Maternal mortality and Caesarean section (C-section) operation are closely linked. Physically, women are designed to give birth through normal delivery. Only in case of about 15% of all delivering women, severe complications may arise where C-section is necessary to save lives and to prevent morbidities. At the country level, there is an interesting interaction between these two.
Maternal Mortality Ratio (MMR) is hovering at 196/100,000 live births for the last one decade in Bangladesh, which is at a higher range and we rank 155 among countries. And, the C-section rate is more than 31% which is way above the World Health Organisation (WHO) recommended range of 10-15%. These two interlinked indicators being at higher range put Bangladesh in a very complex and challenging situation. Bangladesh’s journey towards 2030 milestones is in serious jeopardy. Let’s see where are we.
Countries can be categorised into four scenarios. Category 1 countries are Finland, Israel or the Netherlands where MMR is low and C-section rate is within or around the WHO range. This is the ideal situation that we want to achieve. Here every woman has proper access to C-section and C-sections are done strictly on medical requirement – no unnecessary surgery.
Category 2 countries, like the USA and Sri Lanka, have low MMR and high C-sections. These countries are like the previous category but, after meeting the need for all necessary C-sections, the quality control systems allow unnecessary C-section.
Countries in Sub-Saharan Africa fall under the third category where MMR is high but C-section is low. These countries have weaker health systems and access to C-section is still low, a lot of women who need, cannot access C-section.
Bangladesh, Nepal fall under the fourth category where MMR is high and C-section is also high. This means, we have a weaker health system which at one hand cannot ensure access to C-section for all women on the other, the quality control is weak enough to allow a lot of unnecessary C-sections. Are there ways out?
The Ministry of Health & Family Welfare (MOH&FW) needs to prioritise a two-pronged concerted approach. Out of over 3 million total births in a year, 53% (over 1.7 million) is still taking place at homes. It is estimated that of these women - some 160,000 women - who need C-section are deprived of getting so, left with a high probability of dying or ending up being severely morbid. The task is to shift these home deliveries to health facilities at the soonest possible.
Our primary care facilities need to be prepared to handle the caseload. There are about 4,000 Union Health and Family Welfare Centres built and meant to provide normal delivery care. By ensuring physical preparedness and by appropriate manning of these facilities with skilled providers we could achieve this objective in the short run – a low hanging fruit to avail indeed.
The second approach is to stop the skyrocketing of C-section rate and to make sure that these surgeries are done only when absolutely necessary. This huge undertaking is largely quality control and regulatory enforcement. For the last few decades, there is a positive trend of shifting from home delivery to facilities which now stands at 47%. Unfortunately, almost two-thirds of that is at private clinics which, in the country’s context remain practically unregulated. Unbelievably, 83% of deliveries at private clinics are done by C-section!
The entire achievement of increased care-seeking is substantially outweighed by unethical, profit-driven, sub-standard care. As a consequence, women are exposed to a myriad of physical risks leading to fatal conditions and chronic morbidities, families are burdened with a high cost of C-section paid out of pocket and the health system is overloaded with unnecessary surgical procedure. The immediate task for the MOH&FW is to expedite production of midwives, place and retain them at primary health care facilities, build the capacity of obstetricians and enforce stringent quality control on all facilities providing delivery care and C-section services.
Childbirth through normal delivery is the most beautiful moment and the most rewarding phenomena of the entire creation. Neither, failure to ensure surgery for those who develop complication nor, unnecessarily taking mothers to the surgical table for profit, is a demonstration of ‘respectful maternity care’ – the theme of this year’s Safe Motherhood Day.
It is a pity that mothers themselves are paying a very high price to that national disrespect – 6,000 maternal deaths every year; should not that be unacceptable?
Ishtiaq Mannan is the Deputy Country Director of Save the Children International in Bangladesh. He is an active health policy advocate and has been instrumental in shaping maternal-neonatal health strategies and systems.