Research Article, J Womens Health Issues Care Vol: 6 Issue: 3
Factors Influencing Caesarian Section: A Case of Bangladesh
*Corresponding Author : Tasneem Imam, MSc
Assistant Professor in Statistics, Department of Agricultural Economics & Social Sciences, Chittagong Veterinary and Animal Sciences University, Chittagong, Bangladesh
E-mail: [email protected]
Received: November 21, 2016 Accepted: May 02, 2017 Published: May 08, 2017
Citation: Imam T, Islam MA (2017) Factors Influencing Caesarian Section: A Case of Bangladesh. J Womens Health, Issues Care 6:3. doi: 10.4172/2325-9795.1000270
Question of the necessity of selecting caesarian section for child delivery has been given attention worldwide including Bangladesh, nevertheless the rates of this surgical procedure is growing at a faster rate. The present study sharply focuses on determining the factors influencing caesarian in Bangladesh on the basis of data of the last live birth obtained from BDHS 2014. It appears that decision of the doctors’ result in 71.5% of the caesarian cases and in more than 45% of the CS deliveries the decision was taken at the day of delivery. However, it is evident from a logistic regression analysis that the doctors’ decision alone does not attribute to the increased rate of CS. We observe positive association of CS with increasing age of respondents, urban residence, residing division with relatively modern facilities, higher educational status, delivery in private hospitals, antenatal care by a skilled person, wanted pregnancy at the time of last delivery, mother ever experienced a terminated pregnancy and larger size of child at last birth with the conduction of caesarian section. It is noteworthy that increasing number of home visits decrease CS rates whereas higher frequencies of antenatal visits increase CS deliveries. Besides, in 52.6% of the cases, women had a previous history of caesarian birth before her last live delivery. Therefore, it is extremely important now to have a closer look to all the determinants of CS births and come up with
some useful recommendations against the misuse and abuse of this process.
Keywords: Women; Health; Pregnancy; Determinants; Caesarian; Logistic Regression; BDHS data
Caesarian section, commonly known as C section or CS, a surgical procedure for child delivery is increasing worldwide in the recent years. About 18.5 million cesarean sections are conducted yearly worldwide . In 2008, among 137 countries, about 40% of the countries have CS rates less than 10%, about 10% countries have 10- 15% and around 50% have more than 15% CS rates which are alarming . In many developed countries it is chosen on choice of patient for avoiding the excessive pain of normal delivery. Also sometimes physicians prefer C section without any medical justification for economic gains and time management . High rates of caesarian deliveries not only create pressure on the surgical equipment and staffs in hospitals but also it has a high physical, mental and economic cost on women going through it. WHO indicated that a caesarean section rate greater than 10-15% is unjustified in any region of the world . Also, the International Federation of Obstetricians and gynecologist (FIGO)  in 2014 stated that CS deliveries can only be conducted to enhance the well-being of mothers and babies and improve outcomes. Though there is an indication of negative impact on mother and child health for high rates of C section conduction  and high risk of mothers’ future medical complications  nevertheless, in recent years the rate has increased to a pick in Germany, Australia, France, Italy, North America and the UK and Ireland [7,8]. Developing countries like Brazil, China and India saw the similar trend in conducting CS. In Brazil CS rates have risen from 30.3 percent in 1978-79 to 50.8 percent in 1994 . In fact, China and Brazil account almost for 50% of the total number of unnecessary caesarian deliveries [1,10]. In Chile CS frequencies have increased from 27.7 percent in 1987 to 37.2 percent in 1994 . CS rates rose dramatically in China especially in the eastern region of Beijing, Shanghai and Tianjin . In 2012, 31.7% of the children were delivered by CS in Germany. In India also proportion of c section deliveries increased and it was higher in urban areas compared to rural ones except in Delhi  and also in Egypt specially in the public sectors .
Over the last century the conduction of caesarean delivery has become more common and is also performed on request (CDMRcaesarean delivery on maternal request) in the absence of any obstetrical or medical reasons [15,16]. In Marine, USA, 84.5% respondents were found to perform CS by self-chosen option and mothers aged under 35 years were more likely to go for a cesarean delivery themselves . Surgical deliveries continue to occur at a high rate in the US despite evidence that they increase the risk for morbidity and mortality among women and their children . 33% of women had c section deliveries in the US in 2011.
