001

Urban

 C-section delivery, N (%)

20 (6.0)

54 (10.2)

69 (16.6)

 

 Model I, OR (95 % CI)

1.00

1.07 (0.66–1.73)

2.56 (1.64–4.02)

<0.001

 Model II, OR (95 % CI)

1.00

0.97 (0.59–1.59)

1.77 (1.11–2.82)

0.005

Rural

 C-section delivery, N (%)

35 (0.8)

81 (2.3)

154 (4.1)

 

 Model I, OR (95 % CI)

1.00

2.48 (1.60–3.86)

4.66 (3.11–6.97)

<0.001

 Model II, OR (95 % CI)

1.00

2.00 (1.28–3.13)

2.65 (1.74–4.03)

<0.001

Model I: logistic regression model with crude odd ratios

Model II: logistic regression model adjusted for age, number of births in last 5 years and mother’s education

Bold values indicate the statistically significant

The crude logistic regression model shows that all the socio-demographic variables were associated with cesarean section delivery in 2011 (Table 4). When adjusted for all the variables simultaneously (Model II), all variables except births in last 5 years remained significantly associated with cesarean section delivery of the mother. Older age, urban resident, being educated, having educated partners and being rich according to wealth index were associated with cesarean section delivery. In the same way, mothers living in Western and Far-western region had negative association with cesarean section delivery.
Table 4

Relationship of demographic variables with cesarean section deliveries, odd ratios and 95 % confidence intervals for women participated in 2011

 

OR, 95 % CI

Model I

Model II

Age

 15–19

1.0

1.0

 20–24

1.24 (0.64–2.39)

1.08 (0.55–2.12)

 25–29

2.09 (1.11–3.95)

1.77 (0.91–3.41)

 30–34

2.01 (1.03–3.94)

1.74 (0.86–3.51)

 35 or more

1.46 (0.71–3.00)

2.67 (1.24–5.75)

Births in last 5 years

 1

1.0

1.0

 2

0.59 (0.41–0.84)

0.94 (0.64–1.38)

 3 or more

0.22 (0.04–1.08)

0.39 (0.07–2.08)

Place of residence

 Rural

1.0

1.0

 Urban

4.61 (3.40–6.25)

2.11 (1.49–3.00)

Region

  

 Eastern

1.0

1.0

 Central

0.93 (0.67–1.29)

0.91 (0.64–1.30)

 Western

0.48 (0.32–0.73)

0.52 (0.34–0.80)

 Mid-western

0.42 (0.24–0.72)

0.62 (0.35–1.10)

 Far-western

0.36 (0.18–0.70)

0.48 (0.24–0.96)

Mother’s education

 No education

1.0

1.0

 Primary

2.43 (1.56–3.79)

2.05 (1.29–3.28)

 Secondary

3.78 (2.58–5.55)

2.33 (1.48–3.67)

 Higher

10.51 (6.73–16.39)

3.96 (2.32–6.77)

Partner’s education

 No education

1.0

1.0

 Primary

1.31 (0.69–2.50)

1.07 (0.55–2.10)

 Secondary

3.61 (2.13–6.11)

1.75 (0.95–3.23)

 Higher

9.22 (5.29–16.07)

2.37 (1.15–4.87)

Wealth index

 Poorest

1.0

1.0

 Poorer

0.69 (0.29–1.62)

0.62 (0.26–1.48)

 Middle

4.06 (2.20–7.48)

3.26 (1.73–6.14)

 Richer

5.87 (3.22–10.70)

3.61 (1.89–6.90)

 Richest

12.46 (7.00–22.20)

4.50 (2.29–8.83)

Model I: crude odd ratios from bivariate analysis

Model II: simultaneously adjusted for all demographic variables included by enter method

Bold values indicate the statistically significant

Discussion

In this study, the prevalence of cesarean section delivery has increased more than four times between 2001 and 2011 with 5.4 % prevalence in 2011. The prevalence ascends especially among the mothers of age group 25–29 and 30–34 years, mothers residing in all regions except Eastern region, mothers with secondary or higher education, whose partner’s education was secondary and the mothers of richest quintile of the wealth index. The prevalence was increased both in urban and rural areas but more rapidly in rural area. Mother of older age (35 or more years), urban residents, being educated, having educated partner and being rich were associated with cesarean section delivery.

