UBC Faculty Research and Publications

A qualitative study to explore the attitudes of women and obstetricians towards caesarean delivery in… Begum, Tahmina; Ellis, Cathryn; Sarker, Malabika; Rostoker, Jean-Francois; Rahman, Aminur; Anwar, Iqbal; Reichenbach, Laura Sep 12, 2018

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-12884_2018_Article_1993.pdf [ 526.19kB ]
JSON: 52383-1.0372031.json
JSON-LD: 52383-1.0372031-ld.json
RDF/XML (Pretty): 52383-1.0372031-rdf.xml
RDF/JSON: 52383-1.0372031-rdf.json
Turtle: 52383-1.0372031-turtle.txt
N-Triples: 52383-1.0372031-rdf-ntriples.txt
Original Record: 52383-1.0372031-source.json
Full Text

Full Text

RESEARCH ARTICLE Open AccessA qualitative study to explore the attitudesof women and obstetricians towardscaesarean delivery in rural BangladeshTahmina Begum1* , Cathryn Ellis2, Malabika Sarker3,4, Jean-Francois Rostoker2, Aminur Rahman1, Iqbal Anwar1and Laura Reichenbach5AbstractBackground: Caesarean section is a lifesaving surgical intervention for women and their newborns, thoughoverutilization is a public health concern. The caesarean rate in Bangladesh is approximately 23% overall, and inprivate facilities it is over 70%. It is essential to know both the supply side (obstetricians) and demand side(parturient women) views on caesarean birth in order to formulate specific interventions to address the escalatingrate of caesareans.Methods: This qualitative study took place in Matlab, a rural sub-district in Bangladesh. We interviewed womenattending their 3rd antenatal visit, those with recent caesareans, and obstetricians from both public and privatehealth facilities. In total there were twenty in-depth interviews and four focus group discussions. Study participantswere asked about their preferences on birthing mode and knowledge of the caesarean section process. Thematicdata analysis was done following a deductive approach.Results: Women from this rural community had a strong preference for normal vaginal birth. However, they werewilling to accept the attending health care provider’s decision for caesarean birth. Antenatal care sessions did notprovide information on the medical indications for caesarean section. Furthermore, some women had themisconception that episiotomy itself is a ‘small caesarean.’ Primary health care providers and clinic agents (brokers)had a strong influence on women’s decision to choose a health facility for giving birth. However, obstetricians,having a preference for caesarean section, were receiving more patients from these brokers which may be animportant reason for the high rate of clinically non-indicated caesareans at private hospitals in Bangladesh.Improper labour monitoring and inadequate staffing at health facilities were additional influences on the preferencefor caesarean section. However, critical knowledge gaps were also observed among study obstetricians, particularlywith regards to the indications for and timing of elective caesarean sections.Conclusion: There is a need to educate women about the advantages and disadvantages of different birthingmodes to ensure their active participation in the decision making process. Strong policy regulations are needed toensure legitimate decision making by obstetricians regarding mode of birthing.Keywords: Caesarean delivery, Qualitative study, Perception, Attitude, Decision-making, Rural Bangladesh* Correspondence: tbegum@icddrb.org1Health Systems and Population Studies Division, International Centre forDiarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, BangladeshFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Begum et al. BMC Pregnancy and Childbirth  (2018) 18:368 https://doi.org/10.1186/s12884-018-1993-9BackgroundCaesarean section is a life-saving surgical intervention forwomen and their newborns though its recent overutiliza-tion is a global public health concern [1, 2]. On average,there is a 4.4% annual rise in caesarean section ratesworldwide, with Asian countries having the second high-est annual increase during the period 1990–2014 [1]. Inthis context, the global recommendation of a 10–15%national caesarean rate has been critiqued and a revisionurged [3]. A more recent multi-country survey conductedin 178 WHO member states has suggested that the popu-lation level caesarean section rate should not exceed 19%,as increased levels of neonatal and maternal mortalityhave been reported above this level [2]. Additionally, un-necessarily high caesarean rates have negative implications[4] at the individual, family, and national levels in terms ofwomen’s well-being, health expenditure, and efficient useof resources [1].When considering the reasons for rapidly increasingcaesarean section rates, non-clinical factors have emergedas equally important factors as clinical factors [5]. Lowerfees for vaginal birth, fear of litigation, and patient’srequests for the procedure are some of the non-clinicalreasons for physicians to conduct caesarean sections [6].Women who prefer caesarean birth consider vaginal birthto be a more painful and dangerous procedure, withoutconsidering the negative consequences of un-necessarysurgical intervention [7]. Women with higher economicstatus and more formal education are more likely to makea self-request for caesarean section [8, 9]. Conversely, poorwomen with little education are presumed to have inad-equate knowledge about caesarean section procedures[10] which is considered a significant barrier to involvingwomen and their families in decision making related tothe mode of birth [7]. As a result, service providers par-ticularly the attending physicians are evolving as the solodecision makers regarding mode of birth, in low-incomesettings [6, 7].However, physicians’ decisions also differ based on thelocation of clinical practice. Doctors working in a publicsector facility assess caesarean indications based on clinicalguidelines, while private practitioners are more concernedwith litigation issues and have a tendency to perform morecaesarean sections for making more business out of