Caesarian section (CS) delivery in Bangladesh: A nationally representative cross-sectional study

A growing trend in the caesarian section (CS) for delivery is a threat to child health as well as maternal health. This study was conducted to identify the potential socioeconomic and demographic factors associated with CS delivery in Bangladesh. Data obtained from the Bangladesh Demographic and Health Survey (BDHS) 2014 has been used for this study. The prevalence of CS delivery among Bangladeshi mothers was 24% (Urban: 36.9%, Rural: 17.9%). A two-level logistic regression showed that mothers having delivery in the private sector or private hospital (adjusted odds ratio [AOR] = 38.70, 95% confidence interval [CI] = 29.58 to 50.62), mother’s age 25–35 years (AOR = 1.73, 95% CI = 1.26 to 2.37), wealth index average (AOR = 1.61, 95% CI = 1.15 to 2.27) and rich (AOR = 1.80, 95% CI = 1.29 to 2.51), antenatal visit 1–2 (AOR = 2.31, 95% CI = 1.47 to 3.64) and ≥ 3 (AOR = 3.68, 95% CI = 2.35 to 5.76), overweight mothers (AOR = 1.44, 95% CI = 1.09 to 1.90), multiple births (AOR = 3.87, 95% CI = 1.15 to 12.58), husband’s occupation professional/technical/managerial (AOR = 1.68, 95% CI = 1.15 to 2.47) were significantly more prone to CS delivery. Also, place of residence, number of family members, birth order, child’s size during birth, and divisions of Bangladesh, were potentially associated with CS delivery. The current epidemiological findings and evidence suggest adopting and implementing some urgent clinical practices and strict guidelines in the healthcare system to avoid unnecessary CS delivery in Bangladesh.


Introduction
Although CS as a mode of delivery is an essential surgical process to reduce the risks associated with childbirth, an increasing trend in CS delivery has continued to boost worries worldwide. CS delivery is a life-saving intervention as a mode of delivery to reduce maternal and newborn death. Still, in the same breath, unnecessary CS delivery is threatening for both mother and child's wellbeing [1]. Failing to conduct CS delivery on time may result in perinatal asphyxia, a1111111111 a1111111111 a1111111111 a1111111111 a1111111111

Data and variables
This study used Bangladesh Demographic and Health Survey (BDHS) 2014 data. Information on data will be available at https://dhsprogram.com/data/available-datasets.cfm. After receiving ethical approval from the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare, Bangladesh, the survey was conducted. Permission was taken from administrative offices, and verbal consent from each participant of the study was obtained before collecting data. The survey used a two-stage stratified cluster random sampling. In the first stage, 600 Enumeration Areas (EAs)/clusters (393 from rural and 207 from urban areas) were randomly selected. In the second stage, 30 households from each of the selected clusters were randomly selected, and each of the ever-married women (age 15 to 49 years) in the selected households were interviewed. Details of the sampling frame, sampling design, EAs, households, and questionnaires are available in the publicly available reports of the mentioned survey. The survey finally collected information from 17886 ever-married women of 15-49 years old, of which 4493 women (having at least one birth in the last three years from 2014) have information on the mode of delivery. Some missing values and abnormal data points have been detected in the considered covariates thereafter eliminated, and a total of 4433 women with complete information have been considered for this current study.
Since the study aims to find out the socio-economic and demographic factors associated with CS delivery, our response variable is the mode of delivery which is a dichotomous variable "1" for CS delivery and "0" for vaginal delivery.
Apart from the variables that were indicated in the previous studies, some new variables have been considered in this study. Variable Division contains six geographical regions (Dhaka, Chittagong/ Chattogram, Barishal, Khulna, Rajshahi, Rangpur, Sylhet). Age of mothers was categorized into three categories: less or equal to 24 years, 25 to 35 years, and greater or equal to 36 years. Place of residence contains two categories: urban and rural areas. Variable wealth index was calculated by principal component analysis based on the assets possessed by the households and categorized as poor (1st and 2nd quintiles), average (3rd quintile), and rich (4th and 5th quintiles). The Body Mass Index (BMI) of the mothers categorized into three categories: Normal (18.5 kg/m 2 � BMI <25 kg/m 2 ), Underweight (< 18.5 kg/m 2 ), and Overweight (� 25 kg/m 2 ). The size of child during birth (larger, average, smaller) was calculated from the mothers' perceptions as BDHS-2014 didn't calculate children's weight at birth. In variable Delivery in the private sector or hospital, we considered two categories: yes and no. Variable exposure to media was coded as 'yes' if a respondent was exposed to at least one of the three media: reading newspaper or magazine, listening to the radio, and watching television; otherwise 'no'. Wanted index child was categorized as yes and no. Variables mother's education level (no education, primary, secondary, and higher), religions (Muslim, non-Muslim), number of family members (less than or equal to 5 members, 6-10 members, and greater than or equal to 11 members), birth orders (1st, 2nd, and 3rd or above), age at first child's birth (less than 20 years, greater or equal to 20 years), antenatal care (ANC) visits (No, 1-2, 3 or more), age at first marriage (less than or equal to 18 years, greater than 18 years), husband's education levels (no education, primary, secondary or higher), type of birth (single birth, multiple births), gender of child (male, female), mother's working status (yes, no), husband's occupation (service/skilled and unskilled manual, professional/technical/managerial, agricultural work, none/other) have also been considered in this study.
Moreover, we had a look at the timing of decision for CS delivery and categorized into four options: on the day of delivery, a day before delivery, 2 to 7 days before delivery, and 8 to 30 days before delivery. We also considered variables to see the decision-makers and the reasons behind their decisions.

