1. Introduction

Clinically when normal vaginal delivery of a baby is considered risky or life-threatening for both mother and baby or any of them, the C-section is a preferable method. In this method, delivery is carried out through scarification of the abdomen and uterus. Despite its value of safety, C-section also holds complications [1]. Due to substantially increasing C-section rates in the LMICs, it is only recommended to practice when there are no other alternatives and when it is medically justifiable [2]. During the past 30 years, there was an increasing trend of practice of C-section; it varies from 5% to 43% among countries around the world. The recent study, which included data from 154 countries, reported an overall C-section rate of 21.1% [3]. Previously, it was observed that economically developed countries have a higher rate of C-sections [3, 4]. However, the scenarios have changed dynamically and observed a growing rate of C-sections in economically less developed countries. The developed countries are strictly imposing restrictions on unnecessary C-sections [5]. The rate of C-sections has increased globally across all regions since 1990. The sub-regions that experienced the largest increases were Eastern Asia, Western Asia, and Northern Africa, with respective increases of 44.9, 34.7, and 31.5 percentage points. On the other hand, sub-Saharan Africa and Northern America had the lowest increases, with 3.6 and 9.5 percentage points, respectively [3].

The reasons for increased use of C-section is attributed to the reduction in mortality risk of mother and child during delivery [3, 6, 7]. Since C-section is a major abdominal surgery, elective C-section should be avoided. It may cause infection, injury, and short or long-term disability for both mother and baby. Sometimes, it may interrupt the start of breastfeeding, and it may also require hysterectomy [8]. C-sections may result in permanent pain and cause complications in future deliveries [9, 10]. Moreover, a positive association between C-section and respiratory diseases and other pulmonary infections is evident [11, 12]. South Asian countries are economically, socially and politically diversified. They attempt to minimize regional health challenges [13], encourage deliveries under the supervision of skilled birth attendants [14], and maintain hygiene. C-sections has been doubled during the period 2000–2015 in the South Asian region, and the yearly increase rate is more than 5% [4]. In 2015, the C-section rate in this region was 18.1%, which exceeded the world Health Organization (WHO) recommended range 10–15% [15]. Although there is a controversy and there is no international consensus regarding this rate, we still kept this number for baseline comparison [16]. So, it is clear that this life-saving method of delivery is being used at a higher than expected, irrespective of the medical justification in many South Asian countries [4].

According to the WHO Report 2010, there were 6 million elective C-sections practiced that cost US$ 2.32 billion [15]. Along with other causes, increasing the income of healthcare providers is a significant cause of increasing C-sections [17]. Elective C-section causes adverse impacts on health as well as an economic burden as they usually require to stay in the hospital longer [18–20].

The association between C-section and several other factors, including maternal age, maternal weight, number of times an individual woman has given birth (parity), prolonged labour, HIV infection, previous C-section delivery, dystocia, breech presentation, placenta previa, and suspected fatal complications are well documented in the literature [21, 22]. The place of residence, educational status [23], and choice of place of delivery [24] are also found to be associated. Several other significantly associated factors include baby size, higher number of antenatal care (ANC) visits, antenatal care (ANC) from private institutions, working husband, first birth and delivery in private hospitals [22, 23, 25]. A contemporary Lancet publication showed a significant difference in the use of C-sections among women in the two extreme wealth quintiles in 82 LMICs [4].

Although some studies dealt with the prevalence and determinants of C-sections in Bangladesh and South Asia [24–28], to the best our knowledge no studies have focused on the most recent scenarios of the trends and determinants of increased use of C-sections across three neighbouring countries, including Bangladesh, Nepal, and Pakistan. These three countries face similar challenges in maternal and child health issues [29, 30]. Despite some differences in specific indicators and methods, they possess similarities in terms of maternal and child health: high maternal and child mortality rates, limited access to quality health care, malnutrition, maternal health services, and socio-economic and cultural factors [31, 32]. Moreover, all three countries face challenges regarding healthcare infrastructure, skilled healthcare professionals, and availability of essential drugs and equipment. Thus, this study focused on these three South Asian countries to determine and compare (i) the trends in the use of the C-section over time and (ii) sociodemographic factors associated with the use of the C-section. It would facilitate understanding the patterns and identifying the socioeconomic and sociodemographic vulnerable cohorts with increased use of the C-section.

