Strengths and limitations of this study

Primary data were used to study on obstetric burden and maternal outcomes of caesarean delivery in Bangladesh.

This study precisely represents the scenario of the obstetric burden of caesarean delivery.

Impact of obstetric and pregnancy-related factors on caesarean delivery were examined using multiple logistic regression analysis.

The study was susceptible to recall bias.

Introduction

Proper exploitation of caesarean section (CS) is life-recovering surgery, which can play a vital role in lessening maternal and child deaths during delivery when the mother’s and/or child’s lives are in danger.1 2 CS rates have risen dramatically worldwide, from 12.1% in 2000 to 21.1% in 2015.3 According to the most recent Betran et al, they analysed data available from 154 countries covering 94.5% of the world’s live births in 2018, 21.1% of women worldwide gave birth by CS, with averages ranging from 5% in sub-Saharan Africa to 42.8% in Latin America. Eastern Asia and Southern Asia experienced the greatest increases (44.9 and 19.0% age point increase, respectively). They also predicted that worldwide CS rates would reach 28.8% in 2030.4

CSs have increased 9-fold in Bangladesh from 3.5% in 2004 to 33% in 2018.5

Considering only intuitional births, Verma et al, in 2020 reported that the overall CS rate in Bangladesh was nearly 59%, with urban and rural settings, respectively, at 63% and 55%.6

Save the Children reported in 2018 that Bangladesh paid approximately 483 million dollars for unnecessary CSs.7 However, the vital reason for women choosing CS delivery is a deficiency of knowledge on caesarean delivery and misrepresentation of vaginal childbirth.8 The WHO recently reconsidered accessible evidence that CSs should ideally be undertaken only when it is medically inevitable.9 Several obstetric and sociodemographic factors would be allied with the increased CS delivery in Bangladesh. Mother education, wealth index, mother’s age,10 prolonged labour, low birth order, pregnancy-induced swollen leg and length of baby more than 45 cm are mentionable.11 Other countries analysed depicted that foetal distress, malpresentation, malposition, antepartum haemorrhage,12 short sleep duration13 and migraine during pregnancy were the most important risk factors associated with CS.14

Medically unnecessary CS can increase short-term and long-term health risks for mothers. The short-term adverse include infection, haemorrhage, visceral injury and venous thromboembolism.15 Fistula, placenta previa, placenta accreta and placental abruption were the common long-term complications found among the mothers having CS. Moreover, pregnancy after CS delivery has a higher likelihood of miscarriage and stillbirths.16 17

If we are to achieve the Sustainable Development Goals (SDGs), we must prioritise the CS issue globally to achieve the SDGs. However, to our knowledge, research has yet to be conducted in Bangladesh to investigate the obstetric risk factors and maternal outcomes of caesarean delivery.

Therefore, the aim of this study was to find out obstetric and pregnancy-related factors associated with caesarean delivery in Rajshahi district, Bangladesh.

MethodsStudy design, setting and subject

The present study was cross-sectional and used quantitative methods. The target area for the study was Rajshahi district. It is in the northwestern part of Bangladesh. The district’s total area is 2425.37 square km, and the population is 2 915 013, including 37.56% urban and 62.44% rural population (BBS, 2022, adjusted on 23 July 2022). All preschool children and their mothers living together at the catchments area of community clinic (CC) in this district were the main respondents in this study. The data were extracted from the field survey conducted from February to June 2017 in the catchment area of CC in Rajshahi district.

Patient and public involvement

Patients and/or the public were involved in ths study.

Participants

The statistical analysis covered a total of 540 mothers. This study exclusively included all preschool children and their mothers living together at the catchments area of CC in Rajshahi district, Bangladesh.

Sample size determination

The following formula was used for collecting sample size for the study:

where n=sample size, n=household size (in this study n=271 302) and d=marginal error (in this study, dis considered as equal to 0.05). 95% CI has been considered in this study. This formula provided that 399 respondents were required for this study. However, 540 respondents were considered for this study, and their information was collected.

Sample selection procedure

Multistage sampling technique was utilised to select the samples from the population. In the Rajshahi district, 233 CCs provide services in nine Upazilas (BBS, District Statistics, 2011); all the CCs are located in the rural areas of the district and provide same facilities to the people living in the catchment areas of the clinics. In the first sampling stage, two CCs were randomly selected from each Upazila, considering all CCS. In the second stage, two villages were chosen randomly from the catchment areas of CCs. Finally, all households with under five children from the selected villages were identified by their identification number (holding number or listing), and 15 households were randomly selected from each village, totalling 540 respondents. The mother of the household had been interviewed from each selected household. Expert community health workers interviewed all respondents, and the required information was collected from the union parishad office.