The movement of CDMR was started in Brazil and its frequency is about 4-18% . The most known reason of CS was previous caesarean section . Women tend to have caesarean section birth if the previous birth was a caesarean child, the child is breech or the mother suffered APH . Among socio-economic factors, education, increased age, wealth index, living area, and receiving institutional antenatal care are at higher risk of having C section. Fever/vaginal discharge around delivery, birth weight, mother’s age, education level of mother, birth order, residence, place of delivery and antenatal visits were important determinants of caesarean section . Common determinants of CS in Egypt are younger age, first pregnancy, receiving antenatal care during pregnancy, ever experiencing a terminated pregnancy and residing in urban area . In northern area of Bangladesh, previous c-section, pregnancyinduced swollen of leg, prolonged labour, mothers’ education level, maternal age more than 25 years, low birth order, length of baby more than 45 cm and insufficiency of balanced diet contributed significantly for caesarean delivery . Worldwide, a very few studies have been carried out to see the determinants of C section deliveries. In the present study, an attempt has been taken to find out the association of some socioeconomic, demographic and clinical variables with the conduction of caesarian deliveries.
The present study incorporates data from the Bangladesh Demographic and Health Survey (BDHS) 2014, conducted by National Institute of Population Research and Training (NIPORT), Ministry of Health and Family Welfare, Bangladesh. In the data set a nationally representative sample of 17863 ever-married women aged10–49 years were selected using a multistage probability proportional-tosize sample design. The survey employs both household as well as individual characteristics of the women. This study is based on the different factors of C section and therefore information on C-section, antenatal care, home care and delivery care were also collected for all live births by caesarian (n=4626) from the survey data set conducted from June to November 2014.
This study addresses the dependent variable as whether the last live birth was by caesarian or not and coded as binary variables (1=if it was a caesarian case, 0=not a caesarian baby). It is noteworthy that data are taken only for the last live birth.
A few selected demographic characteristics of women including other factors of caesarian are taken as the explanatory variables constituting age of respondents (≤ 20 years, 21-29 years, ≥30 years) residence (urban, rural), division (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, Sylhet, level of education (no education, incomplete primary, complete primary, incomplete secondary, complete secondary or higher), respondents’ age at last birth (<20 years, 20-34 years, 35 and more), births in last three years (1, >1), ever had a terminated pregnancy (no, yes), wanted pregnancy at the time of last delivery (then, later, no more), antenatal care provider (skilled, unskilled), antenatal visits during last pregnancy (don’t know/No or one, 2, 3, 4 or more), no of home visits (don’t know or < 4, 4 or more), place of delivery (public sectors, others), size of child at last birth (larger than average, average, smaller than average). In the current study these independent factors are addressed to find out their association with c section delivery.
To investigate the objective of the study first descriptive statistics (frequency and percentage) were used to assess the relationship between the dependent and the set of explanatory variables. To examine the significance of bivariate relationships chi-square test was used. It is noteworthy that the bivariate analysis between an outcome and an explanatory variable depicts the association in isolation from other independent variables and does not take into account the order of the categories of any variables either. On the contrary a bivariate logistic regression model considers the effect of other variables while dealing with the association with the dependent variable and an independent variable . SPSS 16 was used for the analysis.
Differential patterns of factors associated with c section delivery
C section is becoming common in recent times. A total of 4626 live births were delivered because of c section. The percentage of C-section births is sometimes considered to be a proxy indicator of women’s access to skilled care for complicated deliveries . There are many reasons behind C section in Bangladesh shown in Table 1.
|Reasons||Weighted frequency||Percentage (%)|
|Not wanting to go through labor pain||46||4.1|
|Failure to progress in labor||112||10.1|
|Less pressure on baby’s brain||49||4.4|
|Other complications during delivery||349||31.6|
Table 1: Frequency distribution of the reasons of caesarian live births.
Age of the respondents is an important factor behind caesarian delivery in Bangladesh. About 15% of the live births belonged to the mothers aged between 21 to 29 years followed by 233 births in the age group 30 years or more. There is significant association between age and number of live births due to caesarian (p<0.05). Of the respondents, 13.8% residing in the rural areas went for caesarian while 10.4% urban women gave birth through this process (p<0.01). There appears to be a highly significant association between division and number of live births by c section (p<0.001). A highly significant association (p<0.01) is also seen between education and c section as more educated women are more likely to go for caesarian than less educated women.
