Caesarean delivery (C-section), a major surgical procedure to deliver a baby through incisions, has become increasingly common in developing countries like Bangladesh. The 2017-2018 Bangladesh Demographic and Health Survey data reported the C-section delivery rate to be 33 per cent whereas 2019 Multiple Cluster Indicator Survey (MICS) reported the increased figure of 36 per cent. The rate is much higher among women of higher educational attainment and from the wealthiest households. However, there is no logical justification for any country to have C-section deliveries exceeding 10-15 per cent of total childbirths as per the World Health Organisation (WHO). This trend of C-section deliveries in an institutional setting may induce an increase in the pressure on hospital infrastructure (equipment and human resources), and in physical and psychological cost on the mother (increased risk of postnatal depression). Despite the alarming increase of C-section deliveries and its potential health risks in recent years, there is not enough research available to examine the factors, especially, demographic, socio-economic, and institutional causes that may explain this rise in the C-section procedures. There are gaps in the available studies as most of these are old and have generally ignored various aspects of the demand side of the equation. For example, trends and inequality aspects of the C-section have not been explored in these studies.
The study titled 'Caesarean Section Delivery in Bangladesh' published in the Journal of Bangladesh Studies (JBS), Volume 21, and Number 2 of the Bangladesh Development Initiative (BDI) explores the role played by education and wealth in the rising numbers of C-section deliveries in Bangladesh. It also investigates the factors associated with this kind of delivery such as the age at first birth, division (region), place of residence, educational level, access to any media, household wealth quintile of the respondent, birth order, frequency of antenatal care visits, body mass index, and place of delivery.
TRENDS IN C-SECTION DELIVERY BY DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS: The results from the 2014 Bangladesh Demographic and Health Survey (BDHS) show a dramatic increase in the number of C-section births in Bangladesh. C-section delivery accounted for 2 per cent of the childbirths in 1999-2000, 4 per cent in 2004, 8 per cent in 2007, and 17 per cent in 2011, and 23 per cent in 2014. These numbers imply that roughly five in twenty births were delivered by C-section. According to the report of Bangladesh Maternal Mortality and Health Care Survey 2016, the rate now stands at 31 per cent, which implies that almost one in every three births in a health facility are delivered by C-section.
*2016 data was taken from the report of Bangladesh Maternal Mortality and Health Care Survey 2016
This empirical study explores the rising trends in C-section delivery as a medical procedure in Bangladesh in recent years. The research reveals that the rate of this medical procedure varies with age, place of birth, educational level, access to media, and household wealth quintile of the mother. The rate also depends on the frequency of antenatal care visits, mother's body mass index (weight), size of the child at birth, and the place of delivery. According to this analysis, Caesarian delivery is more prevalent among relatively educated women. More than half of women with higher education (54.8 per cent) had C-section in 2014, while only 7.0 per cent of women with no education delivered a child by this procedure. Husband's education level also plays a similar role.
In terms of employment of the women, 24.6 per cent of those who experienced C-section are unemployed, while the figure is relatively lower (17.4 per cent) for women employed. The likelihood of caesarian delivery varies significantly across different parts of the country. The rate of C-section was the lowest in the Sylhet division (10.9 per cent) in 2014. It was the highest in the Khulna division (33.0 per cent), followed by Dhaka (29.1 per cent) and Rajshahi (22.3 per cent). It is not surprising to find that C-section is more prevalent in urban areas (38.1 per cent) than in rural areas (17.6 per cent) according to the recent numbers. Women who have access to media such as radio and television are three times more likely to experience this medical procedure compared to women who have little or no access to media outlets (30.7 per cent vs. 10.5 per cent).
These findings also reveal that C-section procedure is positively associated with women's weight as measured by the Body Mass Index (BMI). Among women who are underweight, the rate of occurrence of this procedure was only 13.4 per cent. However, for obese women or women with higher Body Mass Index (BMI), the rate was much higher at 56 per cent. And compared to a mother with no living child, a mother with three or more living children is more likely to undergo a C-section delivery. The rate of the C-sections was the highest for the first child's birth (29.7 per cent), followed by the birth of the second and third child. For later children, beyond three, the rate for this procedure falls to below 8 per cent.
The trend of C-section is more prevalent among birth at a relatively old age; women who had their first child at age 20 or older have higher odds for a Caesarean procedure. Roughly 38 per cent of women who experienced C-sections at first birth were 20 years or older. In 2014, among women aged between 25 and 34, the rate of C-section deliveries is the highest with 23.9 per cent. This kind of delivery is more common among women belonging to higher-income households than among the poor households. According to the survey, 51.4 per cent of women who underwent this procedure came from rich households, compared to only 6.3 per cent with C-section from the poorest households in 2014. The highest change (31.9 per cent) between BDHS 1999 -2000 to 2014 was for mothers who gave birth to their first child at age 20 and older.
