Unpacking Caesarean in Rural Bangladesh: Who, What, When and Where

doi:10.21203/rs.3.rs-588075/v1

Download PDF

Research Article

Unpacking Caesarean in Rural Bangladesh: Who, What, When and Where

https://doi.org/10.21203/rs.3.rs-588075/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted 15 Jun, 2021

You are reading this latest preprint version

Background: Bangladesh has experienced an alarming increase in birth through caesarean. In this article, we unpack women’s interpretation on why they underwent caesarean, with whom they locate the proposition of the caesarean and when the decision was made in rural Bangladesh.

Methods: We conducted a cross-sectional household survey of 2,299 women in Kushtia district. Of these, 1,233 who gave birth through caesarean completed a supplementary questionnaire. Descriptive statistics were used to report caesarean rates which were disaggregated by sociodemographic characteristics and contact with the health services. We analysed women’s reported reasons for having caesarean, when the decision was taken and who proposed the intervention.

Findings: Over half (54%) of women gave birth through caesarean. The proportion of caesareans was significantly higher among women with higher educational attainment, higher socioeconomic status, and increased antenatal care during pregnancy, particularly if this care was sought in private facilities (p<0.05). Women reported that health service providers primarily proposed the caesarean (73%), followed by family members (21%) and finally, the woman herself (6%). Regarding the reasons for caesarean, 34% of women reported non-medical reasons (convenience and avoidance of labour pain), and 66% mentioned medical reasons. Over half of the women reported that the decision to undergo a caesarean was taken on the day of birth.

Conclusion: Women in rural Bangladesh often report avoidable reasons for caesarean. Better regulation of caesarean services in both public and private health services, as well as improved counselling of women regarding caesarean indications and its consequences, is recommended.

Maternal & Fetal Medicine

Maternal health

Caesarean

Bangladesh

While caesarean can be an important intervention for averting morbidity and death when women or their unborn child experience life-threatening complications during pregnancy or childbirth (1), it is an invasive procedure which carries iatrogenic risks (2, 3). The procedure has been on the rise over the past decades in both high-income and low- and middle-income settings and there is now widespread concern regarding its unnecessary use (4, 5). This concern is reflected in the stepping back of the World Health Organization (WHO) from their long-standing recommendation of a 10–15% caesarean rate at country level, but rather recommending that caesarean be performed only when medically indicated and for women who actually need it (6).

Bangladesh is a particularly interesting case embedded in this global story, as caesarean rates increased dramatically from 12% in 2010 to a staggering 31% in 2016 (7). The rates are high in both urban (39%) and rural (28%) settings, particularly among private facility-based births, where approximately 83% of births are conducted through caesarean (7). These rates are extremely high and raise questions and concerns regarding their necessity and appropriateness. The caesarean trends in Bangladesh suggest a worrisome over-medicalisation of childbirth which may pose increased risks to women (2, 4, 6), particularly as such services are only minimally regulated and monitored (8, 9).

Avoiding unnecessary caesarean has risen to be a critical priority among policy-makers and other key stakeholders in Bangladesh, an interest which is reflected in national initiatives, including the Bangladesh Maternal Health Strategy and the 'Stop Unnecessary C-Section in Bangladesh' movement (2, 10–17). Many have sought to understand the rates, trends, determinants and clinical perspectives of having caesarean in Bangladesh and similar settings (11). However, it is essential to keep in mind that behind rates, trends, determinants and medical indications, there are women whose bodies reside at the intersections of these statistics and policy level debates. Unfortunately, very few studies thus far have tried to understand women's accounts and voices in this regard (18). In the paper, we aim to address this key evidence gap by unpacking women's perspectives regarding with whom they locate the proposition for caesarean, when the decision was made and their accounts of the reasons for undergoing caesarean in rural Bangladesh.

Study design

This study adopted a cross-sectional design employing a quantitative method of data collection. We conducted four rounds of rolling surveys between December 2015 and February 2017, where each round of data collection required approximately three months. An additional module on women’s perspectives on caesarean was introduced in rounds 3 & 4 (June 2016 and February 2017). A detailed description of the umbrella study is available elsewhere (19), and the methodology is presented as an annex to this paper.

Study context and settings

This study was implemented in thirty unions (the smallest administrative unit in Bangladesh, each with approximately 30,000 population) from three rural sub-districts of Kushtia district, approximately 200 kilometres west of Dhaka, Bangladesh's capital.

