Concept Paper on Natural Childbirth

Increase Public Awareness of the Benefits of Natural Vaginal Delivery to Prohibit Unnecessary Caesarian Delivery in Bangladesh.

[Ashulia Women and Children Hospital on Prevention of Unnecessary Caesarian Delivery]

December 2022
Prepared by Ashulia Women and Children Hospital

Caesarian Delivery

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 Context

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.

Effects of C-section

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:

  • Postpartum Infection of the wound and subsequent pain (common) - causing redness, swelling, increasing pain, and discharge from the wound.

  • Deep vein thrombosis (DVT) (rare) – a blood clot in your leg, which can cause pain and swelling, and could be very dangerous if it travels to the lungs (pulmonary embolism)

  • Longer stays in Hospital - The average hospital stay after a C-section is 2 to 4 days, and keep in mind recovery often takes longer than it would from a vaginal birth. Walking after the C-section is important to speed recovery and pain medication may be supplied too as recovery takes place.

  • Difficulty in initiating breastfeeding - there is a negative association between elective cesarean delivery and early breastfeeding. Women who were delivered by cesarean delivery were four times more likely to initiate breastfeeding late as compared with women who gave birth through vaginal delivery.

  • Significant longer recovery - Recovering from a C-section takes time and may take longer than a doctor or midwife says it will. Some women experience muscle or incision pain for several months. Others struggle with urinary incontinence due to weakened pelvic floor muscles.

  • Amniotic fluid embolism (amniotic fluid or fetal material enters the maternal bloodstream).

  • Inflammation of the uterus.

  • Infection of the womb lining (common) – symptoms include fever, tummy pain, abnormal vaginal discharge, and heavy vaginal bleeding

  • Excessive bleeding (uncommon) - this may require a blood transfusion in severe cases, or possibly further surgery to stop the bleeding

  • Damage to your bladder or the tubes that connect the kidneys and bladder (rare) - this may require further surgery.

  • Women are now given antibiotics before having a cesarean, which should mean infections become much less common.

Risk to Babies:
A cesarean can sometimes cause the following problems in babies:

  • A cut in the skin (common) – this may happen accidentally as your womb is opened, but it's usually minor and heals without any problems.

  • Breathing difficulties/Increased risk for Asthma (common) – this most often affects babies born before 39 weeks of pregnancy; it'll usually improve after a few days and your baby will be closely monitored in the hospital.

  • Altered immune development - Research shows that birth by cesarean section can influence your baby's microbiome and immune health. New research has found that babies born via cesarean section may have an impaired immune system in later life due to the lack of exposure to maternal bacteria that would occur during the standard birthing process.

  • Increased likelihood of allergy - It is found that cesarean section was associated with more than a doubled risk of later asthma and allergies, as well as significant changes in the composition of the gut microbiota. However, at one year of age, the risk of asthma was reduced in C-section-born children if their gut microbiota had recovered from its initial disruption and begun to mature normally.

  • Delayed development of mother-infant attachment - The results of a new study published in the Journal of Child Psychology & Psychiatry indicates that mothers who deliver their children via C-section are less responsive to their babies' cries than those who deliver naturally. The scientists from the Child Study Center at Yale University who conducted the study believe that natural childbirth releases important hormones for the child and mother. These hormones impact the responsiveness of the maternal brain.

AWCH’s Initiatives to Increase the Number of Natural Vaginal Delivery

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.

Future Plan of Action to Increase the Rate of natural Vaginal Delivery

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.

1. Building educational platforms
AWCH aims to collaborate with renowned and well-known gynecologists to:
- Bring to light the advantages and disadvantages of cesarean sections and vaginal delivery.
- Indications and contraindications for C-Sections.
- Psych education (for women with fear of delivery-induced pain-comprising information about fear and anxiety associated with childbirth).
-Reflecting on the myths and facts about vaginal childbirth.
- Couple therapy sessions: emotional, self-management, conflict management, problem-solving, communication, and mutual support strategies.
- Discussion on the negative effects of C-Section on women and children.
- Role-play on the method of normal delivery.

2. Spreading Awareness through Social Media
To reach a large audience at once, AWCH will promote the agenda through various relevant social media pages and influencers who have sizable followers.

3. Building Partnership for Achieving Credibility
AWCH strives to partner with a variety of development organizations working on comparable issues to raise awareness.

4. Leveraging Recognized Platforms to Increase Awareness
Articles and features on the importance of vaginal delivery, risk factors of C-sections, and when and why C-sections are recommended will be featured in reputed and renowned daily newspapers.

5. Creating an Optimal Education Platform
Various training and seminars will be organized to educate people.

6. Training and Allocating Resources for Supporting the Cause
To get instant support from health experts for any kind of pre or post-pregnancy related issues AWCH aims to do the following:

  • i. Call center - 24/7 call center. Support by Health experts for gestating and nursing mothers.

  • ii. Midwives support at home –Inclusion of midwives and nursing services for gestating mothers. Area: Ashulia.

  • iii. Promoting these activities:
    - Distribution of handbills in RMG factories.
    - Targeted SMS for the inhabitants of Ashulia.
    - Facebook – targeted promotion at Ashulia.