thisprocedure [11, 12]. This attitude might explain the increas-ing caesarean rate in for-profit private health facilities. Forexample, in Brazil the caesarean rate was 72% in the privatesector, compared to 31% in the public sector [13].In Bangladesh, maternal health has evolved within an ex-tensive national health care delivery system that includesperipheral level health posts (community clinics) and healthcentres (union health sub-centres and health and familywelfare centres) supported by primary, secondary, and ter-tiary level hospitals situated at sub-districts, districts, andregional levels respectively. Different cadres of technicaland lay community health workers are working for mater-nal health that include physicians, nurse-midwives; familywelfare visitors (FWV) and community skilled birth atten-dants (CSBAs). At the most peripheral level, the CSBAsand FWVs are the main maternal healthcare caregiverswho provide services both from health-posts and healthcentres, and through home-visits. At the government hos-pitals level nurses and midwives are the main caregivers forvaginal deliveries. Physicians work mostly at sub-district,district, and medical college hospitals and are responsiblefor managing complicated vaginal and caesarean births[14]. Until recently, there was no accredited midwifery pro-fessionals in Bangladesh educated to the standards of theInternational Confederation of Midwives (ICM) and WHO[14]. During the Millennium Development Goal (MDG)era, midwifery education drew special policy attention inBangladesh and a new strategic direction was initiatedresulting in a three-year diploma in midwifery programlaunched in 2013 by the Ministry of Health and FamilyWelfare with technical support from UNFPA and WHO.Six-month post-basic midwifery training for existing publicsector nurses was also organized as an interim effort to pro-duce a critical mass of ICM/WHO standard midwifery pro-fessionals [15]. To date, 800 midwives have been accreditedat a diploma level, and the vast majority of them have beendeployed in district and sub-district hospitals [15].In line with health related Sustainable DevelopmentGoals (SDG) targets, the government of Bangladesh iscommitted to improve access to both basic and compre-hensive emergency care services to reduce MaternalMortality Ratio (MMR). However, progress is slow; theBangladesh Demographic Health Survey (BDHS) 2014shows that the majority of births (63%) still take place athome, mostly with unskilled birth attendants [16]. Despitepoor progress in achieving high skilled attendance rate,the caesarean section rate increased from 4% in 2004 to23% in 2014, contributed mainly by the for-profit privatehealth sector [16].Experience from high-income settings suggest that ex-ploring obstetricians’ and women’s attitudes towards cae-sarean section might be a productive way to guide policyin reducing un-necessary caesarean sections [17]. However,such information is missing in a number of developingcountries such as Bangladesh. To bridge the knowledgegap in this area, the present study attempts to explore theattitudes of both women and obstetricians towards caesar-ean section birth in a rural area of Bangladesh.MethodsStudy design, setting and participantsWe conducted this qualitative study in 2012 in the ruralsetting of Matlab, a sub-district of Chandpur district inBangladesh. Matlab was selected as the study site becauseBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 2 of 11the proportion of births taking place in health facilities(80%), as well as caesarean section rate (29%) in this areawas much higher than the national average of 37% facilitydelivery rate and the 23% caesarean section rate [18]. Weused in-depth interviews (IDIs) and focus group discus-sions (FGDs) to investigate both client and provider viewson caesarean section as a mode of birth in a low-incomeover-medicalization contexts.The study participants were currently pregnant womenand recent post-caesarean mothers representing the de-mand side, and obstetricians working in public and privatehealth facilities representing the supply side. Study partici-pants were recruited from six health facilities, three publicand three private. Public health facilities were chosen insuch a way that covers a range of referral facilities that in-cluded one district hospital, one sub-district level UpazilaHealth Complex, and one union level Health and FamilyWelfare Centre (UHFWC). From the private sector two‘for-profit’ private hospitals and one ‘not-for-profit’ mater-nity clinic were selected as study sites. All private facilitieswere situated in Maltab township area. Of the six studyfacilities, the public sector district hospital and two of the‘for profit’ private facilities had capacity to performcaesarean sections while the remaining four were basicemergency obstetric care facilities where only vaginal birthstook place.Data collectionWomen’s participationTo explore women’s perspectives about caesarean sectionfour focus group discussions (FGDs) and 14 in-depthinterviews (IDIs) were conducted. FGDs were conductedwith pregnant women during their third trimester of preg-nancy while attending an antenatal care (ANC) visit in thestudy hospitals (public or private). In total 26 pregnantwomen participated in four FGDs. The third stage of preg-nancy was chosen because women usually develop a birthplan by this time, as their expected date of delivery (EDD)is approaching [19]. The FGD sessions were conducted ina separate room in the study hospitals after completion oftheir scheduled ANC consultation.A purposive sampling method was used to find the de-sired study participants from the targeted health facilities.Homogeneity of the participants in the focus groups wasmaintained in terms of education, socio-economic status,and area of residence. However, diversity in terms of parity,obstetric experience, and other socio-demographic charac-teristics was maintained while selecting FGD participants.We also conducted fourteen IDIs with post-caesareanwomen, nine from private clinics