Assessment of sleep status, micronutrients and food consumption during pregnancy sleep status

The survey involved one question about self-reported hours of sleep per day among pregnant women. The questions to collect sleep status were ‘How many hours did you sleep every day during pregnancy, including both day and night?’ The question was a closed question in which interviewees reported the number of hours of their sleep. Based on a previous study, the sleep duration was categorised into three categories: <7 hours/day, 7≤–<9 hours/day and ≥9 hours/day.18 Finally, we followed prior studies and categorised sleep hours into two groups: <7 hours/day (insufficient sleep) and 7–9 hours/day (sufficient sleep).19 20

Micronutrients in pregnancy

Micronutrients were assessed through a self-administered intake supplementation frequency questionnaire (SFQ). Participants reported usual intake supplementation retrospectively during pregnancy. Qualitative information on self-reported nutrient supplementation; specifically zinc supplements; calcium supplements; iron–folate supplements; supplements of vegetables rich in vitamins A, B and C and iodine salt during pregnancy was assessed with the baseline questionnaire. Each question was assigned a value of 0 and 1. The micronutrient frequency of each supplementation was calculated by summing the frequency of each item. Out of the five components, the micronutrients were classified into two groups: ≥4 scored positively defined as adequate supplements and ≤three scored positively defined as inadequate supplements.21 22 Some of the questions used in the study are listed below as examples. Did you eat vegetables rich in vitamins A, B and C (carrots, green leafy vegetables, etc) during pregnancy? (include, yes=1 and no=0). Did you take calcium supplementation during pregnancy? (include yes=1 and no=0).

Food consumption

Eating habits were assessed through a self-administered food frequency questionnaire (FFQ). Participants reported usual food consumption retrospectively during pregnancy. Participants were asked to eat extra food (three times meals and two times snacks) and eat different types of fresh vegetables a day during pregnancy. Each question was assigned a value of 0 and 1. Food consumption was classified into two food groups: adequate food consumption is defined as women who eat three times a meal, 2 times snacks and different types of vegetables and inadequate food consumption is defined as women who eat three times a meal and two times snacks in a day in pregnancy. Some of the questions used in the study are listed below as examples. Did you take extra food (three times meals and two times snacks daily) during pregnancy? (include yes=1 and no=0).

Outcome variable

The outcome variable in the present study was dichotomous: caesarean delivery, (1) yes (caesarean delivery) or (2) no (normal delivery). Caesarean delivery is a surgical procedure in which a fetus is delivered through an incision in the mother’s abdomen and uterus. This variable was measured by a question to participants: what type of delivery was it?

Exposure variables

Most of these exposure variables had been identified from the preceding studies.11–14 16 The explanatory variables are described below, with their codes provided in parentheses.

Pregnancy-related variables of mother

Pregnancy variables include sleep duration (insufficient sleep, sufficient sleep), high Fever problem (no, yes), oedema problem (no, yes), micronutrients in pregnancy (inadequate, adequate), seizures problem (no, yes), severe headache with blurred vision problem (no, yes), vaginal bleeding (no, yes), food consumption (inadequate, adequate), iron–folic supplementary (no, yes), visit of antenatal care (no, yes) and prolonged labour (>12 hours) (no, yes).

Maternal postpartum variables

Postpartum variables include retained Placenta (no, yes), postpartum haemorrhage (no, yes), postpartum abdominal pain (no, yes), postpartum urinary incontinence (no, yes), postpartum preeclampsia (no, yes), obstetric fistula or postpartum anaemia (no, yes) and number of postnatal care visit (≤3 times, ≥4 times).

Statistical analysis

Descriptive statistics were used to enunciate the overall situations of the study variables in this study. To find out the association between caesarean delivery among mothers and their obstetrics, pregnancy-related factors and their outcomes were analysed by χ2 distribution. Binary logistic regression was used to find the overall effects of the maternal obstetric, pregnancy-related factors and their outcome on caesarean delivery among mothers. The SE was used to detect the multicollinearity problem among exposure factors,23 and there is no multicollinearity problem in this analysis. Statistical significance was accepted at p<0.05. The whole analysis of this study is completed with the statistical software STATA, V.STATA_14.2, to reach the objectives.

