Approaches to optimize the unnecessary caesarean section in Bangladesh

Introduction

CS is justifiable when vaginal delivery is not possible due to medical conditions like labor dystocia, fetal malpresentation, abnormal or indeterminate fetal heart rate, suspected fetal macrosomia, etc. that can put the life of the mother and baby at risk. Though WHO expects that medically justified CS rates would not exceed 10%-15% of all births,¹ in Bangladesh, CS rates have risen dramatically from 11% in 2011 to 45% in 2022.² There is, however, no evidence of a dramatic increase in the medical need for CS. The increase appears to be driven by convenience and economic upliftment. The current rates are so high, that they have recast CS as a form of “normal delivery”, and urgent action is required to address the situation. Parturition is a natural physiological phenomenon. In specific situations, cesarean section may be necessary to safeguard the health of the woman and the infant. Even though the procedure itself carries inherent risks, the balancing of risks and harms means that too low a CS rate contributes to Introduction Caesarean section is warranted when vaginal birth is unfeasible owing to medical issues such as labor dystocia, fetal malpresentation, abnormal fetal heart rate, suspected fetal macrosomia, among others, that may jeopardize the lives of the mother and infant. Vaginal delivery is a normal, physiological phenomenon. In some situations, Caesarean section may be necessary to safeguard the health of the women and the infant.³ Despite the inherent hazards associated with the surgery, an excessively low Caesarean section rate results in heightened maternal and neonatal mortality and morbidity due to the risk-harm balance. In contrast, excessive usage (i.e., the use of CS without medical rationale) has not demonstrated advantages. Excessive usage inflicts harm by subjecting both mother and infant to unwarranted risks, while also squandering essential human and financial resources.^4,5 The World Health Organization estimates that 6.2 million Caesarean sections are conducted annually without medical reason.⁶ Consequently, the optimization of CS utilization represents a global problem and a public health dilemma.^7,8

Discussion

Caesarean section is a significant surgical intervention, and before to its execution, the advantages must surpass the potential hazards.^9,10 Current research suggests that neonates born via Caesarean section are at an increased risk of hypothermia, respiratory insufficiency, and necessitate admission to the critical care unit throughout the neonatal period. There is an elevated life-course risk of chronic conditions such as obesity, asthma, and atopic disorders.¹¹ The hazards are significantly heightened if the Caesarean section is conducted before to 39 weeks of gestational age or electively before the onset of labor. Mothers who undergo Caesarean sections exhibit elevated incidences of postpartum hemorrhage, infection, and an increased likelihood of miscarriage and stillbirth in future pregnancies.¹² Certain nations have a dual challenge concerning Caesarean section (CS) service, characterized by the detrimental effects of both unaddressed demand for CS and the delivery of hazardous CS procedures. Other nations encounter a triple burden, which compounds the overutilization of Caesarean sections with their pre-existing double burden.^13,14 Considering the potential for substantial population growth in certain nations already experiencing the dual and triple burden of Caesarean sections (CS), it is likely that the overutilization of CS, unsafe administration of CS, and unmet demand for CS will pose considerable challenges to these countries in attaining their 2030 Sustainable Development Goals (SDGs).

The most recent data from the Lancet CS series, encompassing over 99% of global births from 169 countries, indicates that the Caesarean section rate exceeds the recommended threshold in several nations.¹⁵ The global CS rate exhibits an average yearly growth of 4.4%, as indicated by trend analysis of data from 150 countries spanning from 1994 to 2014.¹⁶ The average yearly growth is significantly greater in emerging nations than in industrialized countries.¹⁷ The prevalence of Caesarean sections without medical justification seems to be concentrated in lower-risk pregnancies (nulliparous, term, single, vertex presentation), which account for around 60% of all Caesarean section cases.¹⁸ The study could not incorporate the indication-based CS rate, which may have provided further insights, as it was outside the scope of this work.

Caesarean section in Bangladesh

In Bangladesh, 65% of all deliveries take place in healthcare facilities: 45% in private hospitals, 18% in state hospitals, and 2% in NGO hospitals.² The present Caesarean section rate in Bangladesh is 45%. Private hospitals constitute 85% of all Caesarean sections (CS), over which the Bangladeshi government exerts minimal control and monitoring. Efforts to decrease the Caesarean section rate in Bangladesh inevitably necessitate governmental engagement in the private sector. The decision to undertake or abandon a Caesarean section may be comprehended as the outcome of evaluating three primary areas of influence: demand-side considerations, supply-side factors, and clinical aspects^19–21 (refer to Figure 1). Each category individually influences the final conclusion regarding the performance of a CS, underscoring the complex nature of this healthcare issue. Each input frequently has a complicated interaction. For instance, a local narrative suggests that ladies opting for elective Caesarean sections are “too posh to push,” so intertwining socioeconomic issues with maternal preferences. The supply side has challenges related to healthcare facility policies, since private hospitals favour Caesarean sections, alongside considerations of time management and operational efficiency.

Figure 1. Conceptual framework of factors associated with caesarean deliveries in Bangladesh adapted from Gosh et al.²¹

Figure 1 clarifies the ramifications of the CS decision, highlighting four primary areas of impact: maternal health cost/benefit, neonatal health cost/benefit, patient economic burden, and institutional economic burden. This highlights the extensive ramifications of CS decisions, which extend beyond urgent medical factors to include long-term health effects and cost impacts for people and broader healthcare systems.

In Bangladesh, private hospitals significantly contribute to the high incidence of Caesarean sections, mostly owing to their profit-driven model. These institutions usually prioritize rapid and efficient services, often resulting in the unnecessary frequency of conducting CS. In contrast to public hospitals, which may have budget constraints and delayed care, private hospitals provide timely surgical operations, typically seen by patients as a safer and more regulated choice for birthing.

The presence of skilled surgeons and the adaptability of arranging consultations beyond standard government hours contribute to the higher frequency of Caesarean sections at private institutions. The convenience, along with enhanced socioeconomic conditions, enables an increasing portion of the population to bear the expenses of Caesarean sections, hence solidifying its choice over vaginal birth. Furthermore, some women and their families regard Caesarean sections as a safer alternative, swayed by the hygienic, well-equipped settings of private hospitals in contrast to the frequently congested and seemingly less sanitary surroundings of public hospitals.

Nonetheless, these activities elicit considerable apprehension. The excessive utilization of Caesarean sections not only subjects’ women and infants to unwarranted surgical hazards but also burdens the healthcare system by reallocating resources that could be employed more efficiently in other areas. The absence of oversight in private hospitals intensifies this problem, since several facilities do not engage in the government's Maternal and Neonatal Health (MNH) initiatives, which prioritize evidence-based procedures and compliance with national and international health objectives. Having one Caesarean section significantly elevates the likelihood of undergoing a Caesarean section in any future pregnancy.

Global evidences to reduce nonclinical caesarean sections

Diana et al.³ proposed, based on a review of literature, that two kinds of interventions can effectively lower the Caesarean section rate in a nation.

Conclusions

Ethics and consent

Ethical approval and consent were not required.