and five from publicsector health facilities. In private sector hospitals, we or-ganized IDIs with post-caesarean women on their 4thpostoperative day which took place in their hospital bed.Since no post-caesarean mothers were available in thepublic sector hospitals during the data collection period,women who had a caesarean in the Chandpur DistrictHospital within the last 42 days of the data collectionperiod were tracked and sampled for interviews. Weconducted IDIs with five such post-caesarean women andthe interviews took place in the local health sub-centerswhere they came for scheduled postnatal checkups.Obstetricians’ participationWe conducted six IDIs with obstetricians, three in pub-lic facilities and three in private hospitals. Only currentlypracticing obstetricians with advanced post-graduatetraining in obstetrics and gynaecology (training for morethan one year) from study hospitals were included. Aconvenience sampling method was used where obstetri-cians available in the study health facilities during datacollection period were approached for an interview. Theinterview took place in the obstetrician’s own visitingroom in the hospital after regular office hours.Each interview was forty-five to sixty minutes in length.Data collection was continued until saturation was reached.The data collection team comprised of the principal investi-gator (PI) and two experienced research assistants (RAs).All interviews were conducted by the PI while the RAs tooknotes. Each RA alternated with the other for each interviewand did the same for data transcription and development ofanalytic memos.We developed interview guidelines first in English andthen translated them into Bangla which was finalizedafter field-testing in a similar rural setting to confirm thecontent and to identify any missing themes. Three separ-ate guidelines were used to direct the interview sessionwith the three different type of study participants. Theinterview guidelines are added as supplementary file(Additional file 1) with this manuscript.All IDIs and FGDs were tape-recorded, with verbalinformed consent, except one with an obstetrician from aprivate clinic who did not permit the audio recording. Inthat case, detailed notes were taken during the interview.During the interview with women’s, their perceptionsand attitudes regarding caesareans, preferred mode ofbirth, source and level of knowledge, cultural beliefs, andfactors influencing decision-making about mode of birth-ing were considered. When interviewing obstetricians,their medical knowledge on indications for caesareansection, pros and cons related to each mode of birthing,perceived non-medical reasons to choose caesareans byfellow colleagues, and fear of litigation, were explored.Ethics approval and consent to participateEthical approval was obtained from the Ethical ReviewCommittee of the James P Grant School of Public Health,BRAC University. Informed oral consent was obtainedfrom all the participants and permission was obtainedBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 3 of 11from hospital authorities for using the hospital premisesfor study data collection. The consent form that was usedfor taking permission from study participants is attachedwith the manuscript as Additional file 2. This consentform detailed out the interview procedure, risk and benefitof participating in the study in front of the interviewee.Ethical Review Committee of JPGSPH reviewed the con-sent form and gave permission for taking Verbal informedconsent considering the rural culture and related con-straints on taking written consent. However, the Relevance,Appropriateness, Transparency and Soundness reviewguidelines were used to check the completeness of all therequired qualitative study activities while preparing thismanuscript [20].Data analysisWe undertook a thematic data analysis using a deductiveapproach developed by the National Centre for SocialResearch, Framework analysis [21]. Data collection, tran-scription, and analysis were undertaken on an iterativeprocesses. Initial transcriptions were in Bengali whichwere then back translated to English before coding [22].WHO recommended “onwards backwards technique”for qualitative data transcription in between two lan-guages was followed [23]. A list of a-priori codes weredeveloped based on research themes. (The definition ofeach code and sub-codes with the condition when to useand not to use is mentioned in the code book which isattached as Additional file 3). The study findings werearranged systematically in matrices using those A-prioricodes, which helped to identify the recurrent themesbetween participants. The summarized findings werecompared and contrasted under themes recorded in thematrices [24]. Women’s attitude towards caesarean sec-tion was compared with obstetricians’ views, and preg-nant women’s views towards caesarean section wascompared with post-caesarean women’s recent experi-ences. The same themes which were commonly beingreflected across the participants were grouped together.However, divergent but relevant themes were also re-ported separately. Intra-coder reliability was reported as80% when checked between one research assistant andthe principal investigator’s initial coding of two inter-views and one focus group. Disagreement over codingwas handled through re-reading interview data and fur-ther discussion between researchers.ResultsStudy participants’ background informationWomen participating in FGDs (N = 26)The average (mean) age of pregnant women who partici-pated in the FGDs was 23 years. The education statusranged from below primary to completed higher second-ary level and four of them were studying at the bachelorlevel. The majority of them were housewives. Regardingplace and mode of last birth, ten births took place athome with TBAs, four were vaginal births at a healthfacility; and two were caesarean birth and the remainingten were primigravidas.Women participating in individual interviews (N = 14)The ages of the 14 post-caesarean mothers ranged be-tween 16 and 