Cesarean section is warranted when vaginal birth is unfeasible owing to medical issues such as labour dystocia, fetal malpresentation, irregular or ambiguous fetal heart rate, suspected fetal macrosomia, among others, which may jeopardize the lives of the mother and infant.
While the WHO anticipates that medically warranted cesarean section rates should not surpass 10-15% of total deliveries, in Bangladesh, cesarean section rates have escalated significantly from 11% in 2011 to 45% in 2022. Nevertheless, there is no indication of a significant rise in the medical necessity for cesarean sections. The rise seems to be propelled by convenience and economic advancement.
The current rates are so high that they have reclassified caesarean sections as a form of "normal delivery," requiring prompt action to address the problem. In some circumstances, a caesarean section may be essential to protect the health of both the mother and the newborn. Notwithstanding the intrinsic risks linked to the procedure, an overly low caesarean section incidence leads to increased maternal and newborn mortality and morbidity due to the risk-harm equilibrium.
Conversely, excessive utilization (ie, the application of CS without medical justification) has not shown benefits. Excessive consumption has detrimental effects by exposing both mother and newborn to unnecessary hazards, while also depleting vital human and financial resources.
WHO estimates that 6.2 million caesarean sections are performed each year without medical justification. Thus, the optimization of CS consumption becomes a worldwide issue and a public health challenge.
The latest data from the Lancet CS series, covering over 99% of worldwide births across 169 countries, reveals that the caesarean section rate is above the recommended limit in several nations. The global CS rate demonstrates an average annual increase of 4.4%, as evidenced by trend analysis of data from 150 countries between 1994 and 2014.
The annual growth rate is markedly higher in developing nations compared to developed countries. The incidence of caesarean sections lacking medical rationale appears to be predominantly seen in lower-risk pregnancies (nulliparous, term, single, vertex presentation), constituting around 60% of all caesarean section cases.
In Bangladesh, 65% of all deliveries occur in healthcare facilities: 45% in private hospitals, 18% in public hospitals, and 2% in NGO hospitals. The current caesarean section rate in Bangladesh is 45%. Private hospitals account for 85% of all caesarean sections (CS), with the Bangladeshi government exercising limited oversight and regulation.
Reducing the caesarean section rate in Bangladesh requires governmental involvement in the private sector. The choice to proceed with or forgo a caesarean section may be seen as the result of assessing three key areas of influence: Demand-side concerns, supply-side issues, and clinical aspects.
Each element independently affects the ultimate assessment of a CS's performance, highlighting the intricate nature of this healthcare concern. Each input often exhibits a complex interplay.
A local myth posits that women choosing elective caesarean sections are “too posh to push,” so linking socioeconomic factors with maternal preferences. The supply side has issues associated with healthcare facility rules, since private hospitals prefer caesarean sections, in addition to factors of time management and operational efficiency.
In Bangladesh, private hospitals substantially influence the high prevalence of caesarean sections, mostly due to their profit-oriented paradigm. These institutions often emphasize swift and effective services, frequently leading to the superfluous repetition of performing CS. Unlike public hospitals, which often face financial limitations and prolonged wait times, private hospitals offer prompt surgical procedures, often perceived by patients as a more secure and controlled option for childbirth.
The availability of proficient surgeons and the flexibility of scheduling appointments outside regular government hours lead to an increased incidence of caesarean sections in private facilities.
Improving the involvement of skilled midwives and promoting active, health-oriented lifestyles among women of reproductive age may reduce the demand for elective cesarean sections
The convenience, along with improved socioeconomic conditions, allows a growing segment of the population to afford caesarean sections, hence reinforcing its preference over vaginal delivery.
Moreover, several women and their families perceive caesarean sections as a more secure option, influenced by the clean and well-equipped environments of private hospitals compared to the often overcrowded and obviously less sanitary conditions of public hospitals.
These actions provoke significant concern. The overuse of caesarean sections exposes mothers and babies to unnecessary surgical risks and strains the healthcare system by diverting resources that could be better utilized elsewhere. The lack of regulation in private hospitals exacerbates this issue, since several institutions do not participate in the government's Maternal and Neonatal Health (MNH) programs, which emphasize evidence-based practices and adherence to national and international health standards.
A previous caesarean procedure markedly increases the probability of requiring another caesarean operation in subsequent pregnancies.
Global evidence to mitigate non-clinical caesarean sections
Diana et al suggested, following a literature assessment, that two types of interventions can significantly reduce the caesarean section rate in a country.
- Clinician-oriented
- Clinical practices: i) Trial of labour after caesarean section and vaginal birth after caesarean section (VBAC); ii) external cephalic version for breech presentation; iii) prudent administration of oxytocin during labour augmentation.
- Nonclinical approaches: i) Audit and feedback mechanisms for facility deliveries; ii) Clinical practice guidelines; iii) Head stop policies (consultation with another obstetrician regarding caesarean section); iv) Financial incentives for healthcare providers.
- Patient-centred strategies:
- Prenatal assistance: i) Ongoing prenatal social support; ii) Prenatal public health education.
b. Intrapartum support: i) Ongoing labour monitoring; ii) Non-pharmacological analgesic methods for labour discomfort.
The necessity for regulatory and educational interventions
The high prevalence of cesarean procedures in Bangladesh, particularly in private institutions, requires urgent action. The government must implement regulatory measures to ensure private healthcare providers conform to the standards of public institutions. This may include mandatory participation in MNH programs, adherence to clinical procedures, and regular assessments of CS practices.
Public education programs are crucial. Women and their families must be informed of the potential risks associated with needless cesarean sections and the benefits of vaginal delivery when medically suitable. Improving the involvement of skilled midwives and promoting active, health-oriented lifestyles among women of reproductive age may reduce the demand for elective cesarean sections.
In alignment with the United Nations Sustainable Development Goals (SDGs), particularly SDG-3, Bangladesh must emphasize the reduction of excessive caesarean section rates as a fundamental aspect of its comprehensive strategy to improve maternal and neonatal health. The inclusion of proficient midwives during childbirth may lead to a reduction in cesarean deliveries.
By addressing the economic, clinical, and policy-related factors that lead to increased caesarean section rates, the nation may pursue more equitable and safe delivery methods, therefore improving health outcomes for both women and children.
Dr Aminur Rahman Shaheen MBBS, MSc, PhD, is Scientist, Health Service Delivery, Health Systems and Population Studies Division at icddr,b.
