RESEARCH ARTICLE
Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014 Md. Nuruzzaman Khan1, M. Mofizul Islam2, Asma Ahmad Shariff3, Md. Mahmudul Alam4, Md. Mostafizur Rahman5*
a1111111111 a1111111111 a1111111111 a1111111111 a1111111111
1 Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh, 2 Department of Public Health, La Trobe University, Melbourne, Australia, 3 Centre of Foundation Studies in Science, University of Malaya, Kuala Lumpur, Malaysia, 4 Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh, 5 Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh * [email protected]
Abstract OPEN ACCESS Citation: Khan M.N, Islam MM, Shariff AA, Alam M.M, Rahman M.M (2017) Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014. PLoS ONE 12(5): e0177579. https://doi.org/ 10.1371/journal.pone.0177579
Background Globally the rates of caesarean section (CS) have steadily increased in recent decades. This rise is not fully accounted for by increases in clinical factors which indicate the need for CS. We investigated the socio-demographic predictors of CS and the average annual rates of CS in Bangladesh between 2004 and 2014.
Editor: Mahfuzar Rahman, BRAC, BANGLADESH Received: November 9, 2016 Accepted: April 28, 2017 Published: May 11, 2017 Copyright: © 2017 Khan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Methods Data were derived from four waves of nationally representative Bangladesh Demographic and Health Survey (BDHS) conducted between 2004 and 2014. Rate of change analysis was used to calculate the average annual rate of increase in CS from 2004 to 2014, by socio-demographic categories. Multi-level logistic regression was used to identify the sociodemographic predictors of CS in a cross-sectional analysis of the 2014 BDHS data.
Result
Data Availability Statement: BDHSs data were collected from the MEASURE DHS. The authors are restricted in sharing or making the dataset publicly available. Interested readers can download this dataset after registering with the MEASURE DHS. Necessary information are available at: http:// dhsprogram.com/data/Using-DataSets-forAnalysis.cfm.
CS rates increased from 3.5% in 2004 to 23% in 2014. The average annual rate of increase in CS was higher among women of advanced maternal age (35 years), urban areas, and relatively high socio-economic status; with higher education, and who regularly accessed antenatal services. The multi-level logistic regression model indicated that lower (19) and advanced maternal age (35), urban location, relatively high socio-economic status, higher education, birth of few children (2), antenatal healthcare visits, overweight or obese were the key factors associated with increased utilization of CS. Underweight was a protective factor for CS.
Funding: The authors received no specific funding for this work.
Conclusion
Competing interests: The authors have declared that no competing interests exist.
The use of CS has increased considerably in Bangladesh over the survey years. This rising trend and the risk of having CS vary significantly across regions and socio-economic status.
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
1 / 15
Socio-demographic determinants of caesarean delivery
Very high use of CS among women of relatively high socio-economic status and substantial urban-rural difference call for public awareness and practice guideline enforcement aimed at optimizing the use of CS.