37 years. Of them, six had below highersecondary level, three had secondary level education,and five had no formal education. Two post-caesareanwomen in private hospitals received no ANC while theothers received, on average, three ANC visits during theirlast pregnancies. All post-caesarean IDI participants werehousewives. The average monthly family income of womenhaving caesareans at a public hospital ranged from 77 USDto 192 USD, while those from private hospitals rangedfrom 128 USD to 384 USD. The direct cost for a caesareanranged between 77 USD and 128 USD in public hospitalsand between 282 USD and 320 USD in private clinics.Obstetricians participating in individual interview (N = 6)The work experience of obstetricians ranged from four anda half to twenty years. All public sector obstetricians inter-viewed were involved in private practice after office hours.The summary of socio demographic characteristics ofall three categories of study participants are mentionedin the Additional file 4.The details of FGDs and individual interviews in termsof number of participants, and location of each event ispresented in Table 1.Study themes and findingsPerceptions and attitudes regarding caesarean birthamong pregnant and post-caesarean women were ex-plored using six major codes: preferred mode of delivery,preferred place of delivery, knowledge about caesareansection, influencing factors, difficulties faced, and culturalpractices. The obstetricians’ attitudes were investigatedusing three major codes: knowledge about caesareans, dif-ficulties faced during vaginal birth, and women’s prefer-ences. (The summary of study findings under all differentcodes are presented in Additional file 5) Subsequently, allthe study findings gathered under these nine differentcodes were merged into three common themes: preferredmode and place of birth, knowledge about caesarean,and factors determining decisions to perform caesar-ean section. Under the theme of ‘preferred mode andplace of birth,’ the codes women’s preference on place ofbirth, mode of birthing, and the reasons behind their atti-tudes were merged with obstetricians’ experiences of talk-ing with women about their wish for normal delivery. Thetheme ‘knowledge about caesarean’ was used to group theknowledge of both women and obstetricians regarding theBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 4 of 11facts of caesarean births. Finally, the theme of ‘factors de-termining decisions to perform caesarean sections’ includedthe findings gathered under codes ‘influencing factors’ and‘difficulties faced’ by the post-caesarean mothers and theobstetricians (Fig. 1).Preferred mode and place of deliveryBoth pregnant and post-caesarean women in this studyexpressed their preferences for vaginal birth at homewhere TBAs are the main delivery caregivers. Even if thecost of both normal vaginal and caesarean deliveries wasassumed to be the same, they preferred a vaginal birthto a caesarean. The reasons included faster postpartumrecovery and living in extended families where elderlymembers who were the main decision makers, had astrong preference for vaginal birth. Obstetricians alsomentioned women’s preference, including those workingoutside of their homes, for vaginal birth in this commu-nity. When asked about attitudes and preferred mode ofbirth among working and educated women, obstetriciansmentioned that home birth is preferred among thesewomen as they still rely on elder women’s decisions inthe family. A twenty-five year-old pregnant woman, dur-ing an FGD, commented on why having a caesarean isdifficult and painful.“We need to carry paddy [rice] bundle over our headand need to feed our cattle. If suddenly rain comes wehave to take the cut [rice] paddy from the yard toinside the house. In that case if I would havecaesarean section, I will not be able to run. Women’slives become really handicapped after having thisoperation” (Quote from pregnant woman)Perceived ‘health hazards to the women and her babydue to caesarean section’ were mentioned as another rea-son for preferring vaginal birth. Respondents expressedtheir views that caesarean babies are more prone to pneu-monia and post-caesarean incisions remain painful for along time. Obstetricians had similar views regarding inci-sion pain; they mentioned that women who had caesareansections visited their clinics with incision pain even sixmonths post-surgery.However, women in-general, were not rigid about theirpreferences but rather willing to accept physician’s decisionfor a caesarean, if deemed necessary. A twenty five-yearold post-caesarean woman from a private health facilityexpressed her concern,“Before my case, none of my family members everattended hospital for birthing purpose. As a part of thetradition, I also went to my natal home and theycalled our family ‘daima’ [traditional birth attendant].When labour pain started, my baby defecated insidethe uterus and instantly she referred me to thishospital. Consequently caesarean delivery saved mybaby’s life.” (Post caesarean mother)Table 1 Data collection methods and participantsMethodology Participant type Number of interview/discussion sessionNumber of participantsFocus Group Discussion Women Pregnant women from private facilities 2 6Pregnant mothers from public facilities 2 7Total 4 26In depth Interview Women Post-caesarean mothers from public facilities 5Post-caesarean mothers from private facilities 54Obstetricians Public health facilities 211Private health facilities 11Total 20Fig 1. Study themes and sub-themesBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 5 of 11Contrastingly, three of the twenty-six mothers partici-pating in the FGDs showed a positive attitude towardcaesarean section. One pregnant women mentioned:“I prefer Caesarean delivery. I heard baby delivered bycaesarean section had a healthier brain compared tonormally delivered baby as it does not stay in thebirth canal for a long time”.