‘Big C-section industry’ in Bangladesh is endangering reproductive health of millions of mothers to make billions

At least 860,000 C-sections were performed in Bangladesh in 2018 and 77 percent of them were "unnecessary". It morphed into an industry that generates Tk 70 billion in revenue a year, according to a report

During her second trimester of pregnancy, Saima Tanha was told by her obstetrician-gynaecologist, commonly referred to as ob-gyn, to “get ready for (sic) caesare.”

Ceasere is the short form of caesarean section, also known as C-section or Caesarean delivery, which is a surgical procedure of delivering babies through an incision in the mother's abdomen, only preferred when a normal vaginal delivery would put the baby or the mother at risk.

At first, the ob-gyn said the C-section is necessary because the positioning of the baby in the uterus was too high for normal delivery. After a few weeks, Saima was told that since she was “below average height” than other expecting mothers, a C-section needed to be performed no matter what.

Saima knows better now.

She suspects the ob-gyn somewhat pushed her to opt for C-section though she did not need it at the time. C-sections are marketed by clinics as the “easy” way to give birth, but they are not without risks.

According to the World Health Organisation, a maximum of 10-15 percent of expecting mothers may require C-sections while delivering their babies. In 2016 alone, that number was a shocking 31 percent,

The Bangladesh Chapter of Save the Children, a UK-based charity which works for children’s welfare, in a report said according to their counts, at least 860,000 C-sections were performed in Bangladesh in 2018 and 77 percent of them were "unnecessary".

The most striking thing in the report was the economic part.

If the level of fluid within the wall of the uterus somehow gets below normal, or if a mother had gone through a C-section once before, a mother would require a C-section. Other than these, any C-section will be deemed unnecessary.

Dr Halima Akhter Happy

According to the report, families have spent at least Tk 38.65 billion in a single year to have their babies delivered, and in about 80 percent of the cases, the mothers did not need it.

By all means, the revenue that has been generated from this “often unnecessary” procedure is close to what some of the major industries in Bangladesh are generating now.

Dr Halima Akhter Happy, an ob-gyn attached to the gynaecology department of Dhaka Medical College Hospital, said general medical guidelines only allow doctors to perform a C-section under some particular situations.

“If the level of fluid within the wall of the uterus somehow gets below normal, or if a mother had gone through a C-section once before, a mother would require a C-section. Other than these, any C-section will be deemed unnecessary,” she said.

The High Court in a 2019 ruling instructed the government to come up with strict guidelines for doctors within six months to stop the growing trend of unnecessary C-sections which, public health experts say, has reached 'epidemic' proportions.

It’s been three years and the guideline, according to the authorities, is still in the drafting stage.

SO, WHY ARE DOCTORS RECOMMENDING THIS PROCEDURE?

Simply put, for money.

Sharmin Banna, a professional midwife and trained maternity support worker, shared her experience with an expecting mother.

Sharmin said the ob-gyn and the clinic the mother was attached with “tactfully nudge” the worried and emotional pregnant woman over several months toward C-section and at some point she started to believe a C-section is the safest way to carry her pregnancy to terms.

“That mother was told by the clinic that she needed a Caesarian [C-section] since her baby weighs over 3 kg. It took a lot of effort, but I eventually managed to convince her to opt for normal delivery. The baby was healthy, weighed 3.8 kg and the mother didn’t face any post-delivery complications,” she said.

Saima, the woman who eventually realised that she never needed to undergo the procedure, painted a detailed picture of the so-called “nudging process”.

“In my case, at first it was the baby positioning factor. I went for a second opinion from a relative, who is also an ob-gyn, and she told me that even if the baby’s position is higher now in the second trimester, it will move in the days to come, so I didn’t need a C-section,” she said.

“My original ob-gyn then brought up my height factor. She said my height, which is five feet and one inch, is ‘lower than average', which may play a big role while delivering the baby normally.”

“Eventually I was sort of pushed to have my first baby with C-section, and for this sole reason, I had to go for C-section again while having my next babies,” Saima said.

Ishtiaq Mannan, a former deputy country director of Save the Children, said it was their report which triggered the legal pursuit to ensure reproductive safety being jeopardised by unnecessary C-sections and millions of savings drained by families after being “duped” by their ob-gyns.