Interestingly, the highest percentage (16.2%) of c section deliveries happened in the age group from 20-34 years. It is to be noted that most of the last deliveries were in this age group. There is a significant relationship between births in last three years and number of c section deliveries. Women gave one birth in the last three years are more likely to opt for c section than the women gave birth to more than one birth. Those who never had a terminated pregnancy did allowed caesarian than those who ever had, though no significant association is found between numbers of c section births and ever had a terminated pregnancy. Wanted pregnancy at the time of last pregnancy appears to be one of the significant independent variables behind c section deliveries (p<0.01).19.3% of the caesarian cases were of the mothers who wanted pregnancy then. The proportion of caesarian deliveries increases positively with the number of antenatal visits taken at the time of pregnancy. Also antenatal care by a skilled person leads to c section. Both these variables have a highly significant relationship with number of live births by c section (p<0.01). Women who take 4 or more antenatal visits during pregnancy are likely to have caesarian births as well as taken care by a skilled person also leads to c section as per the data supported. Number of home deliveries also played a significant role in this study. There is significant association between place of delivery and number of pregnancies (p<0.01). Place of delivery certainly is an important factor of c section deliveries and data on these presented in Table 1 supported it. 19.2% c section deliveries take place in different sectors including respondents home, private clinics, NGO supported clinics and others while only 5.1% of the women delivered their baby by caesarian in public hospitals. Weight of child and number of live births by c section is significantly associated. Surprisingly only 4% child whose weight is larger than average or very large is delivered through c section while 15.9% average weighted child were caesarian case. Association of the factors with CS conduction is presented in Table 2.
|Factors||C Section||χ2(p value)|
|Age (years) of Respondents (n=4628)||Yes
|≤ 20||207 (4.5%)||764 (16.5%)||5.939 (0.051)|
|21-29||683 (14.8%)||2060 (44.5%)|
|≥30||233 (5.0%)||681 (14.7%)|
|Urban||483 (10.4%)||726(15.7%)||219.5 (0.000)|
|Rural||639 (13.8%)||2778 (60.1%)|
|Barisal||49 (1.1%)||219 (4.7%||123.2 (0.000)|
|Chittagong||197 (4.3%)||814 (17.6%)|
|Dhaka||507 (11.0%)||1127 (24.4%)|
|Khulna||128 (2.8%)||244 (5.3%)|
|Rajshahi||109 (2.4%)||356 (7.7%)|
|Rangpur||81 (1.8%)||369 (8.0%)|
|Sylhet||52 (1.1%)||376 (8.1%)|
|Educational Attainment (n=4625)|
|No education||49 (1.1%)||605 (13.1%)||566.7 (0.000)|
|Incomplete primary||81 (1.8%)||667 (14.4%)|
|Complete primary||80 (1.7%)||464 (10.0%)|
|Incomplete secondary||491 (10.6%)||1401 (30.3%))|
|Complete secondary or higher||420 (9.1%)||367 (7.9%)|
|Respondents’ age at last birth
|<20 years||340 (7.3%)||1151 (24.9%)|
|20-34 years||748 (16.2%)||2207 (47.7%)||6.332 (0.042)|
|35 and more||34 (0.7%||146 (3.2%)|
|Births in last three years (n=4627)|
|1||1077 (23.3%)||3277 (70.9%)||9.524 (0.002)|
|>1||45 (1.0%)||228 (4.9%)|
|Ever had a terminated pregnancy (n=4626)|
|No||945 (20.4%)||3022 (65.3%)||2.838 (0.092)|
|Yes||177 (3.8%)||482 (10.4%)|
|Wanted Pregnancy (n=4626)|
|Then||892 (19.3%)||2534 (54.8%)||28.561 (0.000)|
|Later||152 (3.3%)||542 (11.7%)|
|No more||79 (1.7%)||427 (9.2%)|
|Antenatal visits during last pregnancy (n=4626)|
|Don’t know/No or one||156 (3.4%)||1667 (36.0%)||484.2 (0.000)|
|2||183 (4.0%)||565 (12.2%)|
|3||191 (4.1%)||422 (9.1%)|
|4 or more||592 (12.8%)||850 (18.4%)|
|Place of Delivery (n=4625)|
|Public sector||234 (5.1%)||370 (8.0%)||79.586 (0.000)|
|Others||887 (19.2%)||3134 (67.8%)|
|Antenatal Care (n=4627)|
|Skilled||1033 (22.3%)||2906 (62.8%)||55.05 (0.000)|
|Unskilled||90 (1.9%)||598 (12.9%)|
|Size of Child at last birth (n=4627)|
|Larger than average||183 (4.0%)||414 (8.9%)||16.391 (0.000)|
|Average||737 (15.9%)||2369 (51.2%)|
|Smaller than average||203 (4.4%)||721 (15.6%)|
|No of home visits (n=4623)|
|Don’t know or < 4||976 (21.1%)||2962 (64.1%)||3.823 (0.051)|
|4 or more||146 (3.2%)||539 (11.7%)|
Table 2: Background characteristics by number of births through c section.