(Quote from pregnantwoman)One obstetrician from a public hospital mentioned thatmothers demand caesarean sections for stillbirths. Consid-ering it as unjustified on medical grounds, she commented:“We never recommend caesarean section for freshstillbirth. Rather we try to induce normal labourthrough medication. However, women often considerthe dead fetus as a poison within the womb andrequest for caesarean section within the shortestpossible time. I get surprised having similar requestfrom multiple cases in the recent past where mycounselling did not work” (Quote from Obstetrician)With regards to a health facility preference (public or aprivate)., the majority of the pregnant and post-caesareanwomen had no specific preference. Rather they reliedcompletely on the attending health care provider’s tochoose the health facility.Knowledge on caesarean sectionWomen had limited knowledge and several misconcep-tions about caesarean section. They perceived there tobe two types of caesarean section: one, ‘small caesarean’where women deliver normally (vaginally) with a cut in theperineum (episiotomy), and the second, ‘large caesarean’where the abdomen is cut under anesthesia to extractthe baby.One multiparous, post-caesarean mother from a privatehospital said:“I am so happy that I have ‘large caesarean’ sectionthis time. I had to suffer a lot … such as pain &itching in my private parts … even I had pain duringsexual intercourse for a long time, since my last babywas delivered vaginally with ‘small caesarean’ section.”(Quote from Post caesarean mother)However, none of the pregnant women received anyinformation about the medical indications for caesareansection, nor its benefits and risks, although they were at-tending the third trimester antenatal checkup on thedate of the FGD. They received information about cae-sarean section mostly from relatives and neighbors whohad experienced a caesarean section in the past. Theythought caesarean birth was becoming a common eventas more and more private clinics and hospitals werebeing established in their neighborhood.“The word caesarean section arose from the hospital.As, now-a-days number of hospitals has increased,caesarean birth has also increased. More mother andfetus used to die earlier but currently caesarean birthis saving lives of both, though sometime doctors docaesarean section unnecessarily for their financialinterest.” … (Quote from Pregnant woman)When the pregnant women were asked to list thecommon clinical conditions for which their friends orrelatives had undergone a caesarean, the top threecauses were previous caesarean, less fluid, and babydefecating in the uterus.On the other hand, obstetricians stated that they choseto not overburden the mothers with caesarean relatedinformation unless the current pregnancy had clear indica-tions to deliver the baby surgically. All of them mentionedthat although risks exist with operative procedures such ascaesareans, it decreases maternal and neonatal deaths. Two(out of six) obstetricians in the study mentioned thathaving a vaginal birth attended by an inexperienced healthcare provider even in a hospital setting carries more healthhazards than having a caesarean section.When asked about common clinical reasons for per-forming caesareans, obstetricians mentioned two types:emergency and planned. Indications for emergency cae-sareans mentioned by all six obstetricians were similar.However, their responses for the cause of plannedcaesareans varied. While half of them mentioned thatcaesareans performed based on patient request are called‘elective’, other obstetricians said that certain clinicalconditions require a caesarean to be performed electively.However, while validating the obstetrician knowledgeagainst the National Institute of Clinical Excellence(NICE) guideline recommended by the international expertcommittee, certain knowledge gap has observed. After ex-cluding Cephalo Pelvic Disproportion (CPD), all the indi-cations mentioned by obstetricians as planned C-sectionwere in the contraindication list of NICE. The complete listof indications of planned Caesarean section mentioned bythe study obstetricians are presented in the right columnof Table 2 and the recommendation made by NICE onsimilar clinical conditions are presented in the left columnof this table. For example, obstetrician believe women hav-ing breech pregnancy should be a case of caesarean deliv-ery where birth order should not be a concern. On theother hand NICE guideline does not recommend plannedcaesarean section for breech pregnancy in higher orderbirth and for the first time mother without attempting torestore the fetal position through external cephalic version.Begum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 6 of 11There were also mixed findings regarding the timing ofelective caesareans. With the exception of one respondent,all of them stated that an elective caesarean could be doneany time after 37 gestational weeks. One obstetrician saidthat he would only perform an elective caesarean two tothree days before the expected date of delivery. The reluc-tance of obstetricians to choose the time for elective cae-sarean was commented on by a post caesarean motherwho had an elective caesarean fifteen days before the ex-pected date of delivery. Although she had no risk factorsfor vaginal birth, her obstetrician met her directly at theoperation theatre once she was admitted to hospital.