1. Rise of Medically Unnecessary Cesarean Sections: Why are they happening?

2. Why concern?
Global and regional trends in caesarean section, 1990–2014
Betrán AP, Ye J, et al 2014

3. Geographical distribution of C-section rates 2014
Why concern?
Geographical distribution of C-section rates 2014
Betrán AP, Ye J, et al 2014

4. Where are we now? National trends in caesarean section, 2004–2014
1.9 percentage point increase per year!
Bangladesh Demographic and Health Surveys

5. Three broad domains of factors
Health Systems
Provider-Level
Patient level
C-section
Even though your study is focusing upon the provider level factors, all three of these areas are interconnected. So we began our literature review by looking at all three areas.

6. Patient/Mother Level factors

7. Perceptions Surrounding C-section
C-sections are less painful
Less painful, epidurals are available, not covered in NVD cost
Women “fearful” about childbirth prefer CS
“Too posh to push”- high income groups
C-sections are safer than normal deliveries
The best quality of care
Reduce foetal distress, mortality, excessive pain, and trauma to the vagina, no episiotomy required
Baby’s well being
More modern and appropriate forms of care
Previous negative birthing experience
how women share their experiences with birth and C-section highly influence other women’s birthing choices
Previous C-sections require subsequent C-section
Mothers can not have NVD if they had previous C-section

8. Perceptions Surrounding C-section
C-sections act as a form of contraception
C-Sections will prevent future pregnancies
Assisted birth techniques are dangerous to the baby
parents prefer C-Section over assisted vaginal delivery to avoid baby’s injury
Status symbol
“wealthy” women get this procedure done and they want to be like these women
indicator of “high social class”
Privacy (?)
C-Section is considered as a “new normal”
“other women, including obstetricians themselves preferred C-section”
Perceive everyone is getting a C-Section
Limited involvement in decision making process
Women were uninformed/poorly informed ,
Family takes decision often based on doctors advice (mutual agreement)

9. Women's characteristics with higher C-section
Advanced maternal age >35, low maternal age <19
No consensus on what a healthy maternal age bracket
Urban location
More private facility delivery more CS
Relatively high socioeconomic status
mother would change facilities if C-section services are not provided
costs of C-section are not often affordable for them in lower socioeconomic situations, drives catastrophic expenditure
Higher education
Higher ANC attendance
ANC visits correlates with more institutional deliveries and consequently more C-sections
doctors played upon patients and their anxieties and scheduled C-sections during antenatal care visits
Decreasing parity- “precious child”
Being overweight/obese
Hopkins, K. (2000). Are Brazilian women really choosing to deliver by cesarean? Social science & medicine, 51(5), doi:

10. Health System Factors

11. Health systems weakness
Human resource
Limited staff makes scheduling a C-section during working hours
Absence of full time specialists during after hours leads 1st and 2nd year residents feel comfortable to conduct C-section
Gaps in awareness of ideal practice among providers
Public policy and guidelines
Absence /poor compliance monitoring of national protocol /guideline
Greater financial incentive for C-sections over NVD in programmes
Privatization/growing private sector
Competition between the public and private sector
Perceived better quality of care in private sector
“Agents” from private facilities at public facilities
Limited public sector monitoring and accountability for private sector
C-section is sold as packaged service
Absence/limited functioning referral system
Physical infrastructure: “Natural deliveries are not in good condition…have to share basins in front of one another”
Hopkins, K. (2000). Are Brazilian women really choosing to deliver by cesarean? Social science & medicine, 51(5), doi:

12. Provider Level Factors

13. Provider Characteristics
Gender
Male physicians are more likely to delivery through CS
Training and experience
Young obstetricians feels uncomfortable doing NVD in specific obstetrical indications (such as twin pregnancies or breech presentations)
Residents felt more comfortable doing C-sections and often afraid of seeking advice because they would appear incompetent
Physicians with higher numbers of deliveries have lower rates of CS
Physicians own birthing experiences may influence
Obstetricians showed interventionist attitudes in relation to their own preferred mode of delivery

14. Skills and competence of providers
Meet requirements for medical school
Higher rate of CS in teaching hospitals because trainees want chances to practice
Learn C-section before becoming second year residents
Receives inadequate training on delivery protocols
Misconception that C-section is required for every women with previous C- sections
Some health care providers credit C-sections with the reduction of maternal mortality
Limited/no availability of established guideline for deciding upon necessity of C-section (partograph is for after the labour onset)
Use of more subjectively defined indications
Uncomfortable with assisted delivery techniques
(non-reassuring fetal heart tracings, labor arrest disorders, and suspected macrosomia- large sized baby)

15. Financial incentives Dual practice
Doctors practice in both the private facilities and public facilities
C-sections are more financially lucrative
Doctors, particularly those in the private sector, have financial incentive for encouraging C-sections
Financial schemes often compensate more for C-section than NVD
Hospital owners/ business man/ clinics own a high interest in doing C-Section (sometimes set business deal)

16. Providers’ perspective
Convenience
C-sections allow the convenience of setting the date and time
NVD takes much longer time than C-section
Fear/sense of insecurity/pressured by patients
Patient will go to another health facility
Fear of litigation in case of any neonatal adverse event
CS as a cautious alternative: not having enough resource in after hour to handle emergency
Attitude to compliance to protocol
Provider are aware of evidence based practice, however, they believe they do not need to use partograph
Specialists are more interested in C-sections;
Normal delivery is not expert’s job
Rising competition among junior and senior doctors

17. C-section- mutual agreement between provider & client
Charu et al 2016

18. Strategies to prevent unnecessary C-sections
Mandatory second opinion (Argentina, Brazil, Cuba, Guatemala)
small but significant reduction in rates of caesarean section (relative rate of reduction 7·3%)
Hospital policy was modified to provide co-management for cesarean (second opinion from a supervising obstetrician) (Ecuador)
number of caesareans reduced while the number of monthly deliveries increased
Audits of indications for Caesarean delivery, provision of feedback to health professionals, and implementation of best practices (Canada, Taiwan)
significant but small reduction

19. Strategies to prevent unnecessary C-sections
Crisis- oriented counselling of mothers in fear of birth by team consisted of two experienced midwives with additional training in mental health, a senior obstetric consultant and social worker (Norway)
86% changed their original request for caesarean section
Labor and birth care by nurse with midwifery skills (Brazil)
Rate of C-section was lower in maternities that had nurses/nurse-midwives in birth care
Implementation of Obstetric Care Consensus Guideline (USA)
C-section rate reduced both overall and target group
defining 6 cm dilatation as the threshold for active labor and advocating for longer durations of expectant management before cesarean delivery for labor arrest
Used on Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses

20. Acknowledgements Sathya Doraiswamy Aniqa Hasan Farhana Karim
Charu Chhetri
Mohiuddin Ahsanul Kabir Chowdhury