Unnecessary cesarean section (CS) delivery is a major problem in Bangladesh and it is draining resources from both supply and demand sides. Many women do their cesarean delivery because of indicated causes in pregnancy, fear of unbearable labor pain, thinking about the safety of the child, etc. which leads to many unwanted complications. The aim of this research was to investigate the causes and preferences of cesarean delivery and to characterize the outcomes after cesarean section delivery. This cross-sectional study was conducted by using a semi-structured questionnaire among women who delivered in selected hospitals in Coxs Bazaar, Bangladesh. The total sample size number was 273 women with a mean age of 26.72 years. In this study, the key reasons found for doing CS delivery were mothers age, occupation, higher education, previous cesarean, doctors recommendation, fear of normal delivery, and concern about babys health. Results showed that 48.7% of women faced complications and 50.3% of participants didnt face any complications after CS delivery. The most frequent complications were pus, 22%, and obesity,13.9% among the participants and breakdown of the membrane, 28.2%, excess bleeding, 19.4% extreme pain, 19%, and prolonged labor, 18.3% were found as the main causes indicated by the doctors for cesarean delivery. The prevalence of CS found much higher than the anticipation of WHO. The Causes of cesarean delivery lead to complications with various factors that affect womens health directly and indirectly. It is necessary to reduce the rate by making the mothers aware of the risks of cesarean delivery and providing training workshops as well to overcome the fear of normal delivery.
Cesarean section delivery has become very common surgical procedure in the world including in Bangla-desh. Cesarean section is a surgical procedure, use for childbirth when vaginal delivery cant be performed. It is suggested to save the life of mother and baby in case of maternal complications during pregnancy. Before maternal and child mortality rate was high. Every day there are hundreds of maternal deaths reports due to complications of pregnancy (Carlo and Travers, 2016). Now the mortality rate has significant decrease. The ratio was 322 in 1998 to 2001 and 194 in 2007 to 2010 by considered as annual average rate of 5.6% decrease. Now it dropped to 14.1% from 2010 to 13.1% in 2016 (Arifeen et al., 2015; Sabnom and Islam, 2013).
With the improvement of technology, surgery delivery came as a new invention of science as a life savior for most of the women. Home delivery by the unskilled nurse has been decreased with the modern devising. Studies figure out that over the past few years, child birth became too “medicalized” because of some non-obstetrical factors rather than obstetrical factors. These factors point out the concern for mothers health and influence the families (Bruekens, 2001; Khanday, 3013). Nowadays the unnecessary CS delivery is high in Bangladesh. The overuse of technology in medical sector is one specific reason behind this increasing rate. According to the report, the percentage of CS delivery is increased up to 51% which can correlate with the term, epidemic of over-medicalization of maternal health (Hasan, 2019; Bruekens, 2001). With the unnecessary numbers of CS delivery, women are also facing some unwanted complications. This study will explore the causes and also investigate the risk factors of complications associated with different factors.
Cesarean section delivery is now a controversial affair worldwide. The alarming rate of CS is actually surpri-sing as it is high than the recommendation by WHO (2015). The rate has increased 6.7% to 19.1% from 1990 to 2014 all over the country. The less develop countries showed 14.6% absolute increase in CS deli-very where developed and least developed countries showed rose by 12.7% and 4.2% (Betran et al., 2016). 60% of all births take place in low income countries on the contrary only 37.5% of births come off in middle- and high-income countries but mostly the middle- and high-income countries give rise to CS rate globally. As per the estimation, among all 18.5 million annually performed CS deliveries, among that one-third are unnecessary and without any medical indications (Aminu et al., 2014). In Bangladesh the unnecessary CS rate is also high. According to the report, 7.7 out of 10 births are unnecessary. Overall, 860,000 unnece-ssary operations have been conducted last year in Bangladesh. But the women who really need of CS delivery they couldnt afford or access it while child-birth (Gibbons et al., 2010; Maswood, 2019). The trend of CS delivery among Bangladeshi women is increasing day by day. With globalization and adva-nced technology, the medical facilities have improved almost in every urban areas of Bangladesh. The basic emergency obstetric care services were introduced in public health care sector by the Ministry of Health and Family Welfare (MOH&FW). These policies have improved the maternal and infant mortality rate as well as morbidities. However, this improved health care led to CS deliveries following by unintended compli-cations (Rahman et al., 2014). Now women get better antenatal care during their pregnancy. In developing countries, the demand of CS delivery is increasing with the economic and educational advancement. Educated women are more likely to do Cesarean Section delivery to avoid labor pain.
