Introduction

Approximately 18.5 million caesarean deliveries are performed globally each year [1], and the number is expected to increase in middle- and high-income countries [2]. The global rate of caesarean deliveries increased by 6 percentage points from 2010 to 2018, whereas in 2018, the Latin American and Caribbean countries contributed almost 43%, in contrast with the Sub-Saharan African regions contributing only 5%. From 1990 to 2018, the global rate of caesarean deliveries rose from 6.7% to 21.1% [3].

The extensive and unrestricted use of caesarean delivery varies according to socio-demographic indicators and regional factors [4,5] and it also has adverse consequences for maternal and neonatal outcomes [6]. Despite significant disparities at different geographical regions, global caesarean delivery rates have been steadily increasing [7]. Twenty-one percent of women in the world gave birth to their children by caesarean delivery [8], exceeding the World Health Organization (WHO) recommended range of 10% to 15% at the population level [9]. In Bangladesh, the caesarean delivery rate increased by 28 percentage points from 2011 to 2022 (17% in 2011 to 45% in 2022) [10,11]. The caesarean delivery rates at different geographical locations were at least double in 2022, as compared to 2011, with Dhaka and Khulna reporting much higher rates of change, 53% and 66%, respectively. In 2011, the caesarean rate was roughly 10% of all births everywhere apart from in Khulna, where it was 26% [11]. This rising caesarean delivery rate is certainly a major public health concern for Bangladesh [10].

An excessive number of caesarean deliveries are performed without adequate justification or clear medical indications such as fetal distress, non-cephalic presentation, maternal disease, cephalopelvic disproportion, inadequate labor progression, multiple pregnancies, etc. [12–14]. A study estimated that in 2008, around 6.2 million unnecessary caesarean deliveries were performed, costing over US$2.32 billion [1,15]. Financial incentives to perform surgical deliveries may be a possible factor in the increasing rate of unnecessary caesarean delivery worldwide [15].

However, various non-medical factors such as low socioeconomic status, communication barriers, and lack of support during labor and delivery have also been significantly associated with the increasing rate of caesarean delivery [16]. Numerous studies conducted in Bangladesh have identified several socioeconomic and demographic characteristics linked to caesarean delivery, including maternal education, place of residence, wealth index, maternal age, age at first birth, parity, birth order, antenatal visits, husband’s occupation, delivery in the private sector, religion, and divisions [4,17–19]. As previous studies have shown, several individual characteristics, including sociodemographic, health, medical, and institutional factors, can contribute to the rate of caesarean deliveries [20].

Healthcare provider retention is a serious issue in Bangladesh, especially in remote areas, leading to many vacancies in public health facilities [21]. However, the Khulna and Dhaka divisions have comparatively fewer vacant positions, but a relatively high number of accessible emergency obstetric care facilities in the public sector in the Khulna region, resulting in the higher usage of maternity care services in these administrative regions [22]. The higher rate of caesarean delivery in Khulna, despite Dhaka’s superior healthcare infrastructure, can be attributed to several regional factors like antenatal care coverage, maternal health services [23]. Currently, there is a gap in the literature regarding the prevalence and contributing factors of caesarean deliveries across different geographic locations in Bangladesh, presenting a promising opportunity for further investigation. The goal of this study is to explore region-specific variations and identify the region-specific determinants of caesarean deliveries among ever-married women aged 15–49 years in Bangladesh.

Methods

Exposure variables

This study utilized various sociodemographic variables, expanding on prior research that has highlighted the significance of these factors. The potential determinants used in the present study according to the prior literature were administrative divisions (Barisal, Chattogram, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet), women’s current age (15−19 years, 20−34 years, and 35−49 years), women’s educational status (No formal education or primary, secondary, and higher), age at first birth (<18 years, ≥ 18 years), husband’s educational status (No formal education or primary, secondary, and higher), husband’s occupation (agriculture, non-agriculture, others), place of residence (urban, rural), household wealth index (poor, middle, rich), women’s exposed to mass media (“yes” if the frequency of reading newspapers and/or magazines, listening to the radio, and watching television was less than once or at least once a week and otherwise “no”), birth order (1, 2, and 3 or more), maternal body mass index (underweight, normal, and overweight or obese), pregnancy complications (yes, no), survey time (2011, 2014, 2017−18 and 2022). Fig 1 displays the conceptual framework of the linkage of exposure and outcome variables.