ResultsBasic characteristics

We found that the prevalence of caesarean deliveries in Rajshahi district was around 34.4%. The highest percentage of women undergoing CS delivery was observed among those with inadequate food consumption (66.7%), followed by those with adequate food consumption. Furthermore, it was noted that women who had insufficient micronutrient supplements during pregnancy experienced a higher rate of CS delivery (30.6%) compared with those with adequate supplements. Additionally, women facing severe headaches with blurred vision had a higher occurrence of CS delivery (21.5%) than those without such problems (table 1). Table 1 demonstrated a significant association (p=0.001) between CS deliveries and maternal factors such as sleep duration, micronutrient intake during pregnancy, food consumption and the likelihood of having a CS delivery in the study area. Furthermore, receiving ANC services was identified as a significant (p=0.040) predictor of CS deliveries for mothers. The percentage of CS deliveries was notably high (p=0.045) for mothers experiencing severe headaches with blurred vision during their pregnancy period (21.5%). Additionally, mothers with oedema problems during pregnancy were significantly (p=0.011) associated with an increased chance of having a CS delivery compared with those without oedema problems during pregnancy (table 1).

Table 1

Association between caesarean delivery and maternal obstetric and pregnancy-related variables

It was noted that the highest number (40.86%) of caesarean-delivered mothers was in 25–29 years, followed by 20–24 years (27.96%), 30–34 years (17.74%), <20 years (8.06%) and ≥35 years (5.38%) (figure 1). In this study, various reasons were identified as indications for CS delivery. The most common indication was inadequate supplements of micronutrients (30.6%), followed by severe headaches with blurred vision (21.5%), oedema problems (11.8%), no antenatal care visits (11.3%) and insufficient sleep (9.1%) (online supplemental figure 1). Out of the total 186 women who had CS deliveries, 154 (82.8%) delivered in private clinics and 32 (17.2%) delivered in government hospitals (online supplemental figure 2).

Figure 1

Prevalence of caesarean delivery categorised by maternal age in study area.

Table 2 highlighted the key risk factors influencing CS deliveries in Rajshahi district, Bangladesh. Factors such as severe headache with blurred vision, oedema problems, excessive food intake and sleep duration were significantly linked to CS deliveries for mothers. The study revealed that mothers experiencing severe headaches with blurred vision were more likely to undergo CS delivery (AOR=1.72, 95% CI: 1.06–2.81, p=0.028). This study found that mothers who underwent CS delivery were more likely to have insufficient micronutrient supplements during pregnancy compared with those who had adequate supplementation (AOR=1.78, 95% CI: 1.15–2.75, p=0.009). Mothers with inadequate food consumption during pregnancy had a 1.6 times higher chance of having a CS delivery than those with sufficient food intake (AOR=1.65, 95% CI: 1.04–2.62, p=0.032). Mothers having oedema problems during pregnancy had a 2.36 times higher chance of having a CS delivery than those did not experiencing oedema (AOR=2.36, 95% CI: 1.19–4.69, p=0.014). The likelihood of CS delivery was 2.6 times higher among mothers with insufficient sleep compared with those with sufficient sleep (AOR=2.64, 95% CI: 1.44–4.83, p=0.002).

Table 2

Multiple logistic regression analysis of influential obstetric and pregnancy risk factors for caesarean delivery in Rajshahi district

Experiencing health impacts due to CS delivery was significantly related to obstetric fistula, postpartum anaemia or blood pressure (p=0.043). There was a 6.5% chance of having health impacts after CS delivery for mothers facing issues such as obstetric fistula, postpartum anaemia or blood pressure after giving birth (table 3).

Table 3

Association between postpartum factors and caesarean delivery among mothers

The significant risk factors were obstetric fistula or postpartum anaemia. Mothers who did not experience obstetric fistula or postpartum anaemia had a 0.42 times higher chance of avoiding health issues after CS delivery (AOR=0.42, 95% CI: 0.18–0.99, p=0.049) (table 4).

Table 4

Multiple logistic regression analysis of influential postpartum outcomes of caesarean delivery among mothers in Rajshahi district

The model’s overall accuracy in predicting subjects with CS delivery (with a predicted probability of 0.5 or greater) was 69.3%. The sensitivity, calculated as 39/186, was 21.0%, and the specificity, calculated as 335/354, was 94.6%. The area under the receiver operating characteristic curve was 0.68, indicating that the model performed reasonably well in accurately classifying observations (online supplemental figure 3).

