C-section: When exception becomes a norm

Caesarean sections or C-sections, a lifesaving procedure which is done in special cases during birth, have become a norm in Bangladesh, especially in private clinics, data show.

Of the 3.6 million babies born in Bangladesh in 2022, over 1.6 million or nearly 45 percent were born through C-sections, according to data from the National Institute of Population Research and Training, putting both the mothers and the children at unnecessary health risks.

In 2004, the rate was only around four percent, according to statistics from the Bangladesh Institute of Development Studies.

According to Save the Children, between 2016 and 2018, the number of C-sections rose by 51 percent, a rise that experts blamed on the lack of regulation and profit-mongering of private clinic owners.

In 2021, around 84 percent of total C-sections were performed in private hospitals and clinics, according to a report of Bangladesh Demographic and Health Survey in 2022.

To put things into perspective, the rate of C-section was 21.5 percent in neighbouring India as of 2021. Similarly, C-section rate ranges between 16 percent and 22 percent in Pakistan, Nepal and Myanmar.

The World Health Organisation (WHO) recommends that C-sections should not exceed 10 to 15 percent of total births in any nation.

However, C-section rate is high in many of the developed nations as well. For example, nearly 32 percent of all institutional deliveries in the US are done through a C-section, while this figure is 33 percent for Australia, 28 percent for Canada and 35 percent for China.

In Bangladesh, C-section deliveries cost $250, roughly equivalent to Tk21,121, on average, while a normal delivery costs only $60 or roughly Tk5,069, according to a 2019 report published by the International Centre for Diarrhoeal Disease Research, Bangladesh.

Such out-of-pocket expenditures are a huge burden on the poor, the study added.

WHY C-sections on the rise

Despite the risks and monetary burden, C-sections are booming uncontrollably in the country.

The influences of brokers and a class of doctors are encouraging people to have caesareans, according to the 2022 report of BIDS. The rate of Caesarean delivery was 52 percent in private medical facilities, while it was 10.6 percent in public medical facilities.

Other factors like maternal age, maternal and paternal education, working status of the mother, and wealth status among others contribute to rising C-sections, it added.

"Some unscrupulous doctors encourage patients for C-sections only to derive financial benefits," Dr Ishtiaq Mannan, neonatal and maternal health specialist and deputy country director of Save the Children in Bangladesh, told The Daily Star.

TESTCASE MANIKGANJ

This correspondent has recently visited different hospitals in town and villages in Manikganj and talked to dozens of people, including hospital owners, patients and doctors.

It was found that multiple syndicates of doctors, hospital owners, field-level health workers and brokers are active in the district to misguide expecting women to undergo C-sections.

Of the 28,606 children who were born in Manikganj in 2022, 49 percent were delivered through C-section, and 88 percent of the Caesarean deliveries were conducted in private hospitals, according to data from the district's civil surgeon's office, two hospitals, and district family planning office.

During his visits, our correspondent found that a host of clinics -- Monno Medical College Hospital, Doyel Clinic, Apollo Hospital, Doctors' Clinic, Islami Bank Community Hospital, United Hospital, Medilab Hospital, Zamzam Hospital and Surjer Hashi Clinic -- are each conducting over 100 C-sections monthly.

Most of these hospital owners declined to comment on the issue.

Some of them, wishing anonymity, said they have to spend huge sums to run their hospitals and C-section is a major income source for them.

"Caesarean patients are the main source of our income. If we don't get a sufficient number of C-section patients, we will be compelled to shut our hospitals," said a hospital owner wishing anonymity.

Meanwhile, Delwar Hossain, Chairman of City Hospital, said, "Several brokers and health workers are engaged in bringing C-section patients to our hospital. We pay Tk 1,500 to 2,000 to a health worker for each patient."

Swapna Mushtari Ima and Piya Akhter of Shibaloy upazila, Shilpi Akther of Harirampur upazila, and Lamia Akter of Sadar upazila underwent C-section at Chashir Hashi clinic in Manikganj in September last year.

All of them were brought to the clinic by its health workers. They had to pay Tk 12,000 for the procedures. Of which, Tk 2,000 was given to the brokers.

"There are 20 cabins in my clinic. I get a good number of C-section patients each month. I pay at least Tk 2,000 to health workers for bringing each C-section patient," said the clinic's owner Harun-Ar-Rashid.

Dr Moazzem Ali Khan, civil surgeon of Manikganj, said, "We always encourage normal delivery. However, we suggest a C-section if the patient faces health complexities. Also, many women themselves want to go through C-sections."

THE RISKS

"A C-section procedure not only requires a family to spend a huge amount of money but also poses different types of health hazards to mother and baby," said Dr Mannan of Save the Children.

"Immediately after a caesarean delivery, the newborn is kept away from the mother for some time. During this time, the baby cannot be breastfed, although it is very crucial for the newborn at that moment," he added.

"Unnecessary C-section can also cause mutilation, excessive bleeding, infection, complexity in having more babies for mothers and other health complexities," he said.

On October 12, 2023, the High Court directed the health ministry to take necessary measures so that all government and private hospitals follow proper guidelines in conducting C-sections.