Bangladesh has a high rate of maternal deaths, one of the world’s lowest rates of women using skilled birth attendants and a very low rate of caesarean births. To improve maternal health, a greater proportion of women need access to professional medical care, including caesarean delivery. However, in Bangladesh many women distrust caesarean surgery.

One of the Millennium Development Goals is to reduce by three-quarters the global maternal mortality ratio by 2015. In developing countries, a far higher number of women die from pregnancy-related causes compared with developing countries. In Bangladesh, where an estimated 320 to 440 maternal deaths occur per 100,000 live births, only 2.4 percent of children are delivered by caesarean section, whereas the internationally identified need is between five and 15 percent.

Using a skilled birth attendant during birth is one of the most recommended forms of intervention to reduce maternal deaths in low-income countries. Yet in many regions the proportion of women who do so is low as they face a number of obstacles to seeking professional medical help in childbirth. A major reason that skilled birth attendance is encouraged is that it can lead to women being referred for professional medical help if they are experiencing difficulties during birth or pregnancy. In certain instances, a caesarean section may be needed to save the mother and/or her baby. Many women, however, may not believe a caesarean procedure to be useful.

A study by the London School of Hygiene and Tropical Medicine, UK, in collaboration with the Bangladesh Ministry of Health and Family Welfare, explored the experiences and views on caesarean sections of 30 women who recently gave birth in a health facility in a rural district of Bangladesh. The research found that:

• Women’s distrust of doctor’s recommendations for caesarean sections was due to the high cost of this surgery and a belief that it was not always medically necessary.   
• In some cases, this distrust results in women avoiding or leaving medical facilities.
• Some cases showed that there were differences of opinion among medical staff about whether or not a caesarean was necessary.
• This was further complicated by financial incentives for doctors to carry out caesareans and for nurses and midwives to perform normal deliveries.

Bangladeshi women understand the need for professional medical care but it appears that they have good reason not to trust doctors’ advice to have a caesarean delivery. Their fear of caesarean delivery is not simply based in ignorance but may reflect real concerns about medical practice. The study recommends that:

• As there is a social stigma attached to caesarean deliveries and the cost of these deliveries is too high for many families, the medical profession should only recommend caesareans when absolutely necessary and should not charge unaffordable fees.
• Policymakers need to address problems in the health system that may lead to improper service provision.
• They must not only regulate and prevent unnecessary procedures but also address the underlying factors that provide health staff with the incentive to push for these procedures.

Source(s):
‘Life saving or money wasting? Perceptions of caesarean sections among users of services in rural Bangladesh’, Health Policy, by Justin Oliver Parkhurst and Syed Azizur Rahman, 2006 (in press)
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development (DFID)

id21 Research Highlight: 17 November 2006

Further Information:
Justin Oliver Parkhurst
Health Policy Unit
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 20 7927 2359
Fax: +44 20 7637 5391
Contact the contributor: justin.parkhurst@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Bangladesh Ministry of Health and Family Welfare

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