Also, other factors such as infertility, modern repro-ductive techniques, and increased risk factors, age of women, psychology and biological safety for offsp-ring leads women towards cesarean section deliver (Khawaja et al., 2007; Radha et al., 2015; Weaver et al., 2007). Having lack of medical knowledge and misconception about vaginal delivery, works as an important and main factor for CS delivery (Azami et al., 2014). It is true that mortality rate has been decrease after the invention of CS delivery but the natural childbirth is beneficial than operational one. Fear of labor pain impels women to do CS delivery. According to report, women who have already done CS delivery said normal delivery is more painful than CS (Ajeet et al., 2011). Psychological, physical and other related factors are associated with attitudes of labor pain which influence the decision of mode of delivery (Zakeri et al., 2015). Risk of dying during delivery or delivery related issues among women is 100 times higher in Bangladesh than any other developed countries. As a result, 75% babies die within the first week after their mothers death (Kamal, 2003).
In Bangladesh, almost 60% of childbirths take place at clinic and 65% of those deliveries are C-sections (Doucleff, 2018). Only 33% of institutional deliveries has been done through CS in 2000 but it rise up to 63% in 2014 (Haider, 2018).The rate of deliveries is higher in private hospitals (86.2%) than the public hospitals (29.9%). According to research, private hospitals get financial benefits from external agents for performing CS delivery (Aminu et al., 2014). Still mostly people prefer to do delivery in private hospitals than in public because of their better service quality though the cost is high but the outcome was found better in public hospitals (Andaleeb, 2000; Sabnom and Islam, 2013). Delivery cost also depends on the mode of delivery.
Nine out of ten women favoring vaginal delivery prefers CS delivery if the costing is same for both procedure (Ajeet et al., 2011). According to the report of 2010, about 10.3% of Total Health Expenditure (THE) was due to delivery costs from where 6.9% caused by CS deliveries (Haider, 2018). People often receive treatments and other facilities lately due to the cost. In Bangladesh, 49.6% population lives on less than US$1.25 per day and 40% of the population lives below the poverty line (Klugman, 2010). Still people are doing CS deliveries as their perception is CS delivery can save mothers and childs birth without any complications even though for some people it is hard to afford. There are insufficient data on womens preferences for delivery mode, causes and factors associated with complications through CS delivery. The study aimed to examine the main causes and complications of cesarean section delivery specially highlighting womens perception of cesarean delivery in Coxs Bazaar, Bangladesh.
Study design: The study used cross sectional design to collect data from women who were 18 years or older and have done their CS delivery in the selected gover-nment hospital and clinical sites of Coxs Bazaar.
Sampling method: Purposive sampling method was used to selected women from hospitals and clinics who have conducted CS delivery. Study sample size was calculated using 23% reported CS prevalence rates (NIPORT, 2016), 5% absolute precision and 95% confidence level. Using formula as below the desired sample size was calculated to be 272.
n = Z21-a/2 p (1-p)/d2
Data collection: For data collection, a semi-structure questionnaire was used and divided into four parts. The first part contained socio demographic questions such as age, education, occupation, income etc. The second part of questionnaires had indication of CS delivery includes excess bleeding, respiratory problem, history of previous surgery, causes of cesarean, etc. Third part focused on the perception of women like fear of normal delivery, decision making process, affordability etc. Finally, the fourth and last part of the questionnaire was focus on complications of cesarean. Data was collected through face to face interviews from women willing to provide information about their delivery. The medium of the interview was Bengali. Data was collected with the help of research assistants. They had enough knowledge about the research topic. This research has been conducted under the super-vision of Public Health Department advisors who are expertise in the field of research. The study was approved by the Ethical Review Committee (ERC) of Asian University for Women. The study maintained the privacy and confidentiality of the participants by using an identification number instead of name. Verbal consent was taken from the study participants. Before taking the consent the goal of the study was explained to the participants. They were given the chance to ask any questions regarding to the research if they have any. The participants also had the freedom to withdraw from the research any time they wanted.