Study population

The study population included women with a history of birth within 90 days of the date of the interview. The recall period was chosen to avoid enrolment of the same participant in consecutive rounds.

Sampling strategy and sample size

A stratified sampling technique was used to ensure equal representation of all selected unions. Villages were considered as the primary sampling unit. Probability proportional to size sampling was used to select 17 villages from each union. From the selected villages, all eligible women were identified, and a total of 4,436 women were interviewed in four rounds (non-response rate 3%). Among them, 2,299 women were interviewed in rounds 3 and 4. Of these, 1,233 who gave birth through caesarean completed a supplementary questionnaire.

Data collection instruments and procedures

The household survey was conducted by trained data collectors with an interviewer-administered structured questionnaire. The questionnaire included questions on background characteristics, socio-demographic information and information related to pregnancy and birth, including caesarean.

Data analysis methods

Data were analysed using STATA 14.0. Socio-demographic characteristics such as age and educational attainment and pregnancy-related information such as parity and antenatal care (ANC) contacts were transformed into categorical variables. For each household, an asset score was generated based on the principal component analysis using household possession data on durable goods, use of fuel, household materials, ownership of animals and homestead and land ownership. The socio-economic status of households was determined by allocating them to five categories (quintiles) based on their respective asset scores (20). Doctors, nurses, midwives, paramedics (sub-assistant community medical officer and family welfare visitor) and community-based skilled birth attendants were considered as formal providers for providing ANC, attending birth and postnatal care. Place of birth was re-categorised as home (including on the way to a facility), public facility and private facility (including NGO clinics, representing less than 3% of the total births).

Descriptive statistics were used to report caesarean rates which were disaggregated by the following characteristics: age, education, wealth quintile, parity, attending ANC with a formal provider, attending ANC at the private sector and place of birth. Additionally, women's reported reasons for undergoing caesarean, when the decision was taken and the person who proposed the caesarean were also reported. The reasons reported by women were categorised into four broad categories, i.e. avoiding labour pain and convenience of time, medical reasons, history of the previous caesarean and other unspecified reasons. Medical reasons included premature labour, cord prolapse, malpresentation, prolonged labour, obstructed labour, pre-eclampsia, diabetes, multiple pregnancies, and other complications during birth.

Quality control and assurance

The data collectors received one week of training before commencing data collection. Biweekly refresher training was held to discuss data quality issues. Field supervisors conducted regular spot checks. Additionally, monthly supervisory visits and random spot checks were conducted by investigators. Finally, all completed questionnaires were reviewed by field supervisors before data entry.

Figure 1 presents the proportion of women giving birth through caesarean. Among all the women surveyed, over half (54%) gave birth through caesarean. The rate varied based on socio-demographic factors and women's contact with the formal health systems (p < 0.05). Among women with four or fewer years of education, 34% had a caesarean, while 72% of women with 10 or more years of education gave birth through caesarean (p < 0.0001). Similarly, 41% of women from the lowest wealth quintile had a caesarean, which increased among wealth quintiles, with 70% of women from the highest quintile undergoing caesarean (p < 0.0001). Nearly two-thirds of first-time mothers gave birth through caesarean, while around one-third of women having a subsequent birth with no history of previous caesarean gave birth through caesarean. Among women who attended no ANC contacts during pregnancy, only 15% gave birth through caesarean, compared to over two-thirds of women who attended four or more ANC contacts (p < 0.0001). This was particularly pronounced when this care was sought in the private health sector: while only one-fifth of women attending no ANC in a private facility underwent caesarean, this increased steadily with each ANC contact in the private sector, with four-fifths of women attending four or more ANC contacts in a private facility giving birth through caesarean (p < 0.0001). Finally, while less than one-fifth of women giving birth in a public facility delivered through caesarean, 86% of those giving birth in a private facility did so (p < 0.0001).

Three-quarters of women surveyed reported that the doctor first proposed the caesarean (Figure-2). After doctors, women were most likely to mention that a family member had proposed the caesarean (20%), whereas very few (6%) mentioned themselves as having proposed it. This varied only minimally across socio-demographic characteristics and health service utilisation patterns.

