[Ashulia Women and Children Hospital on Prevention of Unnecessary Caesarian Delivery]
Prepared by Ashulia Women and Children Hospital
Caesarian delivery (C-Section) is a major surgical procedure that needs sound medical justification based on maternal and child health. It was developed as a way to enable a safe birth when complications in the pregnancy threatened harm to either the mother or the baby. When it is done on a timely basis, cesarean delivery provides a golden opportunity to prevent adverse obstetric outcomes, including maternal death, stillbirth and nearly neonatal death, obstetric fistula, uterine prolapse, and sexual dissatisfaction. However C-section delivery has some shortterm and long-term risks, particularly in countries that lack adequate health facilities. Studies show that the C-section delivery rate, at the population level exceeding 10% is not associated with the reduction in maternal and neonatal mortality rates. Rather rates of preterm delivery and neonatal mortality both rise with the increase in C-section delivery.
According to the World Health Organization (WHO), there is no logical justification for any country to have C-Section deliveries exceeding 10% to 15% of total childbirths. However, less than 5% of deliveries by C-Section in any population indicates low antenatal and maternal care (WHO, UNFPA, UNICEF, Mailman School of Public Health & AMDD, 2009).
Bangladesh has made remarkable progress in the millennium development goals, particularly in
the area of maternal health. The maternal mortality rate declined from 574 (per 100,000) in
1990/91 to 143 in 2015. The proportion of births attended by skilled health professionals
increased from five percent in 1990/91, to 50 percent in 2015, and antenatal care coverage (at
least four visits) increased to a similar level. The rate of caesarian deliveries has increased almost
eightfold in Bangladesh. In 2004, the rate stood at 4 percent. However, a recent analysis revealed
that the rate was found to be 33 percent in 2017-18 (Bangladesh Demographic and Health
Surveys-BDHS). Bangladesh has also exceeded the standards set by its neighbors as well, in this
regard. The rate of cesarean delivery was found to be 22 percent in India (2019-2021), 22 percent
in Pakistan (2017-2018), 16 percent in Nepal (2016), and 17 percent in Myanmar (2015-16). The
rise of unnecessary C-sections has become a major public health problem in Bangladesh. It is
argued that women experience some complications during normal delivery, but studies have
confirmed that C-sections have a much higher rate of complications than normal delivery. Like
any surgery, C-sections are associated with severe complications for women and their babies.
The most common complications for women are infections, fever, abnormal bleeding, muscular
pain, headaches, and the risks of anesthesia complications. A C-section also increases the risk of
very serious complications in the next pregnancy, including the possibility of being unable to have
children in the future.
Data from Save the Children Bangladesh shows that nationally, about 820,512 C-sections
were performed in 2016, and 571,872 of them were unnecessary. Moreover, it shows about
80 percent of births in private hospitals are now happening through surgery.
Apart from the medical complications, C-sections have severe impacts on women’s finances. In 2018, Bangladeshi parents paid Tk 4,071,031,200 in out-of-pocket expenses for medically unnecessary C-sections, an average of Tk 51,905 per case, according to to Save the Children Bangladesh. The average cost of a C-section was Tk 40,000, while the cost of a normal delivery was Tk 3,565.
Throughout history, women have waited until their bodies decided when they were ready to give birth and how long the birth process would last. Why are some mothers now choosing surgery rather than a natural delivery, in such overwhelming numbers? We know surgical removal of the baby allows birth to be completed on a convenient schedule, rather than the unpredictable timetable of nature. We also find the rise of the idea that a C-section is somehow ‘better’ than a natural delivery. There certainly appears to be some pressure from the health sector related to these attitudes. Some women who choose natural births in hospitals report being verbally abused during their labor for not having the surgery.
The study titled ‘Caesarean Section Delivery in Bangladesh’ was published in the Journal of Bangladesh Studies (JBS). Volume 21, and Number 2 of the Bangladesh Development Initiative (BDI) explore 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. According to the analysis, Caesarian delivery is more prevalent among relatively educated women. More than half of women with higher education (54.8 percent) had C-sections in 2015, while only 7.0 percent of women with no education delivered a child by this procedure. The husband’s education level also plays a similar role.
In terms of employment of the women, 24.6 percent of those who experienced C-sections are unemployed, while the figure is relatively lower (17.4 percent) for women employed. The likelihood of caesarian delivery varies significantly across different parts of the country. It also found that C-sections are more prevalent in urban areas (38.1 percent) than in rural areas (17.6 percent). 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 percent vs. 10.5 percent).
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 percent, whereas it was 37.2 percent in public hospitals.
Given the increasing use of C-sections, particularly without medical indication, an increased
understanding of its health effects on women and children has become crucial.
Risks to Mother:
As with any major surgery, there are several risks associated with cesarean delivery. Some of the main risks to mothers of having a cesarean include:
Risk to Babies:
A cesarean can sometimes cause the following problems in babies:
The management of Ashulia Women and Child Health Hospital (AWCH) has taken several
measures to reduce the number of unnecessary C-sections in the hospital.
To raise awareness among all relevant stakeholders, reduce the number of unnecessary Csections and motivate mothers to ensure a strong desire for natural childbirth, the Ashulia Women and Child Health (AWCH) has undertaken a Plan of Action to be implemented.