Data analysis: For data analysis SPSS software version 23 and Microsoft excel was used. A descript-tive analysis was executed to understand the distri-bution of socio demographic characteristics, decision making process, causes and risk factors of compli-cations for data analysis. Chi-square, t-test and binary regression analyses were done to determine the relationship of the variables with the specific object-tives to set forward this study.
In total 273 women were included in the study. The age of the study participants ranged from 18-40 years with the mean age of 25.48 years. Among them 48% of the respondents have 45”-5 height and relatively fewer percentages (14.3%) was observed in 55- 57. 56.4% women weight between 51-60 kg. 42.1% women said they had bachelor or above level education and 52.4% received education till higher secondary and 5.5% women received no education. Among the participants, 24.9% worked for paid job, 59% women were housewife and 16.1% women were regular student. Regarding their husbands occupation, 62% worked as a government employee, 33% did private employee, 9.5% were day laborer, 31.1% were businessman, 2.1% were farmer and 1.5% were transport workers. About 30.8% women have 15-35 thousand income in their family, 29.7% have 36-55 thousand income, 9.5% earn 56-85 thousand and 30% participants didnt answer the question.
Table 1: Socio demographic distribution of the respondents (N=273).
Obstetric and non- obstetric medical causes of CS delivery: The set of factors affecting cesarean due to medical reasons has shown in Fig 1. Some of the medical factors among the reasons studied in this research are previous cesarean (27.30%), depression (45.40%), prolonged labor (29.30%), respiratory (47.30%) and multiple pregnancies (2.60%) are the main medical reasons for cesarean delivery. Fig 2, includes doctors recommendation (61.20%), fear of normal delivery (63.40%), babys safety (95.20%), own decision (38.80%) and affordability (48.0%).
Fig 1: Obstetric-medical causes of cesarean section.
Fig 2: Non obstetric-medical causes of cesarean section.
Percentages of causes leading to CS delivery: Fig 3 shows the frequency of causes which led to CS delivery. Among the participants 18.30% faced pro-longed labor, 28.20% had breakdown of membrane, 19.40% had excess bleeding, 19% had extreme pain, 11.70% respondents crossed the delivery date, 1.80% said their babys size was too large, 1.50% respondents had fetal distress.
Fig 3: Causes of CS delivery.
Regression analysis: In binary logistic regression, education of the participants was found to as a significant predictor of CS delivery. Women with higher secondary education and no education were less likely to take decision for their CS delivery compared with B.A and above education. The history of patients previous surgery also shows significant result which means this factor drive them to take decision for CS delivery. Besides, the participants medical history of having respiratory showed significance and was found to have association with CS delivery. It was found that participants who reported having no respiratory was at 3.44 times at risk of having CS delivery than who had respiratory and when adjusted the risk of doing CS delivery was 4.90 times among the participants with no respiratory problem. However, It was seen that the risk of doing CS delivery was 0.16 times (CI: .09 - .29, p-value: .000) greater among ones who have fear of normal delivery. When the adjusted risk increased to 0.58 times but didnt show significance. Same thing happened with age (25-30 years), fear of normal delivery depression and number of children. Other variables such as weight, education didnt show any significance in the test.
Table 2: Binary logistic regression analysis of factors associated with decision making of CS delivery.
Percentages of complications faced after CS deli-very: Fig 4 shows the percentages of complications among participants faced after CS delivery and the per-centages are 22.0% pus, 8.80% incision, 13.90% obesity, 4.00% swelling and 51.30% with no compli-cations.
