Unnecessary C-Sections: A major public health issue in Bangladesh

Caesarean section (C-section) is a surgical procedure used to deliver a baby by cutting an opening in the mother's abdomen. It was developed as a way to enable a safe birth when complications in the pregnancy threatened harm for either the mother or the baby.

I did not think a lot about C-sections until I moved to Sweden, where I learned that unnecessary C-section is now a major public health problem. My interest in this issue further increased when I started working in a Swedish University Hospital. I noticed that about 10-12 children are born at this university hospital per day, but C-section is rarely performed. The health team work hard to enable normal delivery. However, nowadays C-section seems to have become the routine method for birth in private hospitals in Bangladesh.

From 2008 to 2016, C-sections increased from four percent to 31 percent. In 2015, the World Health Organization (WHO) stated: "… caesarean section rates higher than 10 percent were not associated with reductions in maternal and newborn mortality rates." It seems clear that an enormous number of surgeries in Bangladesh are being performed on mothers without any medical necessity. 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, the report shows about 80 percent of births in private hospitals are now happening through surgery.

Why is this happening? 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 mothers now choosing surgery rather than 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 an idea that the 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 labour for not having the surgery.

Unfortunately the greater convenience of C-sections is not the only part of the story. 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 anaesthesia 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.

Very recently, I met a Bangladeshi women, Sima, 34 years old, who shared her experience. It was her first pregnancy and she often heard from her private doctor that "the C-section is better because a women will feel nothing until when the baby is pulled out and then she feels a hard pressure." She made her decision to go for the C-section without any medical reasons. Describing her experience, she said "I felt something all the time during the operation. I could not understand what I felt. Nothing hurt, but I felt it. I got very nervous when I heard I was bleeding a lot, and the blood pressure was going down."

Her doctor told her husband to find blood for her as quickly as possible. But it was very difficult for him to manage blood or find someone who can donate blood. The clinic could not supply any blood for her because they did not have this facility, as it was a very small private clinic in her upazila. It was a horrible experience for Sima; she could have died, but luckily, she survived. Many women, like Sima, experience such complications from C-sections that are medically necessary, but such incidents often remain unreported.

Apart from the medical complications, C-sections have severe impacts on women's finances. In 2018, Bangladeshi parents paid Tk 4,071,031,200 (USD 48 million) in out-of-pocket expenses for medically unnecessary C-sections, an average of Tk 51,905 (USD 612) per case, according to Save the Children Bangladesh. The average cost of a C-section was Tk 40,000 (USD 472), while the cost of a normal delivery was Tk 3,565 (USD 42).

My experience in Sweden has further helped me to understand the severity of the complications related to unnecessary C-sections. Sweden has long been known as a country with a liberal society, where every individual has equal opportunities to practice their rights. For instance, a woman has the inviolable right to make autonomous decisions about her own sexual and reproductive health. However, many states in Sweden do not permit access to C-sections without valid reasons. Such a decision is a huge step for a liberal society. According Elisabeth Storck Lindholm, maternal health chief physician in Stockholm state in Sweden, "The fact that one thinks that a caesarean section seems to be an easy way out is not reason enough to be allowed to do so. It is a large abdominal operation with a risk of complications such as bleeding and blood clots."

Overall, 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 to 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. However, the number of unnecessary C-sections continues to rise rapidly and remains a major public health problem. 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 a normal delivery.

The Government of Bangladesh has committed to the United Nations' Sustainable Development Goals, where maternal health has been prioritised, in Goal Three, which aims to ensure universal access to sexual and reproductive health services and education, and reduce maternal mortality ratios to less than 70 per 100,000 live births. Hopefully, the government will give the highest level of priority to maternal health, particularly to reduce the incidence of unnecessary C-sections in Bangladesh. At the same, it is equally important to make this life saving operation accessible for the women who need it.

Mohammad Ali is a nurse at a Swedish University Hospital and a research assistant (part-time) at Uppsala University, with a Master's degree in Public Health from Uppsala University, Sweden.