I am the father of two children. My elder child was born through vaginal delivery, while my younger child was delivered by Caesarean section.
Watching both children grow has made me think more closely about childbirth than I might otherwise have done. The two experiences were very different, but both ultimately brought home the same lesson: the way a child is born is not simply a personal choice. It is also a matter of medical necessity, access to care, health-system capacity and, increasingly, the way families and health providers understand childbirth.
In Nepal, Caesarean section rates have risen sharply over the past decade. National survey data indicate that the proportion of births delivered by C-section increased from 10.2 percent in 2016 to 18.2 percent in 2022. Data from the Routine Health Management Information System also indicate a substantial increase in C-section deliveries in recent years.
The increase is not, in itself, a problem.
Caesarean delivery is one of modern medicine’s most important life-saving interventions. When complications make vaginal delivery unsafe, timely access to surgery can save the lives of both mother and child.
The challenge is finding the balance between ensuring that every woman who needs a C-section can get one and avoiding unnecessary surgery when it is not medically indicated.
That distinction matters for Nepal’s health system.
More women are giving birth in health facilities
Nepal has made considerable progress in maternal and newborn health.
Each year, more than 600,000 women become pregnant, and nearly 91 percent of births now take place in health facilities. Yet significant disparities remain. In Madhesh Province, for example, the proportion of births occurring in health facilities is lower than the national average, while women from the poorest households continue to face greater barriers to accessing institutional delivery.
There are also important differences in newborn care. Only around 38 percent of babies are breastfed within the first hour of birth.
Nepal’s progress in reducing maternal mortality has been supported by the expansion of emergency obstetric and neonatal care, including through the Aama Programme and the training and deployment of skilled birth attendants. Greater access to C-section services has been an important part of this progress, particularly for women experiencing high-risk pregnancies or obstetric complications.
The policy challenge now is different.
Nepal needs to ensure that the expansion of C-section services does not turn into a system where surgical delivery becomes the default option for women who could safely give birth vaginally.
The public-private divide
Government-supported Comprehensive Emergency Obstetric and Neonatal Care services are now available through facilities across the country, while a large and growing private sector provides maternity services, particularly in urban areas.
Research suggests that women giving birth in private hospitals in several provinces, including Koshi, Bagmati, Madhesh and Lumbini, are more likely to have a C-section than those delivering in public facilities.
There are many possible reasons.
Women and families may perceive private hospitals as offering better or more responsive care. Private facilities may have greater availability of specialists, operating theatres and diagnostic services. Differences in staffing, referral systems and the perceived quality of care can all influence where women choose to give birth and how childbirth is managed.
But the difference in C-section rates between facilities deserves closer examination.
It is important to distinguish between medically necessary C-sections and procedures that may be avoidable. Without reliable data on the indications for each procedure, however, it is difficult to determine how much of the increase reflects genuine medical need and how much reflects differences in clinical practice, patient preference or institutional incentives.
That is an area where Nepal needs better evidence rather than assumptions.
The financial cost of Caesarean delivery
A C-section is also considerably more expensive than an uncomplicated vaginal delivery.
During a recent visit to Paropakar Maternity and Women’s Hospital in Kathmandu, I observed a family spending more than NPR 30,000 on a Caesarean delivery. Similar procedures in private hospitals can cost considerably more.
Even a rough estimate illustrates the scale of the issue.
If around one-quarter of births were delivered by C-section and more than half of those procedures took place in private hospitals, the combined annual expenditure could run into billions of rupees. The exact figure requires more systematic costing, including differences between public and private facilities and between uncomplicated and complicated procedures.
For families, particularly those with limited incomes, these expenses can be substantial.
For the health system, increasing reliance on surgical delivery also means greater demand for operating theatres, anaesthesia, surgical teams, medicines, blood supplies, hospital beds and post-operative care.
The financial consequences therefore extend well beyond the cost of the operation itself.
When one C-section leads to another
The consequences of rising C-section rates do not necessarily end with one delivery.
A previous Caesarean can affect decisions in subsequent pregnancies. Depending on the circumstances of the previous surgery and the woman’s current pregnancy, vaginal birth after Caesarean, or VBAC, may be an option. But many women ultimately undergo repeat C-sections.
This can create a cycle in which an increase in primary C-sections contributes to more repeat procedures in the future.
A 2018 study at Paropakar Maternity and Women’s Hospital found that elective C-sections accounted for 25.6 percent of all C-section deliveries during the study period. More than two-thirds of those elective procedures were reported to have occurred because women declined vaginal birth after a previous C-section.
