Palau’s caesarean birth rate has risen sharply to 42 percent, far exceeding the World Health Organization’s recommended limit of 10 percent.
The increase—from 33 percent in 2020 to 42 percent in 2021—places Palau among the countries with the highest cesarean rates globally, raising concerns about women’s health, birth outcomes, and reproductive rights.
A 2023 report from the US Department of Health and Human Services found that more than half of cesarean deliveries in Palau were performed without medical necessity, often citing reasons such as “small pelvis” or “big baby.”
Medical experts warn that unnecessary cesareans can lead to long-term complications, including higher risks of maternal death, uterine rupture, and difficulties in future pregnancies. The World Health Organisation cautions that while cesareans can be lifesaving in emergencies, they should only be used when medically necessary.
Palau’s trend mirrors growing concerns in countries like the United States, where cesarean rates hover around 32 percent, contributing to poorer maternal health outcomes compared to other nations.
Some women in Palau report feeling pressured into early inductions at 39 weeks and cesareans without a full understanding of their options. A lack of access to alternatives, such as vaginal birth after cesarean (VBAC), limits choices for many.
Cesarean deliveries can also impact breastfeeding. The report notes that cesareans often disrupt the natural release of oxytocin, a hormone critical for bonding and milk production. This delay can lead to reliance on expensive imported formula, increasing health risks for infants.
“Including myself, I know of two recent births where the women felt like I did, that we are given no option,” said a Palauan mother, who asked to remain anonymous, fearing repercussions. “I, too, agree that many are being pushed into surgery without clear medical reasons.”
Another Palauan woman in her early 30s said she delivered her first baby via cesarean in 2023 after a doctor cited a small pelvis.
She struggled with recovery and requested a natural birth for her second child in 2025. The doctor refused and performed another cesarean at 39 weeks. Both women said they were healthy and did not have noncommunicable diseases at the time.
A Palauan athlete shared a similar story. She said her doctor recommended induction at 39 weeks. When she declined, the doctor told her they would “give” her a few more days before inducing labor. The induction, performed just before her due date, caused the baby’s heart rate to drop, leading to an emergency cesarean.
These personal accounts, along with the US health report, have sparked broader concerns about maternal health policies in Palau. With the nation’s low birth rate, advocates say it is critical to preserve women’s reproductive health and ensure informed birth choices.
“Perhaps Palau needs to revisit the legend of Mengidabrutkoel, to learn the natural birth model that values and recognises the importance of birth experience and the woman’s survival,” said one mother reflecting on her experience.