“I guess out of 100, only 10 lucky women could delivernormally. I wanted to deliver normally this time afterhaving one ‘Caesar’ (caesarean section) five years back,but none of my doctors were willing to take the risk.Since there was no option other than caesarean, Icame in this hospital 15 days prior to my given date ofdelivery and being delivered through C-section.” –(Quote from post caesarean mother)Factors determining caesarean sectionCommunity health care providers, from both the publicand informal private sectors, played a significant role inthe decision-making process regarding the mode of birthin this study. Being the first line health care provider;Community skilled birth attendants, Family welfare visi-tors, Traditional Birth Attendants and village doctorswere the primary contact point for the pregnant womenand their families at the community level. Almost all ofthe pregnant and post- caesarean mothers in the studymentioned visiting at least one of these communityhealth providers before coming to the obstetrician.The preference for a community health provider isshown in the following quote:“I will contact with ‘Apa’ at the time of delivery, shewill try her level best to deliver my baby here. If myluck would not be good enough to deliver my baby ather hand, she will refer me to appropriate healthfacility. I usually go to her to get the address of doctorwhen any of my family members or me fall sick”(Quote from pregnant woman)A similar comment was made by several pregnantwomen in different FGDs. However, obstetricians in thestudy expressed a different view about community healthproviders. They claimed these community healthcareproviders were serving as brokers for local private clinicsand receiving commissions from these clinics for refer-ring obstetric patients. However, the referral fees givento them varied according to the procedure, get highercommission for caesarean birth. So that they refer patientsto the obstetrician who does more number of caesareansections. Two of the study obstetricians claimed that somedoctors perform caesareans without valid indications toupsurge their practice.“Here in this rural area patients are not choosingdoctors based on academic degrees or experience, ratherthey choose doctors based on the recommendation fromthe referee (community health providers). Referrals werefrequently for doctors who performed more caesareansinstead of vaginal deliveries. I have heard thatsometimes the tariff that they got is more than myoperation charge.”- (Quote from Obstetrician)Obstetricians claimed that private clinics were usingtheir agents, known locally as ‘dalals’ (brokers) to takethe birthing women away from public hospitals. Onestudy obstetrician mentioned that sometimes the serviceproviders in the primary health facility refer birthingwomen to the higher facility without any valid medicalTable 2 Validation of obstetrician responses in contrast to National Institute of Clinical Excellence (NICE) guidelines on plannedcaesareansIndication of planned caesarean section mentionedby obstetriciansContraindication of planned caesarean section mentioned in NICE guidelines• Previous caesarean• Breech presentation irrespective of parity• Twin pregnancy irrespective of parity and presentation• Preterm birth/ Small for gestational age• Cephalopelvic Disproportion (CPD)• Short stature of mother• Obese mother• Elective caesarean: to avoid conflict✓ Hospital staff patients and well off family clients✓ Patient with gestational diabetes✓ Patient having bad obstetric history✓ Primary/ secondary infertility✓ Fear/can’t tolerate labour pain• Pre-eclampsia• Postdates pregnancy• Previous caesarean• Primigravida breech without attempt of external cephalic version and breechin multiparous women• Twin pregnancy in cephalic presentation• Preterm birth/ Small for gestational age• Suspected CPD (that means short stature women could not be an indication)• Obese women even with BMI≥ 50• Elective caesarean (without obstetrical or medical indication) [36]Begum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 7 of 11indication and often with misleading clinical findingsindicating the need for caesarean section.“Once I received a referred patient with complaints offetal distress and meconium for caesarean section, buton examination I found no evidence of such things. Incontrast, the woman presented to me had progressivenormal labour with normal fetal heart rate, maternalpulse and blood pressure was ok, and so she could beallowed to deliver normally. I allowed the woman todelivery by normal vaginal methods and that occurredsuccessfully. But other doctors may not follow the sameprocedures, because most of the doctors meet patientsin the operation theatre in the private clinic.” (Quotefrom obstetrician)Poor quality of labour monitoring was also a concernfor the private clinics. An obstetrician from a privateclinic stated that:“We usually do not take risks when there is 50/50chance of vaginal delivery even in the private clinics,as nurses working there are reluctant to do regularfollow up and are not competent to manage normaldelivery. My whole career will be ruined for a singlefetal death.” (Quote from obstetrician)Similarly, obstetricians working in public hospitalsclaimed that inadequate numbers of skilled human re-sources was the main constraint for provision of highquality maternity care services. Although the healthfacility was well-equipped logistically, caesarean sectionservices were not available after office hours (2 p.m.) dueto unavailability of obstetricians and/or anaesthetists.Moreover, only one duty doctor was available after officehours to manage emergencies in both 50-bed UHC andin 250-bed district hospitals, and the duty nurses werenot competent to manage normal vaginal deliveries.Obstetricians mentioned that they perform caesareansection in public hospitals only during office hours.A lack of respectful treatment towards women inlabour was reported to be a factor influencing the choiceof delivery mode. One of the post-caesarean motherscomplained about the attending nurse’s unsupportive be-havior as a cause of her self-request for a caesareanbirth. A nineteen year-old post-caesarean mother from aprivate clinic expressed her frustration:“I was admitted with labor pain in this hospital at 11a.m. The nurse examined me there and said that itwas not labor pain but I got sweating with thatextreme pain. She did per vaginal examination severaltimes, it was also much embarrassing and painful. Iwas losing my patience but they did not speak a singlepleasant word to me. Then I left the hospital by giving‘risk bond’ and went for caesarean section in a nearbyclinic at 7 p.m.” (Quote from post- caesarean mother)DiscussionThis study identified three key factors affecting the