This finding points to an important part of the conversation.
A woman’s preference matters. But preference is shaped by information, previous experiences, fear of labour pain, advice from health professionals, family expectations and perceptions about the safety of different modes of delivery.
Women need to be able to make these decisions with accurate information and appropriate clinical counselling.
What does a C-section mean for the child?
There is no simple answer to whether vaginal birth or Caesarean delivery is “better” for every child.
A planned C-section can avoid some complications associated with difficult labour and may be medically preferable in certain pregnancies. But it is major abdominal surgery and carries risks for the mother and newborn.
For newborns, planned C-section can be associated with a higher risk of certain short-term respiratory problems, particularly when performed before the onset of labour and without a medical indication.
Research has also found associations between Caesarean birth and some longer-term outcomes, including childhood obesity, asthma and certain immune-related conditions. However, these relationships are complex. It is difficult to separate the effects of Caesarean delivery itself from the medical or social conditions that led to the procedure in the first place.
This distinction is important.
We should not frighten parents by suggesting that a C-section automatically causes poor health outcomes. Nor should we present vaginal birth as universally safer.
The appropriate mode of delivery depends on the individual pregnancy and the circumstances at the time.
The goal should be safe birth, not a particular birth method at all costs.
Choice must come with information
Around the world, Caesarean rates are rising. The World Health Organization has warned that both underuse and overuse can occur within the same health system — some women do not have timely access to life-saving surgery, while others undergo C-sections without a clear medical indication.
Nepal faces both challenges.
In some parts of the country, women still struggle to reach facilities capable of providing emergency obstetric care. In urban areas, meanwhile, the concern may be the opposite: whether surgical intervention is being used more often than necessary.
This makes the question of choice particularly important.
A woman should be able to discuss the benefits and risks of vaginal birth and Caesarean delivery with a qualified health professional. Fear of labour pain, previous birth experiences and concerns about complications should be addressed through counselling and childbirth preparation rather than allowing fear alone to determine the mode of delivery.
Family members also matter. In Nepal, husbands and other relatives can have considerable influence over decisions about where and how women give birth. They therefore need access to the same accurate information.
Informed choice cannot be the responsibility of the woman alone.
Reducing unnecessary C-sections
Nepal does not need to reduce C-sections simply for the sake of reducing the national rate.
It needs to reduce unnecessary C-sections while ensuring that every woman who needs one can receive it quickly.
That requires action at several levels.
First, preventing unnecessary primary C-sections should be a priority. Every first C-section can influence the options available in future pregnancies.
Second, hospitals should strengthen clinical audit systems. Reviewing the indications for primary C-sections and providing feedback to clinicians can help identify variations in practice and encourage adherence to evidence-based guidelines.
Third, where clinically appropriate and safely supported, hospitals should offer women the option of vaginal birth after Caesarean. VBAC can reduce the need for repeat surgery for appropriately selected women.
Fourth, Nepal should strengthen midwifery-led care and ensure that women with low-risk pregnancies are not unnecessarily medicalised. Better-designed birthing spaces, continuous support during labour, appropriate labour-monitoring tools and reliable referral mechanisms can all contribute to safer maternity care.
Finally, women and families need balanced information.
They should understand both the benefits and risks of vaginal birth and Caesarean delivery. Counselling should address concerns about pain, complications and previous birth experiences without presenting either option as inherently superior in every situation.
The question Nepal needs to ask
The rise of C-sections is not simply a story about doctors, hospitals or mothers making the “wrong” choice.
It is a story about a health system in transition.
More women are reaching health facilities. Emergency obstetric care is more available. Private hospitals have expanded. Families have changing expectations. Medical technology has improved. At the same time, Nepal continues to face major inequalities in access to quality maternal care.
All of these factors are shaping how children are born.
As a father of two children who experienced both vaginal and Caesarean delivery, I do not believe one experience should be held up as the correct model for everyone.
What matters is that women have access to safe, respectful and evidence-based maternity care, wherever they live and whatever their economic circumstances.
Nepal has spent decades working to ensure that women who need Caesarean delivery can get it.
The next challenge is more nuanced.
We must make sure that every C-section is driven by the best interests of the mother and child — not by lack of alternatives, inadequate information, institutional habit or financial incentives.
The goal should never be fewer Caesareans simply because the number looks high.
The goal should be the right care, at the right time, for every mother and every child.
