Elevation of cesarean delivery in Bangladesh: a ten-year follow up study Shajratul Alam, M Moinuddin Haider, Mizanur Rahman, Nurul Alam, Dr. Quamrun Nahar 1 BACKGROUND A pregnant women is exposed to many risks that may put both lives of herself and her unborn child into jeopardy. Even if she doesn’t show any sign of complication during pregnancy, the incidences of delivery complications cannot be avoided in some situation. With an aim to saving mother and child in risky cases (for example, when opening of cervix is blocked by placenta or when the fetus position is not suitable for safe delivery) [25], physicians resort to cesarean surgery (CS) - a major operation that involves cutting a mothers abdomen and taking out the child. Beyond such cases that involve medical indication, CS is said to be justified when a mother’s psychological health is involved [20]. CSs are considered safe and, in many situations obvious for life saving [8]. However, they do not carry additional benefit to the mothers who are eligible to have a normal vaginal delivery (NVD), otherwise known as natural births [12]. A mother, going through CS, is prone to greater risk of postpartum complication[2, 24]. She has to spend more days in the hospital and also needs longer recovery days compared to mother with a normal delivery [12]. Repeated CS puts the mother in greater risk of future pregnancy complications [19, 18]. The newborn goes through life threatening situation as well [26, 22]. It takes a large economic toll on patient’s family that accumulates with the charges of operation theatre, hospital lodging, engulfing expensive anti- biotic and drugs for avoiding risk of infection at the incision site etc. These expenses not only put pressure on the family but also on the economy of that country as a whole [21]. Such consequences (both economical and medical), however, couldn’t stall the acceleration of CS rate worldwide [1]. Studies, trying to find the reason for such rise, found that – other than medical emergencies, factors such as mother’s age, parity, obesity [27], previous CS [23],in what type of community the mother lives in [11], choice of caregiver [14] also plays vital role for up-taking of such decision. Mother’s own desire for CS in absence of any medical or clinical complexity also attributes to this rise [5, 13]. A growing concern for avoiding such un-welcomed (both medical and economical) harm has prompted World Health Organization (WHO) to sug- gest that number of CS per 100 births should not exceed 15 regardless of development status of any country [15]. While WHO argues that this figure should be considered as a target to be achieved [3], worldwide 18.6% births are being delivered by CS with rates fluctuating from 6% to 27.2% from least to most developed countries [1]. The percentage of births delivered by CS has been rising sharply in the last 10 years in Bangladesh - it has increased from 4% in 2004 to 23% in 2014 [16]. The scenario becomes worse when we see CS is the procedure of 6 in 10 deliveries in health facilities. It is evident that with the increase of facility delivery, from 12% in 2004 to 37% in 2014 [16], CS rate is also sloping upward. While Bangladesh Demographic Health Survey reports give cross-section picture of this trend for some specific years (2004, 2007, 2011 and 2014), in our study this is shown using 1
a ten year follow-up surveillance data from Matlab [10]. This will allow us to rigorously analyze the trend from a population perspective in typical rural setting of Bangladesh - along with examining the different socio-demographic background of mothers going through the procedure. 2 MATERIALS AND METHODS 2.1 Study area Matlab Health and Demographic Surveillance System (HDSS) was established by icddr,b in 1966 [10]. It has has two distinct service provision zones - 1) icddr,b service area (SA) where icddr,b provides selected maternal and child health services -such as full-immunization, nutrition education and some other - parallel to government services since 1987 and 2) government SA where government provided health services are available. Along with this activity, in 1978, a hospital with four sub-centres was established in icddr,b SA to provide pregnant mother with basic essential obstetric care through a midwife and paramedic. These health care is also accessible to all mother of Matlab from Upazila Health Complex (UHC) and Union Health and Family Welfare Centre (UNFWC) provided by the government. Moreover, a District Hospital (DH) and a Maternal and Child Welfare Centre (MCWC) provide emergency obstetric care to mothers from both SA. These health facilities reside in Chandpur Town, forty minutes drive south of Matlab. From 2004 private sector contribution has also increased in Chandpur. Around 26 private hospital and clinics are now giving delivery care of varying degree [9] to the targeted population. 2.2 Data After the establishment of HDSS, it has been registering births, deaths, migrations, marriages, pregnancy outcomes including live births, stillbirths, spontaneous and induced abortions. Data on mothers ANC visits, place of delivery, mode of delivery, litter size and other selected informa- tion are collected from mothers. Community Health Research Workers (CHRWs) collects these data using structured questionnaire through bimonthly visits of each household. The HDSS collects household socio-economic data like education of all individuals, household assets, and other characteristics through periodic censuses. We accumulated data of all birth outcomes occurring in Matlab over 10 years of time period, 2005 to 2014. A mother may have several birth outcomes during this period. 2.3 Methodology First we explored the trend of facility delivery and CS across 2005 to 2014 with different demonimator. Then we focused on quantifying how different factors contribute to this rise through multiple logistic regression. We have controlled womens ANC pattern, place of delivery, education, husbands education, household wealth quintile, and experience of non-live birth in the regression model. For the analysis of CS delivery we have considered live births that took place in a facility where CS facility is available. It includes Upazila (sub-district) Health Complex, District Hospitals, and private clinics. Mothers with birth litter size more than one were also excluded from our analysis which accounts for less than 2% observations of our data. 3 RESULTS During 2005 to 2014, 57469 pregnancies took place in Matlab HDSS. Eighty four percent of the pregnancy outcomes resulted in live births (n=48,622) and are considered for this study. Overall, 50% of births were delivered in facilities, ranging from 31% in 2005 to 69% in 2014 2
Figure 1: Trend of facility delivery and CS of two SA in Matlab Number of delivery per 100 live births (Table 1). Caesarian section (CS) rate was expressed in two measures(a) CS rate per 100 live births and (b) CS rate per 100 facility deliveries which are shown in Table 1. In Matlab, there were 5.3 CSs per 100 deliveries in 2005. This rate increased over time and came close to the WHO recommended rate of needed CS (10-15%) of a country in 2009 and then it continued to a level of about 40% in 2014. Of those births that were delivered in facilities, there were 54 CSs per 100 facility deliveries in 2005 and sharply increased over time and reached an alarmingly high rate over 80% in 2014 (Table 1). A huge gap is noted for the CS rate between government facility and private facility. A mother is more likely to have CS if she is to deliver her baby in a private facility than in a government facility. The CS rate is increasing for both government and private facilities. A pictorial view of this rising trend is shown in Figure 1. The facility delivery rate has always been high in icddr,b SA during the period of the study. However, rate of CS is becoming prevalent as well with both SA crossing the WHO recommended rate for any region. More or less 4 out of 10 mothers are now going through this intensive surgery. 3
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