2. Materials and methods

3. Results

Table 1 presents the places of deliveries for different DHS rounds in three South Asian countries. The number of deliveries at hospitals in each country has increased over time (S1 Appendix: Figure A1). In 2004, the prevalence of delivery at hospitals in Bangladesh was only 10.0%, which increased almost fivefold (49.9%) in 2017. In Nepal, this prevalence was 11.0% in 2001, which also increased about five times (58.6%) in 2016. The scenario was similar for Pakistan (13.7% in 1990 and 66.3% in 2017).

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Table 1. Place of birth reported at different demographic health survey rounds across three countries: Bangladesh, Nepal, and Pakistan.

https://doi.org/10.1371/journal.pone.0311082.t001

Table 2 summarizes the distribution of C-section deliveries by country and survey years. We also demonstrated the trend of C-section deliveries in [S1 Appendix: Figure A2]. In 2004, the C-section rate in Bangladesh was about 3.5%, which increased to 32.8% in 2017. Nepal had relatively the lowest C-section rate among the three countries. In 2001, the rate was 0.8%, while 2016 it increased to 9.0%. Pakistan also demonstrated a sharp increase from 1990 to 2017 (2.7% to 22.3%).

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Table 2. Delivery by C-section in Bangladesh, Nepal and Pakistan at different DHS rounds.

https://doi.org/10.1371/journal.pone.0311082.t002

Table 3 shows that the C-section rate in urban areas was higher compared to rural areas. In Bangladesh and Pakistan, the urban C-section rates were approximately two times higher (27.2% vs 12.0% for Bangladesh and 27.8% vs 13.9% for Pakistan) than the rural rates. In Nepal, the C-section rate in urban areas was 10.0%, whereas it was only 2.0% in rural areas. The likelihood of the C-section among mothers with higher education was higher, and a similar scenario was evident for husbands with higher education. Among women without any formal education, the C-section rates were 3.1%, 1.1%, and 8.6% for Bangladesh, Nepal and Pakistan, respectively. In contrast, among women with more than twelve years of education, the C-section rates were 59.2%, 23.8%, and 50.4% for Bangladesh, Nepal and Pakistan, respectively. A significant difference in the C-section rates was also evident in the economic status of women. In Bangladesh, only 2.9% received C-section delivery among those in the poorest quantile, whereas 37.7% in the richest quantile. A similar pattern was also observed for Nepal (0.4% vs 11.2%) and Pakistan (8.5% vs 45.5%). The birth order observed a distributional difference in the C-section rates. The highest rates were evident for the first birth in all countries (Bangladesh at 25.5%, Nepal at 8.7%, and Pakistan at 28.3%). Bangladeshi women seeking more than four antenatal care visits had the highest rate of C-sections at 40.1%, Pakistani was in second at 36.0%, and in Nepal, the rate was 13.3%. However, with no antenatal visits, the prevalence of C-sections was low at 2.6%, 0.5%, and 2.4%, respectively for Bangladesh, Nepal and Pakistan. The C-section rate among Bangladeshi obese women was the highest (55.2%), followed by Pakistan at 39.0%, and the lowest was in Nepal at 19.7%.

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Table 3. Association between C-section delivery and socio-demographic factors in Bangladesh, Nepal, and Pakistan.