Introduction Caesarean Section (CS) is a surgical procedure to prevent poor obstetric outcomes and can be life-saving for both mother and fetus [1]. CS reportedly prevents approximately 187,000 maternal and 2.9 million neonatal deaths annually worldwide [1, 2]. However, unnecessary CS presents risks for both women and neonates [3, 4]. On the basis of findings from the survey of 373 facilities across 24 countries in 2008, the World Health Organization (WHO) concluded that unnecessary CS increases the risk of maternal mortality and morbidity, neonatal death, neonatal admission to intensive care [5]. These findings were recently supported by a hospital based prospective study, which used data from nine countries in the wider Asian region (Bangladesh, China, Indonesia, Mongolia, Myanmar, Nepal, Thailand, Sri Lanka, Vietnam) [6]. In addition to potential adverse health consequences, unnecessary CS also causes a substantial economic burden on individual, family and overall society [7]. The estimated cost of post-partum medical care and re-hospitalization associated with unnecessary CS is approximately US$ 2.32 billion globally [7]. Over the past few decades there has been upward trend in global CS rates [8]. While very low and very high rates of CS can be harmful, an optimum rate is unknown. According to WHO, 5–15% is a reasonable range estimate [4] until further research produce a better estimate. In 2014 around 18% of the world’s births were delivered by CS [8]. The highest rate of CS (32%) was reported in Latin America and the Caribbean region, while the African region reported the lowest rate (7%) [8]. A recent analysis of combined data of demographic and health surveys of the 43 Asian and African countries found higher rate of CS among the urban rich and a lower rate among the rural poor women [9]. Several studies, mainly from high- and middle-income countries, examined the determinants of CS use, but results were conflicting [10–12]. A recent cohort study in the United States showed that prior CS was the strongest indication of CS operation [13]. A systematic review of 17 studies found maternal choice was the strongest indication of CS [14]. Two regional studies in Bangladesh found maternal education, age, birth order and prolonged labour were significant factors for caesarean delivery [11, 15]. However, these studies did not explore the variation in CS across different socio-demographic variables and were limited to only some specific determinants. Moreover, instead of national data only regional data were used. It is important that regional variation is accounted for, otherwise the national rate can mask substantial degree of intra socio-geographic variation. Identification of factors, while adjusted for regional variation, can inform appropriate measures in rationalizing utilization of CS. Bangladesh has achieved remarkable success in improving maternal and child health. The majority (79%) of the Bangladeshi women now receive antenatal care, and 36% receive postnatal care [16]. In 2014, overall 37% of births were delivered informal healthcare facilities including 22% births in the private facilities, of which a staggering 61% and 77% of births ended in CS, respectively [16, 17]. A number of factors may influence this increasing rate of CS in Bangladesh, including high rate of adolescent pregnancy (35%), increasing rate of late aged pregnancy (5%), improving educational and socio-economic status of mothers, and the ongoing dual nutritional burden (co-existing conditions of under and over nutrition) [15, 18]. However, there is no clear indication as to which socio-demographic groups are experiencing
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
2 / 15
Socio-demographic determinants of caesarean delivery
the relative upward or downward trends in utilization of CS, and if these trends are influenced by factors such as locations. It is important, therefore, to carry out a comprehensive analysis of the relative rate of change in the prevalence of CS in Bangladesh and identify the factors influencing this change. The primary objective of this study was to (i) determine change over time in the average annual rates of CS by selective socio-demographic factors, and (ii) identify the significant socio-demographic factors of CS in 2014.
Methods Study design and data sources We analyzed four waves of data of Bangladesh Demographic and Health Surveys (BDHSs), which were conducted between 2004 and 2014. These nationally representative cross-sectional household surveys were conducted approximately every three years in all seven administrative regions (divisions): Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur and Sylhet–covering both rural and urban areas. Each division is sub-divided into districts and each district into sub-districts (Upazilas), which are further divided into rural and urban areas. Each wave of these surveys used two-stage cluster sampling whereby enumeration areas (clusters) were first drawn from the national population and housing census sampling frame conducted in 2001 and 2011 by Bangladesh Bureau of Statistics [16, 19–21]. In the first stage of sampling, 600 primary sampling units were selected, with the probability of selection proportional to the unit size. In the second stage, 30 households were selected within each primary sampling unit by systematic random sampling. Further details about sampling design and other related issues of BDHSs can be found elsewhere [16, 19–21]. The overall response rate was around 98%. These surveys are periodically conducted by the National Institute of Population Research and Training where the United States Agency for International Development provided financial support and ICF International of Calverton, USA offered technical support. National Research Ethics Committee in Bangladesh reviewed and approved the survey protocol. Data collection procedures were also approved by the ORC Macro (Macro International Inc) Institutional Review Board. Informed consent was obtained from all participants. The BDHSs collect a range of information including intimate partner violence. Because the existence of a signed consent form can provide a risk in itself for the abused person, oral informed consent was obtained from respondents by interviewers. The ethics committee approved this consent procedure. These surveys were conducted to collect data on a wide range of population for monitoring a range of indicators including health and nutrition. Detailed information on the socio-demographic characteristics of all participants were collected by trained staff. Each wave of these surveys used standard questionnaire and little or no differences exist between the questionnaires across the waves.