Half of women reported that the decision to have a caesarean was taken on the day of birth. These proportions were somewhat more pronounced among women of lower socioeconomic status (58% of women from the lowest wealth quintile vs 41% of women from the highest wealth quintile, p-value 0.0003). Women attending four or more ANC contacts in the private health sector were also more likely to make this decision well in advance, more than 30 days before caesarean. (23% of women having attended four or more ANC in the private sector vs 11% of women having attended 1 ANC in the private sector, p-value 0.0006).

Figure 4 presents women's reported reasons for having a caesarean. Two-thirds of women reported at least one medical reason for the caesarean, while one-third mentioned the convenience of timing or avoiding labour pain as a reason. The most reported medical reasons included mal-presentation (28%), prolonged labour (21%) and obstructed labour or cord prolapsed (14%) (not presented in the tables and figures). Seventeen percent of women mentioned the previous caesarean as a reason, while 10% mentioned other reasons. It is also worth noting that 31 women (2.5%) reported that they did not know the reason that they had a caesarean.

Figure 5 presents the overlaps between reasons for caesarean as reported by women. Among women surveyed, 14.5% mentioned the convenience of timing or avoiding labour pain as the only reason for having undergone caesarean. Among these, 48% of women mentioned that the decision was taken the day or the day before birth. Half reported that it was the doctor who had proposed the caesarean and only 10% mentioned that they had proposed it first. Of the women who reported the previous caesarean as the reason (9%), only 52% reported that the decision was taken a month prior to the procedure and 20% reported that the decision was taken on the day of or the day before surgery. Among the surveyed women, 44% mentioned medical reasons as the only reason for having the procedure. Of them, 65% reported that decision was taken on the day of the birth.

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.

For years, the promotion of facility birth has been central to the maternal health strategy of the Government of Bangladesh and development partners. While facility birth has been increasing over the past decade, Bangladesh is now suffering from an epidemic of caesarean delivery. Based on the findings of this study, we suggest that health services supporting normal vaginal births be expanded throughout Bangladesh which place women at the centre and respond to their need and desires. This includes taking their desire for pain management seriously by emphasizing pain management in policy and making these options accessible to all women at the times of birth. Additionally, in many cases, decisions around having a caesarean, even for non-emergency reasons, are made at the last minute, that is, on the day of birth. Therefore, better pre-birth counselling for high risk women regarding having a caesarean is essential to avoid this phenomenon.

Moreover, very few women are primarily locating the proposition of having a caesarean with themselves; the majority of them located this proposition with a medical doctor. Meaningful dialogue during ANC visits should be established between the health-worker and women by promoting person centred-care. By promoting a culture of participation, women can be the centre of the decision-making around their own bodies and childbirth experiences. Finally, we recommend a policy response to better regulate the caesarean services in both public and private health facilities.

WHO: World Health Organization; ANC: Antenatal care

Ethical approval and consent to participate

Ethical approval for the study was obtained from the Institutional Review Board of icddr,b (Protocol Number: PR 15074) and the Save the Children Ethics Research Committee in the United States. Written informed consent was obtained from all participants before beginning interviews. Privacy, anonymity, and confidentiality of the participants were strictly maintained during data collection and analysis. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and material

The datasets will be made available upon a valid request to the corresponding author (Ahmed Ehsanur Rahman, [email protected]).

Competing interests

The authors declare that they have no competing interest.

Funding

The study was funded by the Bill and Melinda Gates Foundation through the Saving Newborn Lives Programme of Save the Children.

Authors’ contribution

AER and JEP wrote the paper as joint first authors. SEA and AER lead the study as Principle Investigators with technical contributions from GB and SW in designing the study. AER, JEP and SEA conceptualised the paper with contributions from ATH, GB and SJ. ATH analysed the data. All authors reviewed the final draft and contributed in finalizing the paper. SEA lead the process as the senior author.

Acknowledgements

The authors would like to acknowledge the contribution of the Government of Bangladesh to this project. We also would like to give a special thanks to all the local health managers and participants from the three sub-districts of Kushtia district and the research team without whose dedication and expertise this study could not be accomplished. We acknowledge the contribution of the Saving Newborn Lives Programme of Save the Children in designing and implementing the study.

