Stopping unnecessary C-sections

There might be many reasons behind opting for a Caesarean delivery – for instance positioning of the baby inside the womb, delayed pregnancy and many more. However, even without any such complications, doctors still suggest C-sections to couples. Without lending positivity to build a strong mindset among upcoming parents, doctors often try to persuade them either by subtly telling about negative aspects, such as the pain involved, or make up excuses of being unavailable during the delivery. 

According to WHO, caesarean sections should be within 10% to 15% of total deliveries in a country, this proportion has increased dramatically from 12% in 2010 to 31% in 2016, indicating a rise of C-sections even in cases where it could have been avoided. Caesarean section is becoming a common practice in private clinics accounting for an astounding 83% of the delivery, whereas in government clinics, it is 35% only. Over 80% of all births in private hospitals across the country are now C-sections. 

In order to discuss Caesarean Section as a life saving intervention and stopping unnecessary use of it, on May 10, public health experts, together with other key stakeholders organized a meeting titled ‘Stakeholders' Consultation on Prevention of Unnecessary Caesarean Section’ at the MIS Conference room in Mohakhali, DG Health office. They talked about a draft action on prevention of unnecessary C-Sections as well as the promotion of normal deliveries. Supported by Developing Midwives Project, James P Grant School of Public Health, BRAC University, the event is being considered as a step to rein in this “unacceptably” high rate of caesarean sections. 

The real scenario

During her first pregnancy, Sonia was happily counting days under the supervision of a renowned doctor of a prevalent hospital in the capital. As her delivery date came nearer, the couple went to the hospital after feeling a slight pain and contraction. Although Sonia’s pain began to subside, the doctor suggested her to stay back at the hospital in case the pain increases at night. However, the couple opted to go back home.

The pain came back next morning with elevated intensity. The patient’s mother re-admitted her to the hospital as she was dilated and her contractions increased. After conducting the initial check-ups and measuring delivery indicators, the doctor suggested opting for a C-section if the patient wanted to avoid the pain, although Sonia was determined enough to endure the pain and wait till the right moment. “I was mentally prepared to bear the pain and have a normal delivery. Despite the healthy condition of my baby and my strength, I gave in to his suggestion of an easy way out,” informed Sonia.

On the other hand, the patient’s mother, who is a gynaecologist said, “According to my daughter’s reports, the baby and mother were in great condition for a normal delivery. I just couldn’t understand why the doctor urged for a C-section.”

Tanjim Haque and his wife Naila, went through regular follow-ups with their gynaecologist. Three months before the delivery, they came to know about their child's condition through a certain test. The couple had to undergo a C-section due to remarks by the doctor that left them in a fragile mental condition. The doctor’s constant queries about whether the mother was prepared to endure the 6 to 8 hours-long delivery pain had made the couple nervous. When they also came to know that the doctor would also be  unavailable during the delivery date due to some personal reasons, they decided to go for a C-section. “Even though the doctor had suggested another assistant doctor as replacement, we didn’t have the courage to change our doctor in the last minute. If we were informed a few days earlier we could have looked for someone else to conduct the normal delivery instead,” said Tanjim, the father.

The risks involved

There are quite a few risks associated with this surgery. Mothers who undergo C-sections can face post-operative wound infections, complications from anaesthesia, injury to organs, blood clots and infertility and placental complications in future pregnancies. Moreover, the babies are at risk of accidental surgical cuts, need for intensive care, being delivered prematurely and breathing difficulties at birth and beyond.                      

Addressing the issue

A campaign addressing unnecessary c-sections began about a year ago, teaming up with like-minded organizations to raise awareness about the risks of unnecessary caesareans. It’s calling for better regulation of the industry, more checks and balances and greater funding for vital maternal health services.

“Addressing the situation was an extremely concerning issue,” Dr Ishtiaq Mannan, an expert in newborn and maternal health and Deputy Country Director, Save the Children, Bangladesh, said. “In spite of leaving the C-section upon the preference of the service-seeker, it is essential to provide them with the correct information in order to make the decision-making process easier,” he added. 

Dr Sham El Arifeen, Head, Child Health Unit, Icddrb said, “C-section must be an informed decision and shouldn’t be left to patients as their choice. Patients should know about the pros and cons of delivering their baby through c-section.” 

“One of Bangladesh’s biggest challenges is addressing a major shortage of accredited midwives, who not only support natural child birth when mothers are healthy to do so, but help reduce the burden faced by busy doctors,” said Selina Amin, Head, Midwifery Education Program, James P Grant School of Public Health, BRAC University.

“We have sent directives to all of our members throughout the country to ensure of partograph and to maintain monitoring of standard of procedures,” says Professor Laila Arjumand Banu, President, Obstetrical and Gynaecological Society of Bangladesh (OGSB).

A crucial step

A draft action called ‘Prevention of Unnecessary C-Section and Promotion of Normal Delivery in Bangladesh’ was developed in consultation with the key stakeholders. As the next step, the plan will be presented to the Government.

The draft action plan looks at seven areas where further attention is necessary. Prioritization of regulatory frameworks, strengthening of health system, awareness building on promotion of normal delivery, enhancement of skills among medical practitioners for normal delivery and facility readiness were some of the items on the draft action plan.