Reining in the culture of unnecessary C-sections

Many private hospitals favour the Caesarean delivery method due to its commercial advantages. Photo: Collected

According to historians, Caesarean Section, also known as C-Section or Caesarean delivery of babies, dates back to 1580, performed by a man on his wife in Switzerland. The wife survived and later gave birth to five more children. It is the surgical procedure by which one or more babies are delivered by cutting the pregnant woman's abdomen and then incising the uterus and bringing out the baby.

A report by the National Institute of Population Research and Training (NIPORT), published in 2023, showed the rate of C-section deliveries had risen from 34% in 2017 to 45% in 2022. These numbers are surprisingly high in private facilities in comparison to government hospitals and birthing centers. The same report mentions that in 2004, the rate stood at 4%, which rose to 34% in 2017–18 and is now at 45%, which is more than 11 times higher within a span of 20 years.

If we consider the WHO benchmark (10%–15%), the current rate is way above it. What is happening in the C-Section arena where the providers deal with two lives, the mother and baby?

The potential risks associated with a Caesarean section include thromboembolic disease, injury to pelvic organs, incision scar dehiscence in subsequent pregnancies, secondary infertility, complications from anaesthesia, infection, placenta previa, haemorrhage, and an increased risk of uterine rupture in future vaginal deliveries.

Additionally, it is worth noting that maternal mortality rates following Caesarean sections are significantly higher in low- and middle-income countries compared to other settings.

Children delivered via Caesarean section (C-section) exhibit elevated prevalence of various diseases, such as asthma, type I diabetes, allergies, obesity, higher primary pulmonary blood pressure, risk of transmission of pathogenic bacteria from the hospital environment to the infant's body, blood infection, schizophrenia, and jaundice, as well as diminished cognitive functioning and decreased academic achievement.

In Bangladesh, an annual birth rate of over 3.6 million children has been observed over the years. The likelihood of giving birth in a healthcare facility has shown a notable increase in recent decades. The percentage of institutional delivery has witnessed a significant rise, surging from 4% to 49% throughout the period spanning from 1993–94 to 2017–18. 

However, it is noteworthy that around 50% of all childbirths in Bangladesh continue to occur in the home setting. The delivery rate in healthcare facilities in urban regions is 63%, but in rural areas, it is 45%.

It is worth noting that a significant proportion of institutional deliveries, namely two-thirds, occur in private care facilities. It is important to highlight that these facilities exhibit a considerably high rate of Caesarean section (C-section) procedures, reaching as high as 83%. Government hospitals exhibit a relatively low rate of Caesarean sections (35%). The percentage of births that are now accomplished through a Caesarean section is 2.5 times higher than it was in earlier decades.

According to the NIPORT data, there is a notable disparity in the likelihood that women have access to media, specifically social media. The statistics reveal that women who have access to these media outlets are three times more likely to have the surgery compared to women who have limited or no access to such media platforms.

Many doctors working in private hospitals in Bangladesh are advocating for their patients to have Caesarean sections regardless of the mother's medical state and the position of the foetus in the womb, on the plea of the safety of the baby in the womb in particular. Therefore, moms who receive antenatal care from a private institution are more likely to choose to have their babies delivered via Caesarean surgery.

Many educated pregnant women do not want to face the time that would be required and the likelihood of delivery pain and opt to undergo C-sections. This notion of pregnant women giving an opinion to face the operation is construed to be a reflection of patients' rights. This issue remains debatable, as most of these pregnant women did not receive the proper counselling about normal vaginal delivery.

In addition, these elevated rates of C-section births may be the result of a number of socioeconomic and demographic reasons. Additionally, many private hospitals favour the Caesarean delivery method due to its commercial advantages.

A Caesarean section, like any other type of surgery, comes with both a short-term and a long-term risk. These risks can last for many years after the actual delivery and have an impact on the woman's health as well as the health of her child and any future children she may have. Women who do not have access to comprehensive obstetric care are at greater risk for these complications. 