Statistical analysis
We have constructed frequency distribution (percentage) for obtaining the prevalence of CS delivery among Bangladeshi women of reproductive age. Chi-square (χ 2 ) test has been carried out to find the association between response variables and covariates. A single-level model might not be appropriate for analyzing the BDHS-2014 data as the obtained data was collected in the survey in several hierarchies. Because in multi-stage sampling, respondents are usually nested with the higher-order clusters. Therefore, to consider the cluster effects, a two-level logistic regression has been implemented to evaluate the impact of socio-economic and demographic factors on CS delivery. Level-I was regarded as an individual level and level-II as EAs or clusters level. To check the clustering effects, we assessed the Median odds ratio (MOR), one of the widely used methods [24,25]. The formula for calculating MOR is as following- is the cluster variance. MOR value is always greater or equal to one. MOR value one indicates that there is no cluster effect. MOR greater than one means the presence of clustering effects and needs to be removed to get more accurate results [24]. All the analyses have been done by using STATA statistical package (version 15) and SPSS (version IBM 20).

Association between CS delivery and different factors
The association of the mode of childbirth of the married women (reproductive age: 15-49 years) in Bangladesh with different socioeconomic and demographic factors along with the descriptive statistics has been delineated in Higher educated mothers were more likely to have CS as a mode of delivery (57.7%), and the education level was significantly associated with mode of delivery (p < 0.001). The scenario was also similar to husbands' educational qualifications: the higher the study level, the higher rate of CS. Besides, religion was also significantly associated with mode of delivery (p < 0.05), and Muslim mothers had a lower rate of CS delivery compared to non-Muslim mothers (23.60% vs. 28.50; p < 0.05). Furthermore, mothers who live in a family having five or fewer members had a higher rate of CS childbirth (25.30%), where the number of family members has also significantly impacted the mode of delivery (p < 0.05). Moreover, the wealth index was significantly associated with mode of delivery (p < 0.001), where the rich mothers showed the highest rate of CS delivery (41%), followed by middle (19.90%) and poor mothers (8.70%). Interestingly, the order of childbirth had an opposite relation with the prevalence of CS delivery; the birth order was ascending, while the proportion of CS cases was significantly (p < 0.001) declining. Mothers' aged � 20 years at their first childbirth were more inclined to CS delivery (38.2%) and the factor had a significant association (p < 0.05) with mode of delivery. Besides, the mothers who were greater than 18 years old during their first marriage exhibited 16.3% higher prevalence of CS than their counterparts with � 18 years (35.7% vs. 19.4%; p < 0.001). The number of antenatal care (ANC) visits during pregnancy has significantly influenced the mode of delivery (p < 0.001), where the CS rate was the highest for the mothers having three or more ANC visits (37.20%). Obese mothers (45.8%) held a higher rate of CS, and BMI was significantly associated with CS delivery (p < 0.001). Also, child's size at birth was significantly associated with CS (p < 0.001). Surprisingly, there was no association between mothers' working status and mode of delivery. Contrary, the husband's occupation was significantly associated with mode of delivery (p <0.001), and the women whose husbands worked as professional, technical, and managerial workers had a higher CS rate (53.7%). Furthermore, the prevalence of CS was significantly higher during male childbirth than female childbirth (25.30% vs. 22.70%; p < 0.05). Apart from, mothers exposed to media were more prone to CS delivery than mothers who were not exposed to media (32.2% vs. 10.8%; p < 0.001). The mothers who wanted the indexed child possessed a higher prevalence of CS delivery than their counterparts (25.2% vs. 14.2%; p < 0.001). Finally, mothers who got delivered in private facilities had a significantly higher CS rate than the mother who had no private facilities during childbirth (79.7% vs. 7.30%; p < 0.001).