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Fig 1. Conceptual framework of linkage of exposure variables and outcome variables.

https://doi.org/10.1371/journal.pone.0328830.g001

Results

The background characteristics of study participants are described in Table 1. A total of 17,704 ever-married women aged 15–49 were included in this study, drawn from the four latest consecutive nationally representative surveys. The proportion of ever-married women who had caesarean births was 15%, 24%, 33%, and 46% in the survey years 2011, 2014, 2017−18, and 2022, respectively (Fig 2), and it varied by demographic, socio-economic, and geographical characteristics (Table 2). More than forty percent of women gave birth to their first child before the age of eighteen, and more than seventy percent of all women were between the ages of 20 and 34. More than half of the participants had completed their secondary or higher educations. In all regions, the proportion of women between the ages of 15 and 49 who were regularly exposed to mass media exceeded 61.8%. Overall, 36% of the mothers experienced difficulties during their pregnancy to give birth to their child, whereas the proportions were 40% and 42% in Khulna and Rangpur divisions, respectively. Around 19% of mothers were found to be overweight or obese in the Chattogram and Dhaka divisions, while 20% of mothers were underweight in the Khulna division.

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Table 1. Background characteristics of the study participants.

https://doi.org/10.1371/journal.pone.0328830.t001

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Table 2. Region-specific variations of caesarean delivery by background characteristics among the ever-married women aged 15-49 years in Bangladesh from 2011 to 2022.

https://doi.org/10.1371/journal.pone.0328830.t002

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Fig 2. Region-specific variations of caesarean delivery among ever-married women aged 15–49 years in Bangladesh from 2011 to 2022.

The divisional level shapefiles of Bangladesh were obtained from the open-source website Humanitarian Data Exchange (https://data.humdata.org/dataset/cod-ab-bgd) and are licensed under CC BY 4.0. This figure is a replacement for previously copyrighted maps and has been recreated using openly licensed data for illustrative purposes.

https://doi.org/10.1371/journal.pone.0328830.g002

Region-specific determinants of caesarean delivery

In the multiple regression analysis, women’s age, women’s educational status, age at first birth, husband’s educational status, husband’s occupation, place of residence, religion, wealth status, exposure to mass media, birth order, maternal body mass index, pregnancy complications, and survey time were the significant covariates for caesarean delivery. After adjusting for theses relevant covariates in each of the models across all seven regions, women with highly educated husbands had significantly greater odds of having a caesarean delivery than those with less educated husbands, particularly in the Barisal (OR: 4.48; 95% CI: 2.92, 6.87), Chattogram (OR: 2.69; 95% CI: 1.97, 3.68), Dhaka (OR: 2.04; 95% CI: 1.55, 2.69), Khulna (OR: 2.00; 95% CI: 1.38, 2.89), Rajshahi (OR: 1.93; 95% CI: 1.35, 2.75), Rangpur (OR: 2.46; 95% CI:1.62, 3.74) and Sylhet (OR: 1.76; 95% CI: 1.19, 2.60) divisions. In contrast, educated women also had a higher chance of having a caesarean delivery, ranging from 1.71 in the Rangpur division to 2.93 in the Sylhet division, compared to women with primary or no formal education. Women from households with higher wealth status had significantly higher odds (adjusted odds ratio ranging from 1.39 in Rajshahi division to 2.95 in Sylhet divisions) of having a caesarean delivery than women from low wealth status households across all divisions. However, except the Rangpur division, overweight or obese women had a higher chance of having a caesarean delivery than the women with normal weight in Barisal (OR: 1.85; 95% CI: 1.35, 2.54), Chattogram (OR: 1.97; 95% CI: 1.58, 2.47), Dhaka (OR: 2.33; 95% CI: 1.91, 2.85), Khulna (OR: 1.80; 95% CI:1.37, 2.36), Rajshahi (OR: 1.94; 95% CI: 1.45, 2.60) and Sylhet (OR: 2.50; 95% CI: 1.85, 3.38), respectively. The effects of the factors on caesarean deliveries with the interaction effects of survey time and division are also presented in Table 3.