From the bivariate analysis of c section deliveries by several background characteristics, a significant association between some of these selected factors and the total caesarian births were observed. However, a bivariate relation between two variables does not necessarily imply a significant causal relationship between them. Multivariate analysis explores the effect of different independent variables on a dependent variable taking into account the effect of other explanatory variables.
Table 3 employs a binary logistic regression Model  for number of births by caesarian delivery. All the variables in the bivariate analysis were included in the model.
|Delivery by C Section|
|Characteristics||Estimate||SE||OR||95 % CI|
|25 – 39||-0.015||0.149||0.985||0.736-1.318|
|Secondary complete or higher||2.005||0.187||7.423||5.142-10.718|
|Births in last three years|
|Ever had a terminated pregnancy|
|Place of Delivery|
|No of home visits|
|Don’t know or < 4|
|4 or more||-0.327||0.116||0.721||0.574-.906|
|No of Antenatal visits during last pregnancy|
|4 & more||1.513||0.116||4.541||3.615-5.703|
|Size of child at birth|
|Very large/Larger than average|
|Very small/Smaller than average||-0.366||0.140||0.693||0.527-0.912|
|Respondents’ age at last birth|
|35 and more||0.354||0.282||1.425||0.821-2.474|
Table 3: Estimates of the parameters of the logistic regression model for caesarian section deliveries.
It should be noted here that the number of births through c section is very small in the present study. That is why; a definite conclusion cannot be recommended based on these findings. Nevertheless, the results provide a good framework for conducting and deriving any future studies in this field with a larger sample.
Women in the age group of 25 to 39 years are less likely to go for caesarian compared to women aged less than 25 whereas women more than 39 years are more likely to have caesarian children. The respective odds ratios for both the categories are 0.985 and 1.245. Women residing in Chittagong (OR=1.080), Dhaka (OR=2.233), Khulna (OR=2.240), Rajshahi (OR=1.577) tend to deliver their children by c section as compared to Barishal while women from Rangpur (OR=.933) and Sylhet (OR=.879) are less likely to go for this option. Rural women were less likely (OR=0.527) to have a caesarian birth compared to urban women. The results from the logistic regression indicate the positive relationship between the level of education and number of births by c section. The ORs for primary incomplete, primary complete, secondary incomplete, secondary complete or higher are 1.414, 1.919, 2.800 and 7.423 respectively with reference to no education. Women who had more than one birth in the last three years preceding the survey are less likely to have a caesarian birth(OR=.849) compared to those who had only one birth in the last three years. On the contrary, those who ever experienced a terminated pregnancy are more likely to choose caesarian (OR=1.209) than those who never experienced. Wanted pregnancy is one of the significant variables in this study. Women wanting pregnancy later are positively associated with c section deliveries and wanting no more pregnancy is negatively associated. The respective odds ratios are 1.066 and 0.759.
Place of delivery emerged as a significant factor of c section deliveries. Places other than the private sectors are more likely (OR=1.412) that caesarian deliveries take place. Number of antenatal visits is positively associated with c section birth. Women who take more than one antenatal care tend to choose caesarian than women taking no or one antenatal visits. The respective odds ratios for two visits, three visits, four and more visits are 2.716, 3.498 and 4.541. On the other hand, women having more than four home visits during pregnancy are less likely to have a caesarian birth than women having less than one visit or they don’t remember. Also antenatal care with a skilled person is 2.277 times more likely to go for a c section birth than it is with an unskilled person. The results from the logistic regression model indicate that women who gave birth their last child at the age of 20 to 34 years or more than 35 years are more likely to choose c section option than women who had their last child not exceeding 20 years. Also, mothers whose children are very small/smaller than average (OR=.635) and average (OR=.693) are less likely to go for c section compared to mothers with larger or very large child.