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet. 2000;356(9239):1375-83.
Victora CG, Barros FC. Beware: unnecessary caesarean sections may be hazardous. The Lancet. 2006;367(9525):1796-7.
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007;335(7628):1025.
Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3):237-44.
Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PloS one. 2016;11(2):e0148343.
Betran A, Torloni M, Zhang J, Gülmezoglu A, Section WWGoC, Aleem H, et al. WHO Statement on caesarean section rates. BJOG: An International Journal of Obstetrics & Gynaecology. 2016;123(5):667-70.
NIPORT, International Centre for Diarrhoeal Disease Research Bangladesh, MEASURE Evaluation. Bangladesh maternal mortality and health care survey (BMMS) 2016: Final Report. Dhaka, Bangladesh and Chapel Hill, NC, USA; 2017.
National Institute of Population Research and Training (NIPORT), Associates for Community and Population Research (ACPR), ICF International. Bangladesh Health Facility Survey 2014. Dhaka, Bangladesh; 2016.
National Institute of Population Research and Training (NIPORT), Associates for Community and Population Research (ACPR), ICF International. Bangladesh Health Facility Survey 2017 Preliminary Report. Dhaka, Bangladesh; 2018.
Rahman M, Shariff AA, Shafie A, Saaid R, Tahir RM. Determinants of caesarean risk factor in northern region of Bangladesh: A multivariate analysis. Iranian journal of public health. 2014;43(1):16.
Kamal SM. Preference for institutional delivery and caesarean sections in Bangladesh. Journal of health, population, and nutrition. 2013;31(1):96.
Begum T, Rahman A, Nababan H, Hoque DME, Khan AF, Ali T, et al. Indications and determinants of caesarean section delivery: evidence from a population-based study in Matlab, Bangladesh. PloS one. 2017;12(11):e0188074.
Aminu M, Utz B, Halim A, Van Den Broek N. Reasons for performing a caesarean section in public hospitals in rural Bangladesh. BMC pregnancy and childbirth. 2014;14(1):130.
Haider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM. Ever-increasing Caesarean section and its economic burden in Bangladesh. PloS one. 2018;13(12):e0208623.
Begum T, Nababan H, Rahman A, Islam MR, Adams A, Anwar I. Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh. PloS one. 2019;14(8).
Shahabuddin A, Delvaux T, Utz B, Bardají A, De Brouwere V. Determinants and trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh. BMJ open. 2016;6(9):e012424.
Bangadeh Directorate General of Health Services, Bangadeh Directorate General of Family Planning. Bangladesh Maternal Health Strategy 2019.
Khan R, Blum LS, Sultana M, Bilkis S, Koblinsky M. An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh. Journal of health, population, and nutrition. 2012;30(2):159.
Rahman AE, Herrera S, Rubayet S, Banik G, Hasan R, Ahsan Z, et al. Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh. PloS one. 2020;15(5):e0232675.
Córdova A. Methodological note: Measuring relative wealth using household asset indicators. Americas Barometer Insights. 2009;6:1-9.
Rahman MM, Haider MR, Moinuddin M, Rahman AE, Ahmed S, Khan MM. Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh Demographic and Health Survey 2014 Data. PloS one. 2018;13(9):e0202879.
Aziken M, OMO‐AGHOJA L, Okonofua F. Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta obstetricia et gynecologica Scandinavica. 2007;86(1):42-7.
Behague DP. Beyond the simple economics of cesarean section birthing: women's resistance to social inequality. Culture, Medicine and Psychiatry. 2002;26(4):473-507.
Donner H. Domestic goddesses: maternity, globalization and middle-class identity in contemporary India: Routledge; 2016.
Afsana K. The tremendous cost of seeking hospital obstetric care in Bangladesh. Reproductive health matters. 2004;12(24):171-80.
Lobel M, DeLuca RS. Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Social science & medicine. 2007;64(11):2272-84.
National Institute of Population Research and Training (NIPORT) and ICF. Bangladesh Demographic and Health Survey 2017-18: Key Indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, and ICF; 2019.
Khawaja M, Kabakian-Khasholian T, Jurdi R. Determinants of caesarean section in Egypt: evidence from the demographic and health survey. Health policy. 2004;69(3):273-81.
Kambo I, Bedi N, Dhillon B, Saxena N. A critical appraisal of cesarean section rates at teaching hospitals in India. International journal of gynecology & obstetrics. 2002;79(2):151-8.
