BACKGROUND: The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal. METHODS: A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis. RESULTS: The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78). CONCLUSIONS: About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.