Outcome variable Our primary outcome was the method of pregnancy delivery. The BDHS collected a range of birth information including baby weight, method of pregnancy delivery, and type of pregnancy complication from each of the respondents who were of at least 15 years old and who gave birth within the last three years prior to the survey. Respondents were also asked about the method of pregnancy delivery for their last child and were flagged if caesarean delivery was reported.
Explanatory or independent variables A range of socio-demographic variables were used in this study based on previous research demonstrating the importance of these factors [11, 22–24]. The potential determinants were
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
3 / 15
Socio-demographic determinants of caesarean delivery
the age of women during delivery (19, 20–34, 35 years), respondent’s place of residence (rural, urban), wealth quintile (poorest, poorer, middle, richer, richest) [25], region (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, Sylhet), interval between deliveries (2 year, 3–4 year, 5 year), number of births delivered (2, 3–4, 5), maternal body mass index (underweight, normal weight, overweight, obese) and the number of antenatal visits (no visits, 1–4 visits, >4 visits). Level of education was described in mean years of schooling completed, and was used as a categorical variable (no formal education, primary, secondary, higher) in regression models.
Statistical analysis Rate of change analysis was performed by using four successive BDHS data conducted in 2004, 2007, 2011 and 2014. For this analysis the average annual rate of increase (AARI) was calculated by using the formula Yt+n = Yt (1 + r)n for caesarean delivery in which Yt = prevalence of caesarean delivery of any given year, r = annual rate of change, n = number of years between two surveys, and Yt+n = prevalence of caesarean delivery of the (t + n)th year. This formula was adopted and modified based on the information provided in the UNICEF technical note [26]. In this dataset individual women were nested within household, households were nested within cluster/primary sampling unit, and clusters were nested within regions. To account for this multiple hierarchy and dependency in data, we performed multi-level logistic regression to assess the factors associated with CS recorded in 2014 dataset. Additionally, we performed likelihood test to choose preferable models. The tests compared random effects model against fixed effects model and found statistically significant results (p4
0.76
1.13
0.10
2.11
0.28
6.91
2.32
0.85 1.99
Maternal body mass index Underweight (
Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014 Md. Nuruzzaman Khan1, M. Mofizul Islam2, Asma Ahmad Shariff3, Md. Mahmudul Alam4, Md. Mostafizur Rahman5*
a1111111111 a1111111111 a1111111111 a1111111111 a1111111111
1 Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh, 2 Department of Public Health, La Trobe University, Melbourne, Australia, 3 Centre of Foundation Studies in Science, University of Malaya, Kuala Lumpur, Malaysia, 4 Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh, 5 Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh * [email protected]
Abstract OPEN ACCESS Citation: Khan M.N, Islam MM, Shariff AA, Alam M.M, Rahman M.M (2017) Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014. PLoS ONE 12(5): e0177579. https://doi.org/ 10.1371/journal.pone.0177579
Background Globally the rates of caesarean section (CS) have steadily increased in recent decades. This rise is not fully accounted for by increases in clinical factors which indicate the need for CS. We investigated the socio-demographic predictors of CS and the average annual rates of CS in Bangladesh between 2004 and 2014.
Editor: Mahfuzar Rahman, BRAC, BANGLADESH Received: November 9, 2016 Accepted: April 28, 2017 Published: May 11, 2017 Copyright: © 2017 Khan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Methods Data were derived from four waves of nationally representative Bangladesh Demographic and Health Survey (BDHS) conducted between 2004 and 2014. Rate of change analysis was used to calculate the average annual rate of increase in CS from 2004 to 2014, by socio-demographic categories. Multi-level logistic regression was used to identify the sociodemographic predictors of CS in a cross-sectional analysis of the 2014 BDHS data.
Result
Data Availability Statement: BDHSs data were collected from the MEASURE DHS. The authors are restricted in sharing or making the dataset publicly available. Interested readers can download this dataset after registering with the MEASURE DHS. Necessary information are available at: http:// dhsprogram.com/data/Using-DataSets-forAnalysis.cfm.