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Table 3. Region-specific determinants of caesarean delivery among the ever-married women aged 15-49 years in Bangladesh.

https://doi.org/10.1371/journal.pone.0328830.t003

Discussion

This study analyzed the four most recent nationally representative pooled datasets from BDHS to explore region-specific variations and their determinants contributing to caesarean deliveries in Bangladesh. The rate of caesarean deliveries has drastically increased over time across all the regions of the country. This analysis revealed that educated couples have a higher contribution to the increased rate of caesarean deliveries in all regions. We also found that the caesarean deliveries were more prevalent among the women living in the wealthier households and those with a greater BMI. Additionally, the birth order of the children, survey time, and pregnancy complications were also found to be notable correlates of caesarean deliveries in all seven regions as well as in the pooled analysis.

Women with higher levels of education residing in the Sylhet, Rajshahi, and Khulna divisions had notably higher rates of caesarean deliveries compared to their counterparts. Rajshahi and Khulna divisions reported the second-highest rate of higher (more than secondary) education among the ever-married women [11]. Additionally, Khulna and Rajshahi regions also had higher rates of antenatal care utilization from medically trained personnel among pregnant women, while Sylhet had the highest fertility rates [28]. Prior fertility and desire for further children may result in more pregnancies, increasing the total number of caesarean deliveries [29]. Previous studies have also confirmed these region-specific disparities of caesarean delivery among educated women [30,31]. A possible explanation for this finding can be that women with greater levels of education are more likely to be of higher socioeconomic status, which influences their decision in favor of private delivery facilities and results in a higher number of caesarean deliveries [32]. Educated women tend to opt for caesarean sections due to perceived lower pain levels, the belief in increased safety, minimal disruptions with daily tasks, and a perception of greater social prestige compared to natural vaginal delivery [33]. Access to healthcare facilities, exposure to health information, and improved health-seeking behavior are all correlated with education levels [34]. It is likely that educated mothers comprehend both the pros and cons of caesarean deliveries, which enables them to choose this procedure [24]. To mitigate the long-term consequences of rising caesarean section rates, policymakers ought to notify and encourage educated women by highlighting both the advantages and potential risks of caesarean deliveries.

Our findings indicate that, in all the regions, the husband’s educational status was also an important predictor of caesarean deliveries. Women who live with highly educated husbands were more likely to undergo caesarean deliveries, a pattern observed consistently across all geographic regions, with the lowest odds recorded in the Sylhet division. Sylhet had the lowest proportion of husbands with formal education [11]. Limited education and low standard of living among husbands often hinder access to healthcare, which, in turn, affects maternal healthcare practices [25,35]. Prior studies have also found that partners with higher educational backgrounds were associated with caesarean deliveries [23]. According to a meta-analysis study on 36 Sub-Saharan African DHS data, the husband’s level of education was an important driver in the rising number of caesarean deliveries [36]. Meanwhile, educated husbands with better financial stability are often more knowledgeable about healthcare, and may play a more active role in decision-making regarding birth, which might influence the couple’s belief that having a caesarean delivery is safer and less disruptive to their workload and free time [35,36]. The policymakers could introduce culturally and socially tailored interventions that actively engage educated husbands to improve awareness and promote appropriate health behaviors, thereby discouraging unnecessary or elective cesarean deliveries.