https://doi.org/10.1371/journal.pone.0311082.t003

Table 4 presents the adjusted odds ratio (crude odds ratio enclosed in S1 Table in S1 Appendix) and the corresponding 95% confidence interval. Age was significantly associated with increasing likelihood of C-section (Bangladesh: AOR = 1.05, CI = 1.03, 1.07; Nepal: AOR = 1.08, CI = 1.06, 1.11; Pakistan: AOR = 1.02, CI = 1.00, 1.04). A significant association with place of residence was only observed in Nepal (AOR = 1.20, CI = 1.05, 1.50). A tendency for a higher likelihood of C-sections among educated women was observed both in Bangladesh and Pakistan compared to those with no formal education. The AOR was 2.45 (CI = 1.88, 3.35) for women with more than 12 years of education in Bangladesh, while it was 2.34 (CI = 1.70, 3.24) in Pakistan. A higher likelihood was also evident for the first birth in all countries. Women with more than four antennal care visits showed a higher likelihood of C-sections in all three countries (Bangladesh: AOR = 7.03, CI = 5.56, 8.66; Nepal: AOR = 5.27, CI = 4.09, 9.15; Pakistan: AOR = 5.01, CI = 4.33, 8.90). A significantly positive association between the C-section and body mass index was observed. In Bangladesh, Nepal, and Pakistan, the AORs of C-sections for obese women were 4.25 (CI = 3.29, 5.51), 2.51 (CI = 1.33, 3.67), and 2.11 (CI = 1.51, 2.93) compared to underweight women. The significantly increasing odds of C-sections in private hospitals compared to the public hospitals were observed in all three countries (Bangladesh: AOR = 5.31, CI = 4.76, 5.93; Nepal: AOR = 2.03, CI = 1.61, 2.56); Pakistan: AOR = 1.30, CI = 1.08, 1.54).

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Table 4. Adjusted odds ratio (AOR) and 95% confidence interval (CI) for the risk of C-section corresponding to the associated factors of Bangladesh, Nepal and Pakistan.

https://doi.org/10.1371/journal.pone.0311082.t004

4. Discussion

In this study, we investigated the trends and prevalence of C-sections across three neighbouring South Asian countries and assessed the association of sociodemographic factors with the uptake/prevalence of C-sections. We observed that there were dramatic increases in the number of deliveries at hospitals as well as C-sections across three countries over time. While this finding indicates a noticeable improvement in healthcare facilities and health service provision, the rapid increase in C-sections causes an huge economic burden on the healthcare system and may have negative health effects for both mother and kids if coupled with unnecessary C-sections [38]. The prevalence of C-sections in Bangladesh and Pakistan was almost consistent with other LMICs [39–41]. However, both countries exceeded the WHO recommended standard level of C-sections [15]. Although there is a controversy and there is no international consensus regarding this rate, we used it for baseline comparison [16]. While the prevalence of C-sections dramatically increased in Nepal over the 16 years, the rate was well below the WHO recommended range in compared to other countries. The prevalence of C-sections in other Asian countries, for example in India and Indonesia, also increased over a similar period [42, 43]. While the improvement of healthcare facilities may partly contribute to the increased prevalence of C-sections, unnecessary C-sections also occur due to mothers’ misconceptions of delivery pain, convenience, and lack of patience [22]. Besides, relative underpayment of physicians across the three countries, many intend to have inappropriate financial benefits, which may also result an upsurge in elective C-sections [44].

We found that several factors were associated with the increased prevalence of C-sections across the three South-Asian countries. Consistent with other studies [45, 46], increased age of pregnancy/delivery was associated with a higher likelihood of receiving a C-section. Women who had a pregnancy at a relatively higher age underwent high risks of preterm delivery, low birth weight, perinatal death, and C-section [47–49]. We also observed a significant difference in the prevalence of C-sections by mothers’ place of residence. In Bangladesh and Nepal, urban women are more inclined to undergo C-sections, but in Pakistan, urban women are less prone to C-sections. Previous researchers also found similar results [41, 45, 50, 51]. The reasons of lower rate of C-sections in rural areas in Bangladesh and Nepal could be due to a number of factors such as lack of accessibility to hospitals, customs and traditions of the society, financial ability, awareness, and others [52–56]. Availability of improved medical facilities, more antenatal care (ANC) visits, the tendency to take children at a later age, high socioeconomic status, highly educated mothers and their partners, increased BMI, and post-partum reasons may be some possible reasons for increased use of C-section in the urban regions. However, the lower number of C-sections among urban women in Pakistan warrants further investigation.

