Life saving or money wasting? What users think of caesarean sections in Bangladesh

Bangladesh has a high rate of maternal deaths, one of the world’s lowest rates of women using skilled birth attendants and a very low rate of caesarean births. To improve maternal health, a greater proportion of women need access to professional medical care, including caesarean delivery. However, in Bangladesh many women distrust caesarean surgery.

One of theMillennium Development Goals is to reduce by three-quarters the global maternalmortality ratio by 2015. In developing countries, a far higher number of womendie from pregnancy-related causes compared with developing countries. InBangladesh, where an estimated 320 to 440 maternal deaths occur per 100,000live births, only 2.4 percent of children are delivered by caesarean section,whereas the internationally identified need is between five and 15 percent.

Using a skilledbirth attendant during birth is one of the most recommended forms ofintervention to reduce maternal deaths in low-income countries. Yet in manyregions the proportion of women who do so is low as they face a number ofobstacles to seeking professional medical help in childbirth. A major reasonthat skilled birth attendance is encouraged is that it can lead to women beingreferred for professional medical help if they are experiencing difficultiesduring birth or pregnancy. In certain instances, a caesarean section may beneeded to save the mother and/or her baby. Many women, however, may not believea caesarean procedure to be useful.

A study by theLondon School of Hygiene and Tropical Medicine, UK, in collaboration with theBangladesh Ministry of Health and Family Welfare, explored the experiences andviews on caesarean sections of 30 women who recently gave birth in a healthfacility in a rural district of Bangladesh. The research found that:

• Women’s distrust of doctor’srecommendations for caesarean sections was due to the high cost of thissurgery and a belief that it was not always medically necessary.   
• In some cases, this distrust resultsin women avoiding or leaving medical facilities.
• Some cases showed that there weredifferences of opinion among medical staff about whether or not acaesarean was necessary.
• This was further complicated byfinancial incentives for doctors to carry out caesareans and for nursesand midwives to perform normal deliveries.

Bangladeshi womenunderstand the need for professional medical care but it appears that they havegood reason not to trust doctors’ advice to have a caesarean delivery. Theirfear of caesarean delivery is not simply based in ignorance but may reflectreal concerns about medical practice. The study recommends that:

• As there is a socialstigma attached to caesarean deliveries and the cost of these deliveriesis too high for many families, the medical profession should onlyrecommend caesareans when absolutely necessary and should not chargeunaffordable fees.
• Policymakers need toaddress problems in the health system that may lead to improper serviceprovision.
• They must not only regulate andprevent unnecessary procedures but also address the underlying factorsthat provide health staff with the incentive to push for these procedures.