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Caesarian section (CS) delivery in Bangladesh previous caesarian section (16.53%), and so on. Convenience (9.30%) and avoiding labor pain (7.04%) were two elective choices in upward CS delivery rate, and doctor dominated both the reasons as decision-maker. More than 50% of decisions for CS delivery occurred before the delivery date, and most of the decisions have been made by a doctor (Table 3).

Two-level logistic regression analysis
The estimated MOR value was 1.715, which indicated that the cluster effect was present in the current study. So, we considered two-level logistic regression analysis upon the cluster effect to get more accurate results. The findings of the two-level logistic regression model in terms of adjusted odds ratio (AOR), standard error (SE), p-values, and their associated confidence interval (CI) at 95% have been summarized in Table 4. Regression analysis also depicted a clear view of a significant correlation between the number of family members and prevalence of CS delivery mode, where the mothers from families containing above 11 members exhibited a lower rate of CS childbirth compared to the mothers from families with less than or equal five members (AOR = 0.48, 95% CI = 0.295, 0.781; p = 0.003). Besides, mothers who were economically rich and middle level had significantly higher rate of CS delivery than economically poor mothers [(AOR = 1.80, 95% CI = 1.287, 2.512; p = 0.001) and (AOR = 1.61, 95% CI = 1.148, 2.269; p = 0.006), respectively]. In contrast, CS delivery was significantly lower for second and successive childbirth than the first delivery [(AOR = 0.70, 95% CI = 0.524, 0.942; p = 0.018), and (AOR = 0.50, 95% CI = 0.334, 0.747; p = 0.001), respectively].

Timing of decision Total (%) Respondent said N (%) Family member said N (%) Doctor said N (%)
Day  However, the regression analysis has traced no significant variation of CS rate among the mothers from various educational levels from the reference group (mothers with no education) (p > 0.05). Similarly, mothers' religious status, age at first childbirth, age at first marriage, working status, exposure to media, including wanted indexed child and husband's education level, resulted in no significant CS rate difference among various groups from their corresponding reference groups.

Discussion
This study aimed to identify socio-economic, demographic, institutional, and social-networkrelated risk factors associated with CS delivery based on data obtained from a nationally representative survey. The prevalence of CS delivery was found at 24%, which was substantially

