Reasons for performing a caesarean section in public hospitals in rural Bangladesh

Abstract

BackgroundIt is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as “unnecessary”. Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure.MethodsRetrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS.ResultsThe commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and “post-term dates” were common indications for elective CS with “post dates” – the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to “lobby” for CS.ConclusionFactors other than evidence based practice or the presence of a clear medical indication influence providers’ decision to perform both elective and emergency CS in public hospitals in Bangladesh.

Cesarean Section: Incidence, Causes, Associated Factors and Outcomes: A National Prospective Study from Jordan

“…[31,32]. Consistent with another study [33], the most common reasons for emergency CS in the current study were prolonged fetal distress, obstructed labor, and abnormal presentations such as breech or transverse presentations. The most frequent reason cited for planned CS was scarred uterus, which mostly reflects previous CS.…”

Current Trend of Caesarean Section in a Tertiary Care Military Hospital

“…33 They studied 100 physician mothers and revealed that 60% underwent caesarean section and 40% have normal vaginal deliveries between 2000 to 2015, 33%had caesarean section and 67% normal vaginal deliveries according to collected data before 2000.Radha et al explained that the rapid socioeconomic changes and the outlook towards medical intervention by the women, families and society are increasingly responsible for the current high incidence of caesarean section in many states and urban centers. 33 Findings of this study are not consistent with findings of Aminu et al 30 They found that the rate of caesarean sections was 21.2% which was conducted in the five public hospitals of Thakurgaon district of Bangladesh among 2503 deliveries during July to December 2011. Thakurgaon is a peripheral district situated northern part of Bangladesh.…”

“…These findings are not in agreement with the findings of others. 30,32 Aminu et al observed that 68% of CS was performed as emergency. 25 Kaur, Singh and Kaur found higher number of emergency (52.3%) over elective (47.7%) caesarean sections.…”

“…Aminu et al found that the commonest indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). 30 Kaur, Singh and Kaurfound that fetal distress, repeat caesarean sections, multiparity, high socioeconomic status, 21 to 30 yrs of age group were the indications of cesarean sections while primiparityand low socioeconomic status were the indications of vaginal births. 31 Shiba et al found that fetal distress, arrest of descent, multiple gestations, and fetalindications contributed to the increase in the rate of CS.…”

“…Aminu et al found that the mean age of women was 23.5±4.2 years which is similar to this study. 30 CS is used in cases where vaginal delivery is either not feasible or would impose undue risk on mother or baby. Rising incidence can be explained by the fact that our hospital is a tertiary care centre and receives a good number of high risk emergency cases with inadequate or no antenatal care.…”