Association of complications and risk factors: The relationship between types of complications and socio demographic variables has shown in Table 2. Women aged 18-24 years old are more likely to have pus (50%) and become obese (55.3%). Others aged bet-ween 25-30 years mostly suffers from incision (48%) and swelling (57.1%). Women aged with 31-40 years old have less a case to become pregnant that is why the complications percentage seems less than other parti-cipants. Women who have 51-60 kg weight have more complications than others. Among the listed compli-cations pus is the usual factor for service holders women (46.8%), housewife (37.1%) and students (16.1%). For incision complications house-wives (60%) have more cases than service holders and students. Housewives (42.1%) and students (39.5%) become obese after delivery than service holders (18.4%). 7.1% service holders, 78.6% housewives and 14.3% students have observed swelling in their CC cut. Women received education till higher secondary, B.A and above faces more complications than uneducated women.
Fig 4: Level of complications after CS delivery.
From the chi-square test we found the p-value which shows age, weight and education have no relation with types of complications but occupation influence the types of complications after CS delivery. Among the listed complications pus is the usual factor for service holders women (46.8%), housewife (37.1%) and students (16.1%). For incision complications house-wives (60%) have more cases than service holders and students. Housewives (42.1%) and students (39.5%) become obese after delivery than service holders (18.4%). 7.1% service holders, 78.6% housewives and 14.3% students have observed swelling in their CC cut. Women received education till higher secondary, B.A and above faces more complications than uneducated women. From the chi-square test we found the p-value which shows age, weight and education have no relation with types of complications but occupation influence the types of complications after CS delivery.
Table 3: Association between types of complications and socio demographic factors.
Cesarean section delivery cost distribution: Figure 5 summarizes the expenditure of CS delivery. Among the participants 52% spend 15-25 thousand, 28.20% spend 26-35 thousand, 5.90% spend 36-50 thousand and others around 13.90% participants didnt answer the question. The lowest amount is 15 thousand and 50 thousand is the highest cost of CS delivery. 49% participants could bear the cost because they had savings, 16.8% took loan and 34.1% could cover the cost from their salary.
Among the participants 52% said they didnt have affordability to pay the cost of CS delivery but they hardly managed it and 48% said they didnt find any difficulties to pay or arrange money for CS delivery.
This study was aimed to identify the causes and comp-lications of CS delivery in Bangladesh. In this study, complications were reported by 48.7% of the women which is much higher compared to the study conducted in 2014 by Bangladesh Demographic and Health Survey with 23% prevalence rate (NIPORT, 2016).
Fig 5: Approximate expenditure for doing cesarean section.
Table 4: Cost and affordability related to cesarean section delivery.
The World Health Organization (WHO) recom-mends a C-section rate of between 10% and 15% of all births per country but the percentage found in this study is 50.9% which is much higher than the recommendation by WHO (WHO, 2015). It has been reported that now in Bangladesh the percentage has increased up to 51% due to unnecessary CS delivery (Save the Children, 2019). The recent data showed that, more than 60% of the worlds nations have overused the CS procedure within 169 countries (Weule, 2018).
According to the CNN report, all over the region the prevalence of CS delivery is 4.1% in West and Central Africa, 6.2% in Eastern and Southern Africa, 29.6% in the Middle East and North Africa, 18.1% in South Asia, 28.8% in East Asia and the Pacific, 44.3% in Latin America and Caribbean, 27.3% in Eastern Europe and Central Asia, 32% in North America, 26.9% in Western Europe (Howard, 2018). The percentage of CS delivery varied differently in different regions for various reasons such as cultural, educational and economic differences.
The result of this study highlighted that depression and respiratory problem were the prime reasons for obste-tric medical factors. Others reasons included previous cesarean delivery, prolonged labor, multiple pregna-ncies were among the least common medical factors. On the other hand, non-obstetric causes like babys safety were the priority for all the parents which led to CS delivery. It was strongly perceived by the participants that CS delivery would save the life and health of the child. But CS delivery caused compli-cations for neonatal as well. Studies showed that, respiratory disorder was higher among the newborn with cesarean delivery. Not only preterm infants but also near-term babies suffer from severe respiratory distress syndrome caused by surfactant deficiency (Roth-Kleiner et al., 2015). However, the expert reco-mmends that without any emergency and obstetrical indications, no cesarean should perform for the sake of newborns health (Rafiei et al., 2018).