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higher than the ideal value recommended by WHO (10% to 15%) [3]. The current finding is too alarming because the CS delivery rate of Bangladesh was only 2.37% in 2000 [26]. It is a common trend that the CS delivery rate considerably varies in different regions of the world concerning differences in socio-economic conditions, culture, and education. According to a global survey by WHO, CS delivery was the highest in China (46.2%) and lowest in Cambodia (14.7%) in Asia [27]. Besides, this method of delivery rate was the highest in Brazil (45.9%) and lowest in Chad (0.4%), and in our two neighboring countries (India and Pakistan) was around 7% [28].
The current study revealed that 9.3% and 7% of CS delivery occurred for convenience and avoiding labor pain, respectively, and mothers and their family members played a dominating role in these two reasons as decision-makers. The present results also stated that about 74% of mothers decided CS delivery as doctors or physicians had suggested, and most of the time, physicians determined to CS childbirth due to complications in pregnancies, such as malpresentation of fetus (28.29%), failure to progress in labor (14.38%), and other complications (24.31%). Timing of decision showed that 40.7% of decisions of CS delivery had taken two or more days before the delivery date, which indicated a significant proportion of decisions of CS had taken way before the complications of delivery had arisen.
Bangladesh has been getting tremendous success in the improvement of per capita income for the last couple of decades. This study demonstrated that the wealth index was significantly associated with increased in CS delivery which is alarming. Mothers from higher-income family usually live with more comforts and facilities, and therefore, might be more anxious about the labor pain of vaginal delivery and might go under CS delivery. This outcome might be regarded as consistent and replicable to the previous findings [8,9,26]. A study explicated that the CS delivery rate was increasing with the upward of average income in both urban and rural areas in Bangladesh, and the rate was higher in the urban area compared to the rural area [26]. Similarly, the current analysis demonstrated a significantly higher CS rate in urban mothers compared to the rural mothers of Bangladesh. In the country, most of the medical facilities are available in the city area. The mothers of the urban site can easily access the required nursing care from various private or public care during pregnancy. Besides, above 74% of city dweller women are educated and belong to wealthy or middle-class families capable of undergoing CS mode delivery [8].
In Bangladesh, the ANC rate has increased in the last two decades [29], and mothers who take ANC from private network are more prone to CS delivery [30]. The current analysis proved that mothers having one or more ANC visits were more likely to have CS delivery than the mothers who had no ANC visit. Delivery in private facilities was found as a prominent influencer to increase the risk of CS delivery rate. In the last two decades, the private sector in Bangladesh has flourished dramatically. The private sector is very much profit generative, and physicians in private hospitals get incentives for conducting surgery, and that may influence some physicians to suggest mothers go under CS delivery. There might be some other reasons that increase CS delivery rate in private facilities, such as the perception of providing improved care and availability of modern technologies and regular specialist physicians. On the other hand, lower trust level on public hospitals' provided care, lack of enough specialist doctors and nurses, and insufficient health services and medicines, and so on, are the main reasons for keeping away from public hospital during the delivery time [31,32]. In addition, a fixed obstetrician always investigates a pregnant mother that might be another notable reason for choosing CS delivery in private hospitals.
The birth order of the newborn was also significantly associated with CS delivery. The babies with 2 nd or higher birth orders were less likely to be delivered by CS method than the babies with 1st birth order. The possible explanation is that mothers are more fearful about the labor pain and bleeding at their first delivery. Besides, complications in first delivery are higher than in the second and successive deliveries [33], and that might intimidate mothers to choose CS delivery. Another explanation would be after having CS delivery in the first birth; subsequent deliveries are perceived as high risk, thus decreasing the likelihood. This study also revealed that the geographical region was also significantly associated with CS delivery. Mothers who live in Dhaka and Urban areas were more prone to CS delivery. The availability of private facilities and the higher number of ANC visits contribute to these findings.
Early and delayed pregnancy in the reproductive age might be considered at risk for adverse pregnancy outcomes. Several studies reported an association of advanced maternal age with preterm delivery, low birth weight, perinatal death, and CS [34,35]. Similarly, this research found an association between mothers' age and CS delivery. Mothers aged greater than 25 years were more likely to CS delivery compared to their young counterparts. With the increase in education rate, expansion of the social network, and exposure to cultures of different countries, mothers in Bangladesh are embarking on having a child at a later age. As a result, the chance of CS delivery was higher for them. Furthermore, mothers from families with higher members were less likely to have CS delivery. One reason may be that family bonding among the members of large family is strong, and mothers get motivation and psychological strength from the other members of the family for vaginal delivery. The economic condition might be another contributing factor in this circumstance.
Obesity was significantly associated with a higher rate of CS delivery. Pieces of evidence showed that overweight mothers are at risk of gestational diabetes, induction of labor, miscarriage, preeclampsia, venous thromboembolism, anesthetic complications, and wound infections [36]. As a result, mothers could choose CS delivery mode. This study also showed that child size at birth, twin birth, and occupation of husband were associated with an increasing rate of CS delivery. Although the current regression analysis revealed no significant differences between CS delivery and mother's education, gender of the child, and exposure to media, significant associations were found from bivariate analysis. It has been noticed that with the increase in mothers' education level, CS delivery increase noticeably. Another study with different settings has found mothers' education significantly related to CS delivery [8]. We have also observed that the prevalence of CS delivery was more remarkable for the male than the female, which indicated gender inequality. Sometimes CS is justifiable but should not be occurred because of being a female child. Another alarming finding was that the prevalence of CS delivery was greater for the mothers who were exposed to the media than the mothers who were not exposed.
Several more factors associated with CS delivery in Bangladesh are still to be determined. However, some effective measures considering factors that we have identified in this study might extensively reduce the CS delivery rate.
Since the analysis of study was based on retrospective data, the obtained results might be subjected to be potentially biased. Some significantly associated factors found in several other studies were not available in BDHS-2014 data. Another limitation is pieces of information were collected only from the response of mothers. The collection of information from physicians would help us to do a deeper analysis. As the data was collected from a cross-sectional study, we could not observe a cause-effect relationship. However, one of the strengths of this study was that we had used nationally representative survey data.

Conclusion
The current investigation based on BDHS-2014 data has revealed that the prevalence of CS delivery in Bangladesh was higher than that has been recommended by WHO. This study found mothers from urban areas, Dhaka division, wealthy families, and had a delivery in private facilities were more prone to CS delivery. Mothers' age and education, childbirth order, number of ANC visits, larger baby size at birth, twin childbirth, and husbands' occupation were significant predictors of CS delivery. So, it is high time to take necessary steps considering these factors to control the growing trend of CS delivery rate. It is highly recommended that clinics should be audited regularly, and there must have some strict instructions and proper guidelines when conducting CS is justifiable. Besides, some intervention programs could be carried out to raise public awareness against the harmful consequences of unnecessary CS delivery.