Preference for Institutional Delivery and Caesarean Sections in Bangladesh

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INTRODUCTION

An estimated 358,000 maternal deaths occurred worldwide in 2008--a 34% decline from the level of 1990. Despite this decline, developing countries continue to account for 99% of the total maternal deaths. Of these estimated deaths, sub-Saharan Africa and South Asia accounted for 87% of the global maternal deaths. Overall, maternal mortality ratio (MMR) was the highest in developing regions (290/100,000) in stark contrast to developed regions (14/100,000). Bangladesh was one among the eleven developing countries, which had 65% of all maternal deaths. This implies that Bangladesh still has high MMR (340/100,000), which is one of the highest in the world (1).

Improving maternal health was one of the prior issues of the 2000 Millennium summit. Since the initiation of safe motherhood programme in 2001 with the signature of 189 countries in the Millennium declaration, in which Millennium Development Goal 5 (MDG 5) calls for a reduction in MMR by 75% and achieving universal access to reproductive health by 2015, the progress toward achieving the target of MMR has been uneven all over the world. For instance, among the developing regions, sub-Saharan Africa has the highest MMR, followed by South Asia, South Eastern Asia, North Africa, Latin America and the Caribbean, Western Asia, and Eastern Asia (1).

Globally, there is now consensus that increasing rates of delivery with a skilled attendant, ideally in a well-equipped facility, are essential to reduce maternal mortality (2,3). Appropriate delivery care is crucial for both maternal and perinatal health, and increasing skilled attendance at birth is a central goal of the safe motherhood and child survival movements (4). In addition, it is important that mothers should deliver in an appropriate setting where lifesaving equipment and hygienic conditions are available and can help reduce the risk of complications that may cause death or illness to the mother and the child (5).

Bangladesh has a long tradition of home-delivery practice. Delivery-related complication is one of the leading causes of maternal mortality in Bangladesh. Findings of a study conducted in rural Bangladesh showed that one-third of the women experienced delivery-related complications during their last delivery (6). The estimated lifetime risk of dying from pregnancy and childbirth-related causes in Bangladesh is about 100 times higher than that in the developed countries. The tragic consequence of these deaths is that about 75% of the babies born to these women die within the first week of their lives (7).

Surgical interventions during pregnancy are usually made to ensure safety of the mother and the child under conditions of obstetric risk. Although rates of caesarean section in many countries have increased from the recommended level of 15% in developed and many developing countries (3), the rate of delivery through caesarean section is relatively low in Bangladesh. The country still has very lower use-rate of the maternal healthcare services. Research based on 42 demographic and health surveys in developing countries evidently showed that, in the poorest countries, large proportions of the population have no access to potentially lifesaving caesarean section. Generally, financial costs play an important role in the demand for healthcare and for maternity care in particular (8,9,10). Apart from the clinical indications for caesarean section--breech presentation, dystocia, and suspected foetal compromise--there is growing evidence that many women choose delivery by caesarean section for personal reasons, particularly in profit-motivated institutional settings that may provide implicit or explicit encouragement for such interventions (11).

Caesarean section is a surgical procedure for delivery when vaginal delivery becomes contraindicated (12). The caesarean section is of benefit to pregnant women and the newborns when its indication is well-founded (13). …