The use of CS has increased worldwide in an alarming rate. 18.6% of all births from 150 countries of the world were conducted by caesarian section where Latin America and Caribbean region saw the highest CS rates constituting 40.5% CS deliveries followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%) and the highest and lowest average annual rate of increase was found in Asia and Northern America with 6.4% and 1.6%, of CS births respectively .
In Asia, China has the highest CS rate (46.2%)  and many studies were undertaken to see the factors influencing CS. Increasing age, higher level of education, over diagnosis for maternal risks, insurance of health coverage found to have a positive effect in the upward trend of CS rates in China [29,30]. Though many studies revealed mothers’ interest opting for CS nevertheless 34.9% of women undergoing caesarean section did not have any indications listed in the clinical guidelines nor based on maternal request .
In a developing country like Bangladesh safe delivery has always been a challenge. Safety of both the mother and the child should be the prime priority that can lead to the conduction of CS. But there are many other factors that influence this surgical process. Bangladesh saw a rise in c section conduction rates from 4% in 2001-4 to 23% in 2011-14 . In 45.2% of the caesarian cases decision was made on the day of delivery and in case of 71.5% deliveries the decision was made by the doctors . 52.6% mothers were told about the reasons for CS whereas 47.4% were not informed at all . Influence of doctors in the conduction process of CS without any proper justification is one of the key factors behind CS births worldwide. Chinese doctors play an important role in the decision of using CS . Similar findings were found in Bangladesh, India and Nepal specially in the private hospitals and in Western Australia [32,33].
Increased age, urban location and residing in division with more modern facilities, one birth in last three years contribute to high rates of CS in this study. In similar, women of higher socio-economic background are more likely to go for a CS than women belonged to a lower background in Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam .
Education plays a positive association with higher CS conduction. It has been observed that higher educational status positively contributes to CS deliveries. In Bangladesh and urban India, more educated mothers demand for a caesarian baby as they generally prefer to go to private hospitals with more surgical facilities for financial stability .
Studies revealed that women ever experienced a terminated pregnancy more often opt for CS than women never had a termination in pregnancy [14,35,36]. Similar findings are obtained from the present study.
The present study depicts that delivery in the private hospitals increase the frequency of CS births. Similar results were found in a study of South Asia where 73% of caesarian births in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India were delivered in private sectors .
Antenatal care (ANC) is an important determinant of a safe motherhood. A pregnant women needs to visit health facilities/ providers at certain intervals for antenatal care checkup . This study points out that antenatal visits by a skilled person upwards the rates of CS births in the study. This finding matches the result of another study where it was found that women who had better access to antenatal services are the most likely to undergo a caesarean section .
On the contrary number of home visits contributed negatively to the number of births by CS. The higher the visits were made the lower the frequencies of CS were found.
This study reveals an important association between CS rates and size of child. Women whose children were larger than average or large child in size tend to go for CS compared with mothers with average or small children. In USA, women five times more likely asked for caesarian deliveries when they were informed about the large newborns than women not knowing about the size of the child as it creates a pressure on mother of higher labor pain during delivery .
Though not significant but respondents’ age at last birth contributed positively to higher CS delivery rates. Reciprocal findings were observed in other studies [39,40]. Deliveries through surgery were higher for mothers who wanted pregnancy at the time of last birth but lower for women wanting no more pregnancy.
In the present study besides the clinical determinants, some socio economic and demographic factors also emerged as important factors for performing caesarian deliveries. Some recommendations can be made-
Doctors or health professionals should be accountable for the conduction of caesarian deliveries.
Necessary counseling against the excessive use of this procedure need to be taken to for the mothers by health care organizations.
Women can exchange their reproductive health behaviour with family and closed ones to get the strength opting for a normal delivery.
We are grateful to UGC, Bangladesh and World Bank for supporting the HEQEP Sub-project 3293 and to the authority of the National Institute of Population Research and Training, Ministry of Health and Family Welfare, Bangladesh for providing the data.
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