Let’s face it: This is a question that thousands of families are asking themselves nowadays in Bangladesh – and are mostly answering with yes, especially, if they can somehow manage the money it takes to get a planned caesarean. It is very positive that families care for safer deliveries for their women and babies, but is caesarean section really the answer? Is it true that a caesarean is a guarantee for a healthy baby and mother? In Bangladesh more than 50% of all deliveries are taking place in a clinic or hospital and of those two thirds are caesarean deliveries. A total of 1 million caesarean sections are done per year, 80% in private clinics. Are those deliveries safer? for the mother? for the baby? Safer than what? Safer in what circumstances?
There are many situations where only a caesarean section can safe a mother’s life, e.g. when the baby is too big to pass the birth canal, or to safe a baby’s life, e.g. when the baby’s cord gets compressed and stops the oxygen supply. We therefore would expect that doing more caesarean sections would mean more safer deliveries, meaning less women die in childbirth. Sadly the BMMS 2016 showed us that the same number of women died in 2016 as in 2001 (196 per 100’000 deliveries, called Maternal Mortality Rate), even though there are almost 3 times the number of cesarean sections done. How is this possible?
Sometimes the raising caesarean rates in Bangladesh are just seen as part of the global trend and with 31% we are still in the lower rates, except for mostly African countries. But we have to look more closely: There is no other country combining such high facility caesarean rates with still very high numbers of unattended births. What does that mean? If we take the caesarean rate apart by wealth quintile, we see that the poor have a CS-rate below 10% which indicates that still many women don’t get a caesarean in time to safe their or their baby’s lives. Most of those deliver at home with a dai and the sometimes harmful support by a village doctor.
On the other end we have the CS-rates of the wealthiest people going above 80%, which means many are getting a cesarean who would have delivered normally at a proven lower risk for mom and baby. Some of the caesarean deliveries are done in a high quality hospitals, some in clinics without neonatologist or available blood bank where potential complications like severe bleeding may not be treated ideally.
Many people are not aware that there are many different kinds of potential complications in childbirth that can be a threat to the mother or the baby. Only for some of them cesarean section is the treatment. To treat the most common problems leading to mothers dying, bleeding and eclampsia, drugs play a major role, but it was found in BMMS 2016 that in almost two thirds of the delivery facilities these drugs were not available. Deliveries will only be safer when we overcome these problems.
Often doctors in Bangladesh are offering cesarean section because they cannot offer any safe alternative vaginal delivery. Most public hospitals don’t have midwives to support the woman in labour, observe if progress is normal and don’t routinely monitor the fetal heart rates to assure the baby is doing well. Except for Medical Colleges there is often no doctor available to do a cesarean section if needed out of hours. Many private clinics don’t even have a labour room and no emergency services. Facilities that promote a good birth experience and painless births like in many Western countries are hard to find, even in Dhaka.
So should we just go for the safer way of a planned cesarean? There is yet another dimension to consider. Let’s look at Rohima’s story:
Rohima knew that after having had a cesarean section for her first child she would need another cesarean for her second child. Before her due date, labour started in the night. All night the family was looking for a hospital to have her cesarean done, but only in the morning they arrived in a clinic and when the doctor finally came the scar had torn and the baby died in her womb. Because of massive bleeding her uterus needed to be removed to safe her life. Sadly she noticed few days after the operation that she was constantly loosing urine, caused by a fistula due to injury to her bladder. Thankfully she could be successfully treated (at LAMB hospital).
Even though getting a fistula is a rare complication, we have to be aware that women with previous cesarean have a much increased risk in their following pregnancies. If we don’t have systems in place that offer 24/7 safe vaginal deliveries and treatment of possible complications in the first place, we will find that problems get even worse for those who went for a safer cesarean for their first child.
Last year more than 1000 midwives have been posted all over the country and many more are getting trained. Many initiatives from OGSB and government side are taken to improve obstetric emergency services. Let’s continue to work together to give Bangladeshi women the choice of a safe vaginal delivery, which mostly is safer than a cesarean section!
In Europe midwifery care had lead to massive reduction of mothers and babies dying, long before there were doctors doing cesarean sections. It is not an easy task to catch up on this lack of midwifery tradition, but surrounding countries have proven it is possible, like e.g. Thailand, who only started training midwives in the 60s and has today a Maternal Mortality Rate of 20 per 100’000.
Let’s make vaginal and caesarean deliveries safer in Bangladesh!
Dr. Beatrice Ambauen-Berger, Consultant Obstetrics and & Gyanecology, LAMB Hospital Parbatipur