This study adds an important contribution of women's perspective to the debate around caesarean trends in Bangladesh, which remains under-examined. This study found that even in rural Bangladesh, the rate of caesarean has skyrocketed. Moreover, the decision for undergoing caesarean is often taken at the last minute, even when convenience and avoiding labour pain are mentioned as reasons. Finally, women are primarily locating the proposition of the caesarean outside of themselves, generally with health care providers, and in some cases with family members.
Among women in our study, we found some patterns across socio-demographic characteristics and caesarean rates. Consistent with other studies, we found increasing proportions of women having caesarean as educational attainment increased (11, 21, 22). Although not surprising, it is important to consider what this may indicate regarding the social meanings of caesarean in the rapidly transforming context of Bangladesh. Moreover, while women from the highest wealth quintile had the highest proportion of birth through caesarean, still 40% of women from the poorest wealth quintile did so. It may be reflecting the aspiration of poorer women toward having a caesarean as a marker to class status (23, 24). Further examination of these trends are required as high out of pocket expenditures reported in various studies may expose women and their family members toward catastrophic expenditure and impoverishment (7, 14, 25–27).
Not surprisingly, we found that women were most likely to give birth through caesarean when giving birth in a private health facility. While this point has been well documented in Bangladesh, it is important to consider the extent to which women are aware that a decision to give birth in a private health facility will almost incontrovertibly translate into a caesarean (20). In addition, we also found that increased contact with the formal health system during pregnancy through routine ANC increased the likelihood of caesarean - particularly when this care was sought in the private sector. This is consistent with findings in other settings, where a higher number of ANC contacts was associated with a higher incidence of birth through caesarean (28). This may indicate that health service providers are promoting the caesarean during ANC, or at a minimum that women are not adequately counselled regarding the potential risks and benefits of caesarean during these contacts. The coverage of ANC is increasing rapidly in Bangladesh (7, 27), but there are major gaps in the quality of counselling (21, 27). Therefore, the health system may be missing this opportunity to utilize ANC contacts as a platform to provide options to the women regarding various modes of birth, including caesarean, and discuss their consequences to promote informed decision-making.
The proportion of women giving birth through caesarean in our study was the highest among first-time mothers. This is consistent with findings from studies conducted in Australia and India, in which first-time mothers were significantly more likely to give birth through caesarean (29, 30). This may be because women who have gone through one vaginal birth may have more confidence in their ability to go through the process again and may be less influenced by others' nudges toward caesarean. This is a critical point as most women in this context will give birth more than once, indicating that they will likely have multiple caesareans. Indeed, vaginal birth after a caesarean places women at increased risks for complications at the time of birth, including uterine rupture, thus requiring higher level of health service readiness which is rarely available in resource-limited settings, including Bangladesh (7, 31, 32).
The convenience of time and avoidance of labour pain were reported by women as among the main reasons for caesarean. While some women also mentioned these along with other medical reasons, it suggests that these are still important considerations for women and should be taken seriously. In the context of Bangladesh, it is important to grapple with the idea that women may be considering caesarean as a legitimate pain management strategy. Moreover, Bangladesh Maternal Health Strategy does not acknowledge pain management as a critical issue in maternal health (17). While some studies had demonstrated the fear of caesarean to serve as a barrier to seeking birth in a health facility (18, 33), this may suggest the option of caesarean as attracting women to facility birth as a means to access this form of pain management.
In our study, women were primarily locating the proposition of the decision with the health service provider, even when the convenience of time or avoidance of labour pain was mentioned as a reason. Given this, it is also important to consider the extent to which women are fully informed about the reason for their caesarean and consenting to the procedure. This calls into question whose convenience was being prioritised in this decision, and whose discomfort was being averted in avoiding labour pain. Indeed, doctors often have limited work hours in both public and private health facilities and are often not inclined to stay after hours. Moreover, women are unlikely to receive continuous care during labour and birth, which may contribute to supporting women in pain management during labour and birth.
We asked women about medical reasons from their perspective and did not verify these with medical records. It is interesting that the most common medical reason reported by women was malpresentation (28%), which is notable as it is one of the medical reasons which women are least likely to be able to verify and confirm themselves, therefore they are entirely reliant on the health service provider's opinion regarding the presentation of the baby (37–38). Indeed, this reporting would suggest a much higher occurrence of caesarean as a result of malpresentation compared to other settings, which could indicate supplier-induced demand (29, 37, 39). It is critical to highlight that around 3.5% of women in our sample who were not able to mention any reason for their caesarean. Though this pool represented a small number of women, all woman should be fully informed regarding the reason for which they are undergoing such an invasive procedure.
In addition, among the reasons which we explored, 1 in 10 women mentioned other reasons which we were not unable to assess through this study. However, future studies should consider examining these other reasons These could include how caesarean may be a manifestation of women exercising their agency and achieving their own goals (24), serving as a way to manage birth pollution which has long figured in the construction of birth in South Asia (24, 40–43), or how it is articulated within broader ideas about sexual aesthetics (44, 45).
Finally, in this study, we found that half of the caesarean decisions were taking on the day of birth. This was the case regardless of whether women reported non-medical reasons or medical reasons, or even when they reported that the previous caesarean as the reason. This indicates a disconnect as all previous caesarean and many non-emergency medical reasons can be anticipated in advance. This suggests a need for better counselling during health contacts during pregnancy (46, 47).
Strengths and Limitations
The study accepted a maximum recall period of 90 days which can potentially minimise the recall errors. Moreover, the overall design employed in our study added strengths to this paper. However, it should be acknowledged that the reasons for a caesarean, reported in this paper, are women’s perspective and interpretations instead of biomedical indications as found in other studies (10, 48–50). Similarly, the timing of when the caesarean decision was taken and who proposed it first are women's account of locating the proposition instead of the overall decision-making dynamics. We also did not have data to disaggregate the timing of decision making by pre-labour and intrapartum periods.