modeof birth: client’s attitude, obstetrician’s attitude, and healthfacility influence. Client’s attitude on Caesarean deliverywas mostly influenced by the health care provider and theattending health facility type. Whereas obstetrician’s atti-tude does not depend on their medical knowledge rathermore subjective to financial interest of the clinics or bro-kers from whom they receive patients. In some instancesObstetricians knowledge on caesarean indications did notmatch with international guidelines and recommenda-tions. On the other hand, public health facilities hadcertain challenges to provide 24/7 emergency obstetricservices which creates more dependency to privatehealth sector. However, private health facility’s undueinterest to do medically non- indicated caesarean sec-tion was also being critiqued by the study obstetricians.In general, women in this rural community had strongpreferences for normal vaginal birth. Financial accessdoes not equate with autonomy around decision makingfor mode of birth among women who work for wages.They still rely on elderly women in the family as influen-tial decision-makers. This custom has also been docu-mented in a study about the reasons for using a TBA inBangladesh [25]. Despite the strong cultural preferencefor vaginal birth, women did not demonstrate a negativeattitudes towards caesareans; rather they perceived thesesurgeries as necessary to save lives. This attitude contra-dicts findings from an earlier qualitative study conductedin the same study area, which reported that women whohad caesareans felt it was an insult to their identity as amother [26]. Our study, on the contrary, suggests thatnon-supportive behavior of nurses in the health facility,fear of episiotomy during vaginal birth, and the risk offetal death during labour were the main reasons forwhich participants made self-request for caesarean. Simi-lar to this study, maternal request for caesarean deliveryafter having an episiotomy and subsequent experience ofpainful sexual intercourse in a previous pregnancy werementioned by the women from Nigeria and Turkey[27, 28]. It has also been reported that obstetricians alsobelieved that vaginal birth is associated with more perinealinjury and sexual dysfunction [29]. Despite this, other re-search suggests that postpartum sexual functioning is notassociated with the birthing mode [30]. In addition,episiotomy performed during vaginal birth as a meansof protection against perineal injury has not been proven ef-fective always. A recent study among a large cohort (22,800births) confirmed that statistically significant amount ofBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 8 of 11perineal injury occurred even with lower episiotomy rate(6.7% episiotomy rate) [31]. Given that episiotomy is notprotective against perineal injury and in fact causes shortand long term negative sequalae, birth attendants shouldrefrain from this practice to avoid unnecessary fear of episi-otomy among women willing to give birth vaginally.Some women also mentioned the lack of kind, com-forting, and respectful behavior towards them duringlabour. Since an individual’s pain tolerance varies, it isrecommended that health care workers be compassion-ate and supportive towards women in labour to increaseconfidence in their ability to give birth vaginally [32–34].In our study, women were not knowledgeable regardingthe medical indications for caesarean section. The ante-natal care provided in the third trimester did not includeinformation regarding risks and benefits of caesareanand normal vaginal delivery modes of childbirth. Friendsand neighborhood women who had similar experiencesremained the major source of information. Women’slack of health literacy about surgical birth was used bysome peripheral level lay health workers and informalproviders to convince women to have caesarean sectionseven in the absence of valid clinical indications. Forexample, meconium staining is not listed as an indica-tion for caesarean in the NICE guidelines [35]. However,women in this study believed that caesareans done onthe grounds of meconium stained liquor could save theirbaby and for that they were thankful to their physicians.This finding corresponds to one systematic review whichdetermined that poor knowledge about caesarean sectionis the main reason for women requesting caesareans,and recommended the involvement of parturient womenin informed decision making processes [34].The obstetricians in the study were found to be morepositive towards caesarean section compared to vaginalbirth. Fear of litigation and their prior maternity experi-ences were of paramount importance in determiningtheir attitudes. However, their knowledge of indicationsfor caesarean delivery did not coincide with internationalrecommendations as indicated by the recent NICEguideline [36] and the American College of Obstetriciansand Gynecologists Guideline [37]. For example, otherthan primigravida breech and cephalopelvic dispropor-tion, all other clinical indications provided as reasons forperforming caesareans by the study obstetricians are notlisted in either of these international guidelines [36, 37].Additionally, the obstetricians were not certain of therecommended gestational age for planned caesarean sec-tions. This study identified two women who were havingan elective caesarean fifteen days prior to their expecteddate of delivery. In contrast, the NICE guideline has rec-ommended the appropriate gestational age for electivecaesarean section to be after 39 weeks. Elective caesareansperformed at earlier gestational ages have been associatedwith adverse neonatal outcomes such as increased rate ofinfections, respiratory distress and more admissions toneonatal intensive care units [38]. In this study, physicianswere reluctant to involve women in evidence-based in-formed decision making, and were unaware of inter-nationally accepted guidelines. In this regard, some healthexperts mentioned that if the “ruling class” clinicians per-form caesareans without valid clinical