CS rates increased from 3.5% in 2004 to 23% in 2014. The average annual rate of increase in CS was higher among women of advanced maternal age (35 years), urban areas, and relatively high socio-economic status; with higher education, and who regularly accessed antenatal services. The multi-level logistic regression model indicated that lower (19) and advanced maternal age (35), urban location, relatively high socio-economic status, higher education, birth of few children (2), antenatal healthcare visits, overweight or obese were the key factors associated with increased utilization of CS. Underweight was a protective factor for CS.
Funding: The authors received no specific funding for this work.
Conclusion
Competing interests: The authors have declared that no competing interests exist.
The use of CS has increased considerably in Bangladesh over the survey years. This rising trend and the risk of having CS vary significantly across regions and socio-economic status.
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
1 / 15
Socio-demographic determinants of caesarean delivery
Very high use of CS among women of relatively high socio-economic status and substantial urban-rural difference call for public awareness and practice guideline enforcement aimed at optimizing the use of CS.
Introduction Caesarean Section (CS) is a surgical procedure to prevent poor obstetric outcomes and can be life-saving for both mother and fetus [1]. CS reportedly prevents approximately 187,000 maternal and 2.9 million neonatal deaths annually worldwide [1, 2]. However, unnecessary CS presents risks for both women and neonates [3, 4]. On the basis of findings from the survey of 373 facilities across 24 countries in 2008, the World Health Organization (WHO) concluded that unnecessary CS increases the risk of maternal mortality and morbidity, neonatal death, neonatal admission to intensive care [5]. These findings were recently supported by a hospital based prospective study, which used data from nine countries in the wider Asian region (Bangladesh, China, Indonesia, Mongolia, Myanmar, Nepal, Thailand, Sri Lanka, Vietnam) [6]. In addition to potential adverse health consequences, unnecessary CS also causes a substantial economic burden on individual, family and overall society [7]. The estimated cost of post-partum medical care and re-hospitalization associated with unnecessary CS is approximately US$ 2.32 billion globally [7]. Over the past few decades there has been upward trend in global CS rates [8]. While very low and very high rates of CS can be harmful, an optimum rate is unknown. According to WHO, 5–15% is a reasonable range estimate [4] until further research produce a better estimate. In 2014 around 18% of the world’s births were delivered by CS [8]. The highest rate of CS (32%) was reported in Latin America and the Caribbean region, while the African region reported the lowest rate (7%) [8]. A recent analysis of combined data of demographic and health surveys of the 43 Asian and African countries found higher rate of CS among the urban rich and a lower rate among the rural poor women [9]. Several studies, mainly from high- and middle-income countries, examined the determinants of CS use, but results were conflicting [10–12]. A recent cohort study in the United States showed that prior CS was the strongest indication of CS operation [13]. A systematic review of 17 studies found maternal choice was the strongest indication of CS [14]. Two regional studies in Bangladesh found maternal education, age, birth order and prolonged labour were significant factors for caesarean delivery [11, 15]. However, these studies did not explore the variation in CS across different socio-demographic variables and were limited to only some specific determinants. Moreover, instead of national data only regional data were used. It is important that regional variation is accounted for, otherwise the national rate can mask substantial degree of intra socio-geographic variation. Identification of factors, while adjusted for regional variation, can inform appropriate measures in rationalizing utilization of CS. Bangladesh has achieved remarkable success in improving maternal and child health. The majority (79%) of the Bangladeshi women now receive antenatal care, and 36% receive postnatal care [16]. In 2014, overall 37% of births were delivered informal healthcare facilities including 22% births in the private facilities, of which a staggering 61% and 77% of births ended in CS, respectively [16, 17]. A number of factors may influence this increasing rate of CS in Bangladesh, including high rate of adolescent pregnancy (35%), increasing rate of late aged pregnancy (5%), improving educational and socio-economic status of mothers, and the ongoing dual nutritional burden (co-existing conditions of under and over nutrition) [15, 18]. However, there is no clear indication as to which socio-demographic groups are experiencing
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
2 / 15
Socio-demographic determinants of caesarean delivery
the relative upward or downward trends in utilization of CS, and if these trends are influenced by factors such as locations. It is important, therefore, to carry out a comprehensive analysis of the relative rate of change in the prevalence of CS in Bangladesh and identify the factors influencing this change. The primary objective of this study was to (i) determine change over time in the average annual rates of CS by selective socio-demographic factors, and (ii) identify the significant socio-demographic factors of CS in 2014.