This particular analysis finds that the rate of increase in C-section delivery is higher at private hospitals than at public hospitals. The rate of C-section deliveries in private hospitals was 78.1 per cent, whereas it was 37.2 per cent in public hospitals. This study unearths new and often contradictory findings on the relationship between ANC visits and C-section delivery and between visits by the FP (Family Planning) social workers and C-section delivery. It shows that an increased number of ANC (Antenatal Care Coverage) visits increases the likelihood of C-section delivery, but visits by family planning workers decreases the likelihood. Institutional coverage such as ANC home visits are likely to detect complicated pregnancies before delivery, which may lead to C-section birth instead of normal delivery. However, home visits by family planning workers lead to a decrease in the frequency of C-sections. As per the analysis of BDHS 2014 data, C-section birth is higher (44.5 per cent) for those who reported making four or more visits to ANC. However, the rate of C-sections is only 19.7 per cent in the case of family planning workers.
SOCIO-ECONOMIC, DEMOGRAPHIC, AND INSTITUTIONAL FACTORS OF C-SECTION: The regression analysis of socio-economic, demographic, and institutional variables based on the 2014 BDHS data represents that the C-section procedure is more prevalent among relatively richer households. The odds of C-section procedure for women who belong to the richest households is 4.6 times greater than women belonging to the poorest households. Similarly, educated women have a 2.77 times higher probability of C-section deliveries than uneducated women. The wives of uneducated husbands are two times more likely to have this procedure than the wives of educated husbands. And there still exists a large gap between rich and poor households, and between educated and non-educated households with the prevalence of C-section delivery of a child. However, due to increased access to maternal health care in recent years, these inequalities may be declining.
To summarise, the results from the analysis of BDHS data show that among women receiving institutional antenatal care, those with higher education, residents of Khulna division, belonging to the richer households, and finally women living in urban areas, experience a higher rate of C-section delivery. These findings are similar to what we know from the existing literature on Bangladesh and other developing countries.
Finally, this study also finds that the prevalence of C-section delivery rises with the increased availability of maternity services. Among socio-economic factors, mothers living in Khulna/Dhaka, residing in urban areas, having higher education, being in wealthier quintile of households and four or more visits to the doctor during pregnancy are more likely to experience delivery by C-section. For Sylhet, although, the region is relatively affluent, it is also relatively "conservative" with a traditional socio-cultural outlook that may favour avoiding surgery. The value of the Concentration Index and Gini coefficient reflects higher disparities between the poorest and the richest households, and between illiterate and literate women.
The study highlights two major reasons for preference for C-section delivery in Bangladesh -- convenience factor and avoiding labour pain. Both of these factors may be considered "unnecessary and avoidable." Educated and wealthy mothers prefer C-sections primarily to avoid labour pain, and they feel C-section delivery is more convenient compared to the natural method of child delivery. These factors have led to a steady rise in maternal demand for C-section procedures, which are often unnecessary and avoidable. These two factors alone contribute 15.1 per cent to the total number of C-section deliveries in 2014.
The World Health Organisation (WHO) reported that 6.2 million unnecessary C-sections were performed worldwide in 2008. These have significant negative implications for health equity in a country. The study also identifies that 28.6 per cent of the requests for C-sections came from pregnant mothers or their families, while the rest (71.4 per cent) was based on the doctor's recommendation. If we control the requests from the mother and the families, the rate of C-section delivery in Bangladesh (16.4 per cent) is still overused. According to the WHO categories, if the rate of avoidable surgeries is 15 per cent or more, this would be an overuse which brings into question the ethical role played by the attending doctor in these worrisome trends (High rates of C-section deliveries have severe implications on health sector resources and on the mother's health. This procedure burdens the hospital infrastructure (equipment, space, doctors, and nurses) and adds to the physical and psychological cost on the mother undergoing the surgery.
To reduce maternal health risks, it is important to reverse these trends of C-sections, especially in private hospitals/clinics. Following the United Nations SDG-3 (3.1, 3.7, and 3.8), the Government of Bangladesh should develop specific guidelines and measures, including promoting health education for women of reproductive age to reverse this trend. An increase in the inclusion of trained midwives during childbirth may lead to a reduction in C-section deliveries. And the ethical behaviour of the attending physician must also be reviewed. People should be educated about the effects of caesarean deliveries. Women of reproductive age should be educated on how to reduce obesity and lead active healthy lives, which leads to lower complications and more normal deliveries. Furthermore, we need further research to explore why urban, educated, and wealthy mothers prefer C-sections, and if the attending physicians and for-profit private facilities specifically target women with these characteristics for higher profits and take necessary policy measures according to the need.
Dr Mohammad Mainul Islam, Professor and Chairman, Department of Population
Sciences, University of Dhaka,
Md Zakiul Alam, Lecturer, Department of Population Sciences, University of Dhaka,[email protected]; Dr Sayema Haque Bidisha, Professor, Department of Economics, University of Dhaka, [email protected]; SM Abdullah, Associate Professor, Department of Economics, University of Dhaka,
[The op-ed provides a summary of the key findings of the study titled 'Caesarean Section Delivery in Bangladesh' published in the Journal of Bangladesh Studies (JBS), Volume 21, and Number 2 of the Bangladesh Development Initiative, USA].