A recent study conducted at the State University of Bangladesh reveals that C-sections done rampantly throughout Bangladesh by different kinds of surgeons, including obstetricians and gynaecologists, have raised the incidence of iatrogenic fistula (unusual passage of urine and stool) in women.

In recent years, common people, the government, and clinicians have voiced their concern regarding the rise in the number of deliveries that are performed via a Caesarean section and the potential adverse effects that this trend may have on the health of both mothers and newborns. In addition to this, there has been a growing consensus among members of the international community regarding the requirement to reconsider the rate that was recommended in 1985 by the WHO.

Very recently, the High Court directed the government to take steps to make it compulsory for all hospitals and clinics to follow the relevant guidelines for Caesarean sections to prevent unnecessary operations. The HC bench of Justice Naima Haider and Justice Kazi Zinnat Hoque delivered the verdict on 12th October 2023. This verdict elevates the policy to a formal judgement, per Article 111 of the Bangladesh Constitution.

The Health Ministry(MOHFW)'s proposed policy is under the title "Bangladesh National Guidelines and Technical Standards and Operating Procedure for Promotion of Normal Vaginal Delivery (NVD), Prevention of Unnecessary Caesarean Section, Creating Awareness about Necessity and Justification of Caesarean Section." And the honourable HC was directed to follow the policy.

The verdict was made against a writ petition (No. 7117/2019) filed by the Bangladesh Legal Aid and Services Trust (BLAST) back in 2019. The petition was urging the High Court to intervene. The prayer wanted directives to stop practising unnecessary C-sections in private hospitals and clinics and in all other places where surgeries are being done.

This groundbreaking decision states women's right to sexual and reproductive health protection. The verdict is accompanied by a four-page guideline, providing a comprehensive national strategic guideline to address. There are several priority action areas mentioned, such as:

- Strengthening the regulatory framework
- Health system strengthening
- Awareness building on NVDs, the necessity of medically indicated Caesarean sections, and the harmful effects of unnecessary Caesarean sections.
- Enhance normal vaginal delivery.
- Enhance and expedite the introduction of midwife-led delivery care.
- Strengthen programme strategies.
- Ensure facility readiness and promote standard practice.

The guideline comes with annexures of technical standards and operating procedures. The annexures are:

- Bangladesh Maternal Health Standard Operating Procedure (SOP) (selected sections), MOHFW.
- Standard clinical management

 protocol and flowcharts on emergency obstetric and neonatal care 2019, MOHFW, UNFPA, WHO, UNICEF.
- Standard labour room management protocol for all health facilities. OGSB 20-18, MOHFW, OGSB, UNFPA

However, there are no clear indications of the symptoms that warrant C-sections. Now the question is, wasn't it important to include the indications in the annexures, particularly the Robson classification?

In 2015, the World Health Organisation (WHO) officially endorsed a classification system that distinguishes itself from existing systems by encompassing all women who experience childbirth rather than solely focusing on those who undergo Caesarean sections. This is known as the Robson classification, alternatively referred to as the 10-group classification or ten-group classification system (TGCS).

It is a widely utilised technique employed to categorise pregnant women who endure the process of birth into ten possible groups, which are very easy to use. The purpose of its development was to provide a more precise evaluation of Caesarean section rates across various contexts, including specific healthcare facilities.

Because of this, the authorities in charge of healthcare in the government should work to guarantee that the C-section facilities are utilised appropriately and should encourage individuals to have normal births at any health institution. 

In addition, government and professional bodies should formulate a national guideline for the utilisation of C-sections as well as regular deliveries according to the physiological state of both the mother and the foetus based on the Robson classification. 

This would thus uphold the implementation of the High Court verdict, enabling access to necessary and life-saving C-sections for all those women who are in need and stopping the occurrence of unnecessary C-sections.

Dr Abu Jamil Faisel is a Public Health Expert and Working group member of Bangladesh Health Watch.

Noushin Mouli Waresi works at Bangladesh Health Watch, Brac James P Grant School of Public Health.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the opinions and views of The Business Standard.