“Our analysis clearly showed the co-relation between unnecessary C-sections and financial hardship faced by families later,” he said.

A mother was told by the clinic that she needed a Caesarian [C-section] since her baby weighs over 3 kg. It took a lot of effort, but I eventually managed to convince her to opt for normal delivery. The baby was healthy, weighed 3.8 kg and the mother didn’t face any post-delivery complications.

Sharmin Banna

WHAT HAPPENED TO THE GUIDELINE?

Almost three years into the High Court ruling, the guideline is still very much in its infancy.

Lawyers who moved two separate public interest litigations told bdnews24.com that the government submitted the draft guideline to the High Court bench on Jan 29, 2020, but the follow-up court procedures were stalled as the pandemic forced an abrupt halt to the Supreme Court operation.

The court, however, has swung into full summer stride now, with the grip of COVID-19 pandemic loosening.

Rashna Imam, who moved one of the writ petitions on behalf of Bangladesh Legal Aid and Services Trust, or BLAST, said the legal charity asked the court for some time to go through the draft so that it can come up with some recommendations as well.

“We [BLAST] wanted to speak to some independent experts to verify if the draft needed something more or not. We had recommended some in the meantime. But then the pandemic arrived in full force,” she said.

Though the said guideline is yet to be made official, Ishtiaq said the Directorate General of Health Services, or DGHS, the Bangladesh government’s department responsible for health services, has already put some of the provisions to work.

“[For instance] The DGHS has introduced a form, in which," he said, "it is mandatory for every maternity clinic and hospital to file some information about the number of normal deliveries and C-sections they are performing at a certain period and under what circumstances.”

The government, in line with the High Court ruling, also set up a high-level panel with stakeholders and experts to prepare the draft guideline. The committee, however, went to sleep after the pandemic hit Bangladesh.

Ishtiaq said they are working as of now to reinitiate the activities of the committee, while Rashna said her legal team will focus on reactivating the legal process.

INS AND OUTS OF THE DRAFT GUIDELINES

Azizul Alim, deputy programme manager at the DGHS, told bdnews24.com that short and long-term plans have been incorporated into the draft guideline.

The guideline, he said, emphasised reviewing the weaker provisions of the patient rights law, and record-keeping and updating the reporting system to ensure accountability in the health sector.

Lawyer Rashna said the government must make sure every clinic and hospital keeps an updated record system so that a disgruntled mother can ask a court to examine whether a C-section was indispensable in her case.

She also said the need for regular medical audits was also underlined in the draft to make sure every maternity facility delivers the best possible care to patients.

“The guideline also highlighted the necessity of holding regular ethics seminars for physicians when it comes to maternity cases,” Rashna said.

Private facilities can’t be forced to follow guidelines unless they want to. That’s why making a law to that end is necessary.

Ishtiaq Mannan

THE GOVERNMENT INITIATIVES

Md Saiful Hasan Badal, secretary at the health education and family welfare division, alleged that while most government maternity facilities recommended normal deliveries in most cases, private clinics and hospitals push for C-sections in “100 percent” of the cases to generate revenue.

He termed such practice “disrespectful to the mothers” and said the government by September this year will ensure the family welfare centres at 500 Upazila Health Complexes can provide expecting mothers with round-the-clock care so that they do not have to seek medical attention in private facilities.

“We would like to motivate our colleagues at family welfare centres in every way. We are also working to arrange ethics seminars for the doctors,” he said.

Ishtiaq, who is part of a campaign against "unnecessary C-sections", also highlighted the fact that guidelines are not legally binding, so he stressed turning the draft guideline into law as soon as possible.

“Private facilities can’t be forced to follow the guideline unless they want to. That’s why tailoring a law to that end is necessary,” he said.

Programme Manager Azizul passed the buck to the government when he was asked about the possibility of transforming the guideline into law.

“If the High Court approves the guideline," he said, "we [DGHS] will issue a gazette notification." The rest is up to the ministry [Ministry of Health and Family Welfare].”

[Writing in English by Adil Mahmood; editing by Biswadip Das]