Too many yet too few caesarean section deliveries in Bangladesh: an ongoing public health challenge to improve maternal and child health

Background: Caesarean section (CS) use is on the rise in Bangladesh, particularly among women in improved socio-economic condition. However, the deficit use of CS remains common among disadvantage women in terms of employment, education, wealth quintile, and place of residence. This increases risks of long-term obstetric complications as well as maternal and child deaths. We aimed to determine the interaction effects of women disadvantage characteristics on CS use in Bangladesh. Methods: A total of 27,093 women data analysed extracted from five rounds of the Bangladesh Demographic and Health Survey, conducted between 2004 and 2017/18. The inclusion criteria used to select these women were: (i) having at least one child within three prior to the survey, (ii) reported delivery methods and place, and (iii) do not have twin or more ordered pregnancy for the most recent live birth. The major exposure variables were type of health facilities, divisions, place of residence, economic status, and maternal education. Other factors considered were factors at the individual and household level. The outcome variable was CS use, coded as use (1) and non-use (0). Multilevel logistic regression model was used to determine association of CS with socio-demographic characteristics and the interactions of the working status and wealth quintile with place of residence. Results: We reported a 751% increase of CS use over the last 13 years, from 3.88% in 2004 to 33% in 2017/18. Nearly, 80% of these occurred in private health facilities followed by government health facilities (15%). Rural women with no engagement of formal income-generating activity showed 11% (OR, 0.89, 95% CI, 0.71-0.99) lower use of CS in 2004. This association was further strengthened with the year passes, and a 51% (OR, 0.49, 0.03-0.65) lower in CS use was reported in 2017/18. Similarly, around 12%-83% lower likelihoods of CS use were found among rural poor and poorer women. Conclusion Bangladesh is facing a double burden of CS, that is a group of women with the improved socio-economic condition using this life-saving procedure without medical necessity while their counterpart of disadvantaged characteristics could not access this service. Improved monitoring from the government along with support to use CS services for the disadvantaged groups on necessity are important.