Why are C-sections on the rise?

Muhammad Nabil 

Non-medical individuals influence many women in rural Bangladesh to opt for caesarian section (C-section) delivery despite their initial preference for vaginal delivery, suggests a recent icddr,b finding.

In-depth interviews with women reveal that they rely most on external agents or brokers to choose the delivery facility and obstetricians. Brokers send delivering mothers to obstetricians having a preference for C-section.

Some of the many perils around C-section. Infographic: Inamul Shahriar / Muhammad Nabil

“Women were found to have very little knowledge about C-section and eventually little choice in the decision-making process,” says Dr Tahmina Begum, icddr,b assistant scientist and first author of the study published in BMC Pregnancy and Childbirth.

This may be one of the reasons for overutilisation of this surgical intervention at both public and private health facilities.

The obstetricians who were interviewed also acknowledged that majority of the C-section were conducted without medical indications – conditions in which the need for C-sections genuinely arise.

During the last decade, CS rates in Bangladesh went as high as 31% beyond the justifiable range of 10 to 15% according to WHO standards. Photo: GMB Akash / icddr,b

The study found that till the third trimester antenatal check-up these pregnant women did neither receive any information about the medical indications for C-sections, nor about its benefits and risks. Their knowledge of C-section is entirely drawn from relatives and neighbours who had experienced it.

“We found obstetricians more positive towards caesarean section compared to vaginal birth. Left without enough information, the would-be mothers often have no choice but accept to undergo C-sections,” adds Dr Begum.

Many women do not get any information about C-section during antenatal check-ups. Photo: GMB Akash / icddr,b

“Public hospital obstetricians consider C-sections as ‘the safest mode’ of delivery by conducting planned deliveries during office time. Private clinic obstetricians sometimes adopt financial motives of their health facility for conducting C-sections,” she explains.

Moreover, brokers roaming around public health facilities (where vaginal deliveries are more expected) constantly watch and try to move women to private facilities where C-sections are more likely.

A generation deprived of facility-based delivery but safe from the fear of useless C-sections. Photo: Shehzad Noorani / icddr,b

Strangely enough, over 60% of women in Bangladesh prefer to give birth at home, generally without the support of a skilled birth attendant, according to another icddr,b study published in Birth Issues in Perinatal Care.

Dr Shams El Arifeen, icddr,b senior director of maternal and child health, observes that fear of C- section was one of the reasons mothers reported for choosing home delivery.

Lack of importance of facility birth, financial reasons, and not being permitted by a family member to seek facility birth were among other reasons.

"In urban Bangladesh, C-sections have become the new normal," says Mr Sk. Masum Billah, associate scientist working on maternal and child health at icddr,b. He refers to icddr,b findings published in PLOS One which also identified that fear of C-section is one of the reasons why women in rural areas may not opt for facility-based delivery.

Normal/vaginal deliveries offer faster recovery rates. Photo: GMB Akash / icddr,b

“Many findings tell us why C-sections deliveries are going up, despite its necessity only as a lifesaving measure when a normal vaginal delivery is not possible. The policymakers should think carefully about effectively tackling this rising rate,” adds Dr Arifeen.


High-cost involved: Yet more C-sections?

Urban caesarean birth rates are much higher than rural rates, according to recent icddr,b findings published in PLOS One, that found CS deliveries reportedly increasing eightfold to 63% over the years 2000 to 2014. Costs for CS was 66.5% of the total delivery cost of USD 482 million in 2014.

The study also found that in 2014, over 45% of decisions were made for CS on the day of delivery, leaving questions as to whether the mothers were given appropriate information and time to decide on the matter.

Seeking antenatal care from private providers was associated with higher CS rate. Photo: GMB Akash / icddr,b

“We sought to determine the causes of increasing C-sections,” informs Dr Mohammad Masudur Rahman, icddr,b senior research investigator and author of another study published in PLOS One.

Factors like mother being older, obese, residing in urban areas, first birth, maternal perception of large newborn size, husband being a professional, having higher number of antenatal care (ANC) visits, seeking ANC from private providers, and delivering in a private facility were significantly associated with higher rates of CS, finds the study.

Similar suggestions emerged from other icddr,b findings noting that higher C-section rate was associated with women over 35 years of age, urban area, relatively high socio-economic status and higher education and those regularly accessing antenatal services, as well as overweight or obesity, according to findings published in PLOS One.

An icddr,b study looking at out-of-pocket (OOP) expenditures associated child delivery found that C-sections naturally lead to the highest OOP at about USD 250 in contrast to institutional normal delivery OOP at around USD 62 and normal home delivery OOP at around USD 16, according to findings in the International Journal of Health Policy and Management.

How to determine if CS is really necessary? Can everyone afford it? Photo: GMB Akash / icddr,b

“Our study found that the well-off people are bearing more OOP expenses and such expenses are highest in the capital city of Dhaka – all without any nationally supported insurance schemes," comments Dr Abdur Razzaque Sarkar, icddr,b associate scientist and first author of the paper.

He suggests that an affordable social health insurance might help the marginal population to finance households during child delivery care.

Some of these CS surgeries are really necessary in critical conditions but that is only to be determined by absolute maternal indications (AMI) – clinical conditions in which mothers are unlikely to survive without C-section. icddr,b researchers have already suggested that monitoring of indications at all healthcare facilities is essential to curb unnecessary C-sections.

Findings from an icddr,b study with Save the Children, published in PLOS One, examined the impact of training female paramedics on the use of labour monitoring tool data on labour duration or partographs, only to find poor interpretation of referral indications by these health workers.

The study urges support to better interpret and act on partograph data in a timely manner, to ensure that women in labour receive prompt quality care they and their babies require to survive.

These discrepansies, irregularies and shortfalls - mostly known issues around deliveries are now further strengthened by recent findings. How and when can these change?