Why has the caesarean rate increased dramatically in Bangladesh?

Area of Science:

• Maternal Health
• Health Services Research
• Obstetrics

Background:

• Delivery location and mode decisions are complex, influenced by socioeconomic and healthcare system factors.
• Understanding these decisions is crucial for improving maternal and neonatal outcomes in low-resource settings.

Purpose of the Study:

• To assess family reasoning behind choosing home versus facility delivery and vaginal versus cesarean birth in Bangladesh.
• To identify demand-side (family) and supply-side (provider) factors influencing these choices.

Main Methods:

• Convenience sample of 492 mothers from 16 villages in Sathkira district, Bangladesh, who delivered in 2015-2016.
• Data collected via structured questionnaires administered by local health workers, including quantitative and qualitative evidence.
• Regression analysis used to determine the significance of demand and supply variables.

Main Results:

• 48% home deliveries, 52% facility deliveries; two-thirds of facility births were in private clinics.
• Cesarean rates: 39% overall, 53% in public hospitals, 86% in private clinics.
• Home delivery reasons: uncomplicated pregnancy, trusted attendant. Facility delivery reasons: perceived complications or unclear transfers during labor. Both family income and provider factors significantly influenced decisions.

Conclusions:

• Inadequate nursing support for vaginal delivery in Bangladesh leads physicians to recommend facility births, often resulting in higher cesarean rates.
• Facility births may reduce obstructed labor fistulas but could increase iatrogenic fistulas.
• Reducing cesarean rates necessitates increasing nurses/midwives and expanding their scope of practice for vaginal deliveries.