Physician–patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study

Abstract

Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

An Uninformed Decision-Making Process for Cesarean Section: A Qualitative Exploratory Study among the Slum Residents of Dhaka City, Bangladesh

“…In both cases, there was a lack of communication between the physicians and the patients and the family members of the patient. This study mirrored the findings of similar studies in Bangladesh that reported minimal communication between patients and physicians during C-section decision-making in healthcare facilities [37]. In 2012, a study reported that, in the Dhaka slums, for more than 50% of cases, the physician was the primary decision-maker for C-sections, and for 37% of cases, family members were also involved with C-section decision-making [38].…”

Socioeconomic inequalities in early initiation and exclusive breastfeeding practices in Bangladesh: findings from the 2018 demographic and health survey

“…Moreover, almost all caesarean section takes place in health facilities, which accounts for over 60% of the institutional deliveries in Bangladesh [ 76 ]. High rates of caesarean section in Bangladesh have been associated with previous maternal experience in caesarean section, high risk pregnancies, complications during labour, and maternal or physician preferences [ 77 , 78 ]. This highlights the need to address early initiation of breastfeeding practices in a post-caesarean section setting, and design interventions that facilitate early initiation of breastfeeding among women who had a health facility-based delivery [ 20 ].…”

Prevalence and Factors Associated With Caesarean Delivery in Nepal: Evidence From a Nationally Representative Sample

“…There have been more significant increases in some countries. For instance, in Bangladesh [ 17 ], the CS rate increased eight-fold from 2004 to 2017/8 with a four-fold increase in Nepal [ 12 , 18 ] between 2001 and 2011, with this trend continuing [ 12 , 17 - 18 ]. Previous studies found that CS delivery was higher among urban women, primarily educated women, than rural, uneducated women [ 9 , 11 , 18 - 22 ].…”