Hure A, Powers J, Chojenta C, Loxton D. Rates and predictors of caesarean section for first and second births: a prospective cohort of Australian women. Maternal and child health journal. 2017;21(5):1175-84.
Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio DM, et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. American journal of obstetrics and gynecology. 2005;193(5):1656-62.
Spong CY. To VBAC or not to VBAC. PLoS medicine. 2012;9(3).
Perkins JE, Rahman AE, Siddique AB, Haider MR, Banik G, Tahsina T, et al. Opting for home birth in rural Bangladesh: An assessment of the current status and reasons. Birth. 2018.
Bogren M, Begum F, Erlandsson K. The historical development of the midwifery profession in Bangladesh. Journal of Asian Midwives (JAM). 2017;4(1):65-74.
Moes CB, Thacher F. The midwife as first assistant for cesarean section. Journal of midwifery & women's health. 2001;46(5):305-12.
Butler J, Abrams B, Parker J, Roberts JM, Laros Jr RK. Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. American journal of obstetrics and gynecology. 1993;168(5):1407-13.
Gardberg M, Leonova Y, Laakkonen E. Malpresentations–impact on mode of delivery. Acta obstetricia et gynecologica Scandinavica. 2011;90(5):540-2.
Duffy CR, Moore JL, Saleem S, Tshefu A, Bose CL, Chomba E, et al. Malpresentation in low‐and middle‐income countries: Associations with perinatal and maternal outcomes in the Global Network. Acta obstetricia et gynecologica Scandinavica. 2019;98(3):300-8.
Zgheib SM, Kacim M, Kostev K. Prevalence of and risk factors associated with cesarean section in Lebanon—A retrospective study based on a sample of 29,270 women. Women and Birth. 2017;30(6):e265-e71.
Rozario S. The dai and the doctor: discourses on women's reproductive health in rural Bangladesh. In: Ram K, Jolly M, editors. Maternities and modernities: Colonial and postcolonial experiences in Asia and the Pacific: Cambridge University Press; 1998. p. 144-76.
Jeffery P, Jeffery R, Lyon A. Labour Pains and Labour Power: Women and Childbearing in India. London: Zed Books; 1989.
Afsana K, Rashid SF. Constructions of birth in Bangladesh. In: Selin H, Stone PK, editors. Childbirth across cultures: Ideas and practices of pregnancy, childbirth and the postpartum. 5. Amherst Massachusetts: Springer; 2009. p. 123-35.
Jeffery R, Jeffery PM. Traditional birth attendants in rural north India: The social organization of childbearing. In: Lindenbaum S, Lock M, editors. in Knowledge, Power, and Practice: The Anthropology of Medicine in Everyday Life. Berkeley and London: University of California Press; 1993. p. 7-31
Edmonds A. Can Medicine Be Aesthetic? Medical anthropology quarterly. 2013;27(2):233-52.
Edmonds A, Sanabria E. Medical borderlands: engineering the body with plastic surgery and hormonal therapies in Brazil. Anthropology & medicine. 2014;21(2):202-16.
Rahman A, Nisha MK, Begum T, Ahmed S, Alam N, Anwar I. Trends, determinants and inequities of 4+ ANC utilisation in Bangladesh. Journal of Health, Population and Nutrition. 2017;36(1):2.
Siddique AB, Perkins J, Mazumder T, Haider MR, Banik G, Tahsina T, et al. Antenatal care in rural Bangladesh: gaps in adequate coverage and content. PloS one. 2018;13(11).
Begum T, Rahman A, Herfina Nababan DM, Hoque E, Al Fazal Khan TA, Anwar I. Indications and determinants of caesarean section delivery: evidence from a population-based study in Matlab, Bangladesh. PloS one. 2017;12(11).
Rahman M, Shariff AA, Shafie A, Saaid R, Tahir RM. Caesarean delivery and its correlates in Northern Region of Bangladesh: application of logistic regression and cox proportional hazard model. Journal of Health, Population and Nutrition. 2015;33(1):8.
Rahman M, Shariff AA, Shafie A. Caesarean risk factors in northern region of Bangladesh: A statistical analysis. Tropical Journal of Pharmaceutical Research. 2012;11(5):823-33.

No competing interests reported.

Download PDF

Version 1

posted 15 Jun, 2021

You are reading this latest preprint version

Unpacking Caesarean in Rural Bangladesh: Who, What, When and Where

Status:

Version 1

Abstract

Figures

Background

Methods

Study design

Study context and settings

Study population

Sampling strategy and sample size

Data collection instruments and procedures

Data analysis methods

Quality control and assurance

Findings

Discussion

Strengths and Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1