For conducting CS delivery doctors justified at least one cause under certain complicated problems during delivery time. According to BDHS- 2014 report, due to avoid labor pain (3.2%), and in the cases of mal prese-ntation (41.5%), premature baby (1.7%), cord prola-psed (2.6%), multiple births (0.2%), failure to progress in labor (21.1%), preeclampsia (2.9%), diabetes (0.5%), less pressure on babys brain (9.7%), conven-ience (5.8%) and other complications (38.6%) doctors mentions proposed to undergo CS delivery (Hasan et al., 2019). However, without any complications also some CS deliveries were performed.
Higher educated but housewives aged between 18-24 years were more likely to do CS delivery. The service holder women mostly take their own decision but housewives considered their doctors recommendation. Similarly, in other studies, its alleged that educated and pregnant woman mostly afraid of labor pain and other complications of vaginal delivery. Women with higher education, highest socioeconomic status, age, have access to facilities and mostly deliver a baby boy underwent CS delivery (Khan et al., 2018; Manyeh et al., 2018; Mia et al., 2019). But the individual contri-bution factors were also important to CS delivery. These factors would help us to figure out the conse-quences of CS delivery in order to make awareness and promote health policy.
Women conducted cesarean delivery for one or two times suffers from pus, incision, obesity, swelling more than the women who did normal delivery for their first child. Percentage of becoming obese is higher than other complications among them. The complications were higher among the higher educated women aged 18-24 years old. Surprisingly, the housewives face more complications than service holder women. The percentage of pus (46.8%) obse-rved higher than the other complications among the service holders. This study also found out that 51.3% women faced no complications after CS delivery.
Family income was also influenced CS delivery. From the study, it has been found out that, economically affluent participants were more likely to do CS delivery than others. Those who couldnt afford they spent their salary, took loan or used their savings. Most of the participants reported costing 15-25 thousand taka, while only 5.90% participants mentioned they spent 36-50 thousand for CS delivery. Perhaps, they had better treatment facilities in private hospitals during delivery. It is assumed that the socio demo-graphic and economic factors were associated with the increase rate of cesarean delivery (Vieira et al., 2015).
Womens life style affected by the CS delivery because complications were related to both physical and psychological concerns. This research focused on medical complications after CS delivery not the others factors. But other studies indicated that after cesarean birth women faces additional stress, less satisfaction with birth experience, guilt, anxiety, and loss of self-esteem (Miovech et al., 2013). Maternal care was really important to avoid the complications of CS delivery. The study limitations included having possibility of recall bias in reporting the reasons of CS delivery properly and also lack of generalizability because the study was conducted only in one city of Bangladesh.
The findings of this study showed that those who did CS delivery for the first time were more likely to do it for the second time because they thought they were not capable to do vaginal delivery anymore. Also, the women who did normal delivery for their first child had specific health issues mentioned by doctors to perform cesarean section for their second delivery or next child. Womens age, education, and occupation significantly predicted decision making of CS delivery, which a number of health complications to mothers. The aver-age cost of CS delivery was not affordable for most families yet people are doing CS delivery for the sake of their babys safety and doctors suggestion. The study recommends generalized awareness raising campaign targeting prospective mothers and couples to use antenatal check-up during pregnancy and to increase knowledge about pregnancy danger signs needing emergency obstetric care. Professional inte-grity and ethics training should be strengthening for health care providers to exercise medically oriented protocol in recommending CS delivery.
I am grateful to all the participants who took part in the study. I am deeply grateful to AUW for funding this project and thank the research assistants for help during data collection process.
The author(s) declare there is no conflict of interest.
Academic Editor
Md. Ekhlas Uddin Dipu, Department of Biochemistry and Molecular Biology Gono Bishwabidalay, Dhaka, Bangladesh.
Dept. of Public Health, Asian University for Women, Chittagong, Bangladesh