Methods Study design and data sources We analyzed four waves of data of Bangladesh Demographic and Health Surveys (BDHSs), which were conducted between 2004 and 2014. These nationally representative cross-sectional household surveys were conducted approximately every three years in all seven administrative regions (divisions): Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur and Sylhet–covering both rural and urban areas. Each division is sub-divided into districts and each district into sub-districts (Upazilas), which are further divided into rural and urban areas. Each wave of these surveys used two-stage cluster sampling whereby enumeration areas (clusters) were first drawn from the national population and housing census sampling frame conducted in 2001 and 2011 by Bangladesh Bureau of Statistics [16, 19–21]. In the first stage of sampling, 600 primary sampling units were selected, with the probability of selection proportional to the unit size. In the second stage, 30 households were selected within each primary sampling unit by systematic random sampling. Further details about sampling design and other related issues of BDHSs can be found elsewhere [16, 19–21]. The overall response rate was around 98%. These surveys are periodically conducted by the National Institute of Population Research and Training where the United States Agency for International Development provided financial support and ICF International of Calverton, USA offered technical support. National Research Ethics Committee in Bangladesh reviewed and approved the survey protocol. Data collection procedures were also approved by the ORC Macro (Macro International Inc) Institutional Review Board. Informed consent was obtained from all participants. The BDHSs collect a range of information including intimate partner violence. Because the existence of a signed consent form can provide a risk in itself for the abused person, oral informed consent was obtained from respondents by interviewers. The ethics committee approved this consent procedure. These surveys were conducted to collect data on a wide range of population for monitoring a range of indicators including health and nutrition. Detailed information on the socio-demographic characteristics of all participants were collected by trained staff. Each wave of these surveys used standard questionnaire and little or no differences exist between the questionnaires across the waves.
Outcome variable Our primary outcome was the method of pregnancy delivery. The BDHS collected a range of birth information including baby weight, method of pregnancy delivery, and type of pregnancy complication from each of the respondents who were of at least 15 years old and who gave birth within the last three years prior to the survey. Respondents were also asked about the method of pregnancy delivery for their last child and were flagged if caesarean delivery was reported.
Explanatory or independent variables A range of socio-demographic variables were used in this study based on previous research demonstrating the importance of these factors [11, 22–24]. The potential determinants were
PLOS ONE | https://doi.org/10.1371/journal.pone.0177579 May 11, 2017
3 / 15
Socio-demographic determinants of caesarean delivery
the age of women during delivery (19, 20–34, 35 years), respondent’s place of residence (rural, urban), wealth quintile (poorest, poorer, middle, richer, richest) [25], region (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, Sylhet), interval between deliveries (2 year, 3–4 year, 5 year), number of births delivered (2, 3–4, 5), maternal body mass index (underweight, normal weight, overweight, obese) and the number of antenatal visits (no visits, 1–4 visits, >4 visits). Level of education was described in mean years of schooling completed, and was used as a categorical variable (no formal education, primary, secondary, higher) in regression models.
Statistical analysis Rate of change analysis was performed by using four successive BDHS data conducted in 2004, 2007, 2011 and 2014. For this analysis the average annual rate of increase (AARI) was calculated by using the formula Yt+n = Yt (1 + r)n for caesarean delivery in which Yt = prevalence of caesarean delivery of any given year, r = annual rate of change, n = number of years between two surveys, and Yt+n = prevalence of caesarean delivery of the (t + n)th year. This formula was adopted and modified based on the information provided in the UNICEF technical note [26]. In this dataset individual women were nested within household, households were nested within cluster/primary sampling unit, and clusters were nested within regions. To account for this multiple hierarchy and dependency in data, we performed multi-level logistic regression to assess the factors associated with CS recorded in 2014 dataset. Additionally, we performed likelihood test to choose preferable models. The tests compared random effects model against fixed effects model and found statistically significant results (p4
0.76
1.13
0.10
2.11
0.28
6.91
2.32
0.85 1.99
Maternal body mass index Underweight (