Consistent with several previous studies [23, 25, 40, 41, 45], we observed that women’s (also husband’s) educational attainment was associated with increased likelihood of choosing C-sections. Educated women were more predisposed to select C-section as a better method of delivery than the vaginal delivery. Maybe educated women feel that C-sections reduce delivery-related pain. Additionally, many educated women choose to take a child at a later stage of life compared to non-educated women, which increased their likelihood to choose the C-section methods. In the case of Nepal, women’s education was not associated with C-section rates, which contradicts the previous studies [50, 51]. A further study may help to unravel the reasons. Birth order was reversely related to the prevalence of C-sections. A higher likelihood of C-sections was also evident for the first birth in all countries. Almost similar patterns were reported in the previous studies [39, 41, 46, 50]. Mothers in their second, third or more orders of birth may be less intimidated by the pain of labour, and they develop the physical and mental ability to cope with the delivery related pain. Although WHO suggested at least four antenatal care visits for every pregnant women to reduce pregnancy related complications [57], we found that C-section was associated with the increased number of antenatal care visits across the three countries. Maybe more antenatal care (ANC) influence anxious mothers to choose the C-section method, or physicians suggest them undertake C-section to relieve them from other pregnancy related complications [49]. The number of antenatal care (ANC) visits also interlinked with education and socioeconomic conditions. Several previous studies also in agreement with our findings regarding the association between number of antenatal care (ANC) visits and C-section [23, 25, 40, 41, 46, 51].

We found that there is an increased use of C-section delivery among women who possess the wealthiest economic status than those in economically less affluent positions in Bangladesh. This might happen due to the preference of many people with improved socioeconomic status to visit private hospitals for more comfortable healthcare than the public hospitals. C-section rate is noticeably higher in private hospital than public hospitals [55, 56]. With the increased affordability of women from the wealthiest economic status, doctors are likely to be in favour of not taking any risks and deciding on C-sections. Some other developing countries from Africa and South-Asia reported almost similar relationship between wealth quintile and C-section delivery [23, 24, 45, 58–60]. We found BMI is significantly associated with C-section delivery, with obese women were more exposed to C-section than the normal weight women. Several prior studies in different developing countries also exhibited the comparable and consistent results to our findings [23, 61–63]. The reasons may be much higher delivery-related complications for overweight and obese women than for normal weight women. Generally, overweight/obese women suffer from chronic diseases such as diabetes mellitus, asthma, hypertension, respiratory problems, and others. This may contribute to physicians’ decisions for C-sections in reducing the risk.

5. Strengths and limitations

One key strength of our study is using representative data from the DHS for at least four rounds across the neighbouring countries. We conducted comprehensive analysis (both bivariate and multivariable) including a range of variables, which allowed us to understand how these variables are associated with C-section across the three countries. Our study also has some limitations. First, we could not establish the casual relationship as all DHSs are cross sectional in nature. In addition, there is a lack of valid instrumental variables (strongly associated with the independent variable, not dependent with the variable except only through an independent variable), which could be used to address simultaneity bias. Second, DHS data may be subject to recall bias and response bias since it is held in every three or five years in different countries; also, although survey weight was being used, the variability between the countries was not considered. Third, we fail to consider some important factors such as distance from residence to hospital, pregnancy related complexity due to unavailability in the DHS data sets. These factors may also mediate the association observed in our study. Fourth, as the study considered data from three countries, it may not be generalized to other South Asian countries. Finally, wealth condition is considered as a proxy for the socioeconomic status that is formed based on some household amenities that might underestimate or overestimate the actual socioeconomic condition. There is also no data related to the hospitals’ inclination to be financially benefited by doing unnecessary caesarean delivery.

6. Conclusion

The rapid increase in C-sections across the three countries underscores that this procedure may not always be guided by clinical evidence in practice. Unwanted C-sections may potentially be an economic burden on the health care system as well as have detrimental health effects for both mothers and kids. Our findings regarding the association of sociodemographic factors with increased C-sections may help identify subgroups of women susceptible to C-sections and offer better support regarding C-sections plans. However, the substantial increase in C-sections across the three countries warrants further investigation to identify the reasons.

Supporting information

Acknowledgments

We would like to acknowledge DHS for permitting in data use. Also, heartfelt gratitude to all the participants of the DHS of the three countries.