This study identified a clear regional variation in maternal BMI and caesarean delivery. As expected, overweight and obesity were most prevalent among women in Dhaka, Khulna, and Rajshahi, who also reported higher rates of caesarean delivery. In contrast, regions such as Sylhet and Rangpur, despite showing moderate levels of overweight or obesity, appeared to experience lower rates of caesarean delivery. The Rajshahi, Dhaka, and Khulna divisions emerged as prominent hotspots for caesarean section deliveries [37]. Dhaka and Khulna had the highest prevalence of overweight and obesity in urban areas, while Rajshahi and Chittagong exhibited the highest rates in rural areas [38]. However, a prior study found that the maternal double burden of overweight and short stature increased the odds of caesarean delivery in South Asia [39]. Overweight mothers face potential complications such as gestational diabetes, miscarriage, labor induction, anesthetic complications, preeclampsia, fetal distress, and wound infections [40]. Excess weight can also make it difficult for the baby to pass through the birth canal, leading healthcare providers to recommend a caesarean delivery for the safety of overweight women [41,42]. Given the regional differences in caesarean delivery rates related to the severity of overweight or obesity among women, healthcare providers should offer personalized counseling to address specific health concerns. This should involve guidance on preventing additional weight gain, managing associated complications, encouraging vaginal delivery when possible, and promoting healthier overall outcomes.

According to this study, women who were exposed to media were more likely to have greater caesarean delivery rates than reference groups in Dhaka, Barisal, Chattogram, and Sylhet divisions. Although the proportion of women watching television at least once a week was higher in the Rajshahi, Dhaka, and Khulna divisions, regular internet use was notably more prevalent in Chattogram, Dhaka, and Sylhet, respectively [11]. Women residing in regions with greater Internet access were more likely to undergo a caesarean delivery [43]. Women who often viewed media depictions of caesarean deliveries were more inclined to choose one regardless of whether it was medically necessary [44]. The perceived safety and convenience of caesarean delivery may be frequently highlighted in the media, which could raise demand [44]. To cut the caesarean delivery rate in each location, policymakers could authorize national and local media to air animated videos or advertisements highlighting the health and financial benefits of normal vaginal delivery in several local languages.

The findings of this study indicate the need to examine the increasing prevalence of caesarean sections across various geographical areas. The study also found that the couples with higher educational attainment had a higher rate of caesarean births, particularly in Dhaka and Khulna divisions. Medically indicated caesarean deliveries are often performed in response to obstetric complications, when vaginal delivery might endanger the health mother or newborn health [45]. However, the long-term consequences of repeated caesarean deliveries can put mothers at risk for surgical complications, aberrant placentation in later pregnancies, and prolonged recovery periods [46]. For neonates, caesarean delivery has been linked to increased rates of respiratory difficulties, altered gut microbiome colonization, and potential long-term concerns such as asthma, allergies, and obesity [47].

The policymakers should focus on the provision of adequate maternal and child health services, considering the geographical variation, and make appropriate health facilities available by strengthening existing policies to reduce the public-private disparity in the provision of caesarean deliveries. Public health facilities must be upgraded to prevent economically and socially disadvantaged communities from incurring unmanageable health cost.

Conclusion

The study findings indicate that factors such as level of education, socioeconomic status, availability of healthcare services, and regional disparities can impact the frequency of caesarean deliveries. Considering geographical variations to ensure the provision of adequate maternal and child health services, the government should prioritize educating mothers and families about the benefits of normal delivery, enforce robust regulations, and implement strict oversight of healthcare services. This should include the use of hospital electronic medical records, data management systems, and standardized prescription protocols. The policymakers should take proactive steps based on this evidence. One potential intervention area could be the introduction of a centralized or local pregnancy registration system, which may help improve monitoring and access to maternal health services. Further exploration of the feasibility and implementation of such a system would be valuable.

Supporting information

Acknowledgments

We thank Measure DHS and the national statistical offices/centers of the included countries for supplying the data freely through the Demographic and Health Surveys online archive (http://www.measuredhs.com). The authors also acknowledge the support of the icddr,b where this study was conducted. We also acknowledge the Government of Bangladesh and Canada as core donors of icddr,b. We gratefully acknowledge the reviewers and editors for their insightful reviews and valuable suggestions.