Although there was an increase in the prevalence of cesarean section delivery during last 10 years, but it is still substantially lower than the World Health Organization’s recommended rate of 10–15 % [2]. One earlier study also found that the majority of developing countries with high maternal and neonatal mortality rates had cesarean section delivery rates well below the recommended range of 10–15 % [4], although the cesarean section delivery rates have been steadily increasing over the last decade [7]. However, in this study in urban area the prevalence of cesarean section delivery exceeded the limit of WHO, whereas in rural area the rate is far below the limit. It is noteworthy to point out that the rate of cesarean section has been increased between 2001 and 2011. A similar increasing trend has also been reported in many other countries both developing and developed countries [811]. The slope of the increase of cesarean section delivery in Nepal was not as steep as in some other countries. In Jordan, the rate of cesarean section delivery was increased by 209 % from 1990 to 2002 and also in China, the rates were increased from 36 to 131 % from 2001 to 2007 [9].

In our study, mother of older age group, lower parity, living in urban area, educated mothers, mothers with educated partners and rich mothers had significantly higher odds of cesarean section delivery. The prevalence of cesarean section delivery was about 20 % among women of age group 30–34 and about 11 % among women of age group 35 or more years in the latest survey 2011. This finding of our study was supported by many other studies which found that increased maternal age was the predictor of cesarean section delivery [8, 11, 12]. Although the regression analysis did not confirm our findings but mothers with lower parity (one or two births in last 5 years) had higher likelihood of cesarean section delivery is supported by other studies [1113]. The prevalence levels of cesarean section delivery were lower among rural mothers, but the rate was increased almost by four-times between 2001 and 2011. However, urban mothers had higher likelihood of having a cesarean section delivery more than doubled when all other factors were simultaneously adjusted. This finding reflects a better access of mothers to obstetric care in urban areas. Further, health facilities in urban centers are known to be better equipped than in rural areas, which are required to perform cesarean section delivery. However, the higher rates of cesarean section delivery in urban areas might indicate the overuse of cesarean section delivery in these areas, where patients are more able and willing to pay. The relationship between socioeconomic status and cesarean section delivery was established in several earlier studies [14]. The results of our study also show the regional variation in prevalence of cesarean section delivery with the highest prevalence (58.1 % in 2011) in the Central region. Interestingly, the prevalence of cesarean section delivery was increasing in all regions but exceptionally decreasing in Eastern. The Central region is the most developed among all regions and has a lot of private health facilities which probably explain the highest prevalence of cesarean section delivery in the Central region.

In this study, the variation of the maternal characteristics suggests that increased rates of cesarean section delivery cannot be explained solely by medical reasons. For example, the effect of the mother’s educational level is known to operate through both age and parity [15]. Educated women tend to delay giving birth and therefore, increasing probability of having cesarean section delivery. In our study, we found that educated mothers and their partners with higher education were more likely to have cesarean section deliveries. Highly educated mothers and also their partners with higher education earn more and therefore, are able to afford the expenses to use private services with receiving better quality of care.

Unfortunately, we could not determine in the present study that whether the providers encouraged women for cesarean section delivery or whether it was simply a matter of maternal choice or elective as that kind of information was not collected in the survey. However, the actual rate of elective cesarean section delivery can be assumed to be higher at least in urban areas. The most prevalent and preventable factor leading to the decision to use cesarean section delivery was found to be elective in earlier studies [12]. This could be because of many reasons such as maternal request [16] and the possibility of the misuse of cesarean section delivery for profit drive by private health institutions is the major determinant of cesarean section delivery [15]. The prevalence of cesarean delivery on maternal request is estimated to be 1–18 percent of all cesarean section deliveries worldwide [17].

This study had some strength. Firstly, the data was based on large nationally representative surveys conducted at three time points and therefore widely represents the whole country. Secondly, data on cesarean section delivery was collected from personal interview making the data comparable. Thirdly, the surveys used standardized methods comparable to multiple countries. However, some limitations are worth discussing. All these three surveys were cross-sectional in design. Therefore, we cannot determine the direction of the association since exposure and disease status were measured at the same time. We did not have data on whether the mother had cesarean section delivery due to medical reason or elective, which would provide medical determinants of cesarean section delivery.

In conclusion, the prevalence of cesarean section delivery continues to rise but still lower than the WHO recommended rates. However, the prevalence of cesarean section delivery in urban exceeded the limit of WHO recommendation. In 2011, older age of women, less number of children, urban resident, being educated, having educated partners and being rich were the major characteristics of the mother who had cesarean section delivery. Therefore, it is important to understand the women’s health seeking behavior and the related factors in a country like Nepal where there is a trend of increasing hospital delivery. Further studies are needed to examine the reason of increasing rates of cesarean section deliveries and their effect in maternal and infant morbidity and mortality in Nepal.

Conflict of interest

We declare that we have no conflict of interest.

Copyright information

© Springer-Verlag Berlin Heidelberg 2013