Discussion

In this study, 34.4% of deliveries were done through CS, which is more than what national surveys reported. The Bangladesh Demographic and Health Survey (BDHS) revealed an increase from 23% in 2014 to 33% in 2017.5 Another study mentioned that 36.9% of urban Bangladeshi mothers had CSs in 2021.24 Back in 1985, a WHO stated that CS rates higher than 10–15% are not justified,25 meaning it should only be done when medically necessary.9

Short sleep duration has been linked to higher levels of random blood glucose in pregnant women.26 This study found that pregnant women with insufficient sleep are more likely to have a CS. Women who have insufficient sleep during their pregnancy period may experience longer labour, more pain and discomfort during labour, slowed reflexes, higher rates of preterm labour and caesarean section.27 Several studies also supported that women with short sleep during pregnancy have a higher chance of having a CS.13 28 Getting enough sleep is a modifiable risk factor that can improve the mother’s health and pregnancy outcome.26 Swelling in the lower limbs tends to increase as the uterus enlarges during pregnancy.29 This research indicated that experiencing oedema during pregnancy is a risk factor associated with CS deliveries. One of the Bangladeshi studies found that leg swelling during pregnancy is independently significant for CS deliveries.11 During pregnancy, the pressure from the growing uterus can cause oedema in the ankles and feet; the growing uterus may lead to CS.30 Engaging in safe and enjoyable exercises is a helpful addition to reducing pregnancy-related swelling.31

Ensuring sufficient intake of micronutrients during pregnancy is beneficial, supporting foetal development and overall health.32 Deficiencies in essential micronutrients can significantly impact pregnancy outcomes and newborn health.33 This study found a strong association between insufficient micronutrient supplements during pregnancy and an increased likelihood of CS deliveries. Lack of key micronutrients can lead to complications such as anaemia and preeclampsia, both of which are linked to CS deliveries.34–36 Migraine is a common cause of headaches during pregnancy,37 affecting a significant number of women in the gestational age group.38 This study highlighted that experiencing severe headaches with blurred vision is a significant risk factor for CS deliveries. Migraines, characterised by severe headaches and blurred vision, are associated with an increased risk of CS deliveries.14 39 40 Behavioural interventions and lifestyle adjustments form the foundation for managing migraines during pregnancy, while neuromodulation and neurostimulation devices offer additional options.41

Mothers who have had insufficient food intake during pregnancy face a higher risk of CS delivery. A maternal diet lacking in regular vegetable consumption during pregnancy may be connected to preterm birth.42 Numerous studies have demonstrated a positive link between preterm birth and the likelihood of CS delivery.43 44

The study’s findings indicated that maternal complications such as obstetric fistula or postpartum anaemia were reported after CS deliveries. This aligned with a study conducted among women in Kigali, Rwanda.45 CSs have been associated with an increased risk of postpartum anaemia.46 47 Obstetric fistula, a preventable condition, can be avoided by delaying the age of first pregnancy, discontinuing harmful traditional practices and ensuring timely access to obstetric care. Efforts to prevent and manage obstetric fistula contribute to achieving SDG 3, which focuses on improving maternal health.48

Limitation of the study

There were some limitations of the study. First, this study focused on live births at hospitals/clinics and homes in Rajshahi district, Bangladesh. Since this study relied on primary data analysis, it was confined by the constraints inherent in that data. The self-reported information of the participants might be biased, however, to reduce bias, we engaged health workers from the respective CC to collect information from mothers living in the CC’s catchment area. Some of these workers were familiar to the mothers, as they had provided antenatal care, making the mothers more comfortable and accurate in sharing information. Moreover, some information were recorded in medical report of some mothers, the data collectors verified the self-reported information with medical records. Second, the literature mentioned various impact factors, not all of which were considered in this analysis. Third, the cause-and-effect relationship could not be established because of the cross-sectional nature of the study. Lastly, this study did not review all medical records of CS deliveries to identify the specific reasons noted by doctors.

Conclusions

This research highlighted a concerning trend of increasing CS deliveries in Bangladesh, surpassing the recommended rates set by the WHO. The excessive and unsafe use of this surgical procedure poses a strain on the healthcare system. Factors such as sleep duration, oedema, micronutrient levels during pregnancy, severe headaches with blurred vision and food consumption were identified as significant predictors of CS deliveries. Urgent measures and stringent guidelines are needed to raise public awareness about the adverse effects of unnecessary CSs in Bangladesh. Interventions should include informative programmes aimed at counselling women on the appropriate mode of delivery. The study also revealed that CS deliveries contribute to complications such as obstetric fistula and postpartum anaemia in mothers. Addressing the issue of CSs comprehensively is crucial for achieving global SDGs within the next decade.

Data availability statement

Data are available upon reasonable request. Availability of data and materials: The primary data is available, corresponding author will provide when Journal ask.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by Ethical approval for this study was obtained from the Ethical Review Committee of Institute of Biological Sciences, University of Rajshahi, Bangladesh (Memo No. 69/320/IAMEBBC/IBSC). The written informed consent from each selected subject was taken. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors gratefully acknowledge the authority of community clinic, Rajshahi, Bangladesh for giving permission to acquire data from community. Finally, we would like to gratefully acknowledge the study’s participants, reviewers, and the academic editors of our manuscript.