indications, this erro-neous practice and corresponding attitude may be acceptedas ‘normal’ among the general population [39]. Once a highcaesarean section rate becomes ‘normal’ it is difficult tochange provider attitudes and practices.The attitudes of both women and obstetricians differbased on the type of facility - attending hospital, private,NGO, or public. Concerns about safety included lack ofability to monitor labour by hospital staff and inadequatestaffing of the facility. Other than the NGO clinic, boththe public and private hospitals’ mothers and obstetri-cians did not have confidence on the nurse competencyto monitor normal labour and their ability to handle anybirthing emergency. In Bangladesh, normal childbirth inpublic hospitals is mostly attended by nurses and thereis not yet a functioning midwifery profession. Poor qual-ity of childbirth care has been reported in public healthfacilities [11, 40]. To address this gap, Bangladesh is inthe process of adding newly trained midwives to thematernal and neonatal health care team, who will hope-fully be proficient in attending normal childbirth, thusallaying some of the concerns voiced by mothers andobstetricians [15].This study also highlighted the perception of inadequatehuman resources to provide basic and comprehensiveemergency obstetric care after office hours in publicfacilities. Inadequate staffing and logistics has been docu-mented as a barrier in public health facilities in the con-text of other developing countries as well [6, 11, 41]. Tocompensate for this constraint in resources, a defensiveobstetric practice has been observed among the studyobstetricians, who are performing elective caesareans dur-ing office hours. However, evidence suggests that a caesar-ean done without a valid medical indication increases thechance of maternal death 2.84 times in comparison tovaginal birth [1]. Women and obstetricians in this studyappeared to be unaware of this evidence.Financial motives and avoidance of possible lawsuitsare documented as major influencing factors for caesar-ean births in private sector health facilities. Obstetriciansinterviewed from private clinics stated that they some-times feel the need to perform unnecessary caesareansto meet the clinic’s financial demands. In doing so, thecommunity health care providers and clinic referralagents, performed ‘patient counseling for caesareans’ onbehalf of clinic authorities and obstetricians in the pri-vate sector. Our study findings corroborate other studyBegum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 9 of 11findings from rural Bangladesh that have also confirmedthe presence of a broker or ‘Dalal’ to move pregnantwomen from public health facilities to private facilities[11]. Our study findings depicts that women had to payfor caesarean section services in the public hospitals.This is a potential threat to the movement towards uni-versal health coverage (UHC) as the poor may becomepoorer to meet maternity expenses; this is especially truein Bangladesh where the main mode of payment forhealth services is out-of-pocket [42].Limitations and methodological considerationsIt was definitely challenging to investigate both women’sand obstetrician’s views in the same study. While doingso, the strengths of the study include getting similar re-sponses from both the caregivers and care receivers inregards to preferred birthing mode and quality of care inpublic facilities. Assumptions that most women choosecaesarean sections is challenged, and the pain and fearthat women experience after episiotomy was identifiedas a key reason for requests for caesarean birth.While we are confident in the findings of this study, itwas not without its limitations. The study setting andsampling strategy raise methodological issues. The studywas conducted in Matlab, an area in Bangladesh known forits long history of public health interventions and researchstudies as well as the presence of icddr,b, an internationalhealth research organization well known to the commu-nity. It is possible that the presence of icddr,b researchersmay introduce some response bias. Furthermore, it is pos-sible that the study findings do not accurately representwomen’s and obstetrician’s view from other areas inBangladesh. While the objective of the study was not toproduce nationally representative results, we did provideadequate contextual description allowing readers to deter-mine whether the findings are relevant in other areas ofBangladesh and elsewhere in low and middle incomecountries [22].ConclusionThe preference of women for vaginal birth in this studywas not the major factor determining their attitude to-wards caesarean section birth. Women had inadequateinformation about caesarean birth and were mostlydependent on their provider’s decision regarding modeof birth. The fear of episiotomy was strong among thestudy participants. The context and underlying reasonsfor this attitude and the methods and indications forperforming episiotomies, require further investigation.The need for respectful behavior among health care pro-viders, ethical clinical practice and education of womenand their active participation in the decision makingprocess have been highlighted in this study. Ensuringavailability of 24-h obstetric services in public facilitiesand educating pregnant women about choices in themode of childbirth, including indications for, and complica-tions resulting from caesarean section, is a productive wayto avert third party influence in promoting unnecessarysurgical birth.Additional filesAdditional file 1: Code book. Description of A-priori codes and sub-codes.This file detail out the A-priori code and sub code-list that includes definition,when to use and when not use for each of the codes and sub codes.(PDF 773 kb)Additional file 2: Consent form. Consent form in English. The consentform details out the interview procedure, risk and benefit of participatingin the study. (PDF 306 kb)Additional file 3: Interview guidelines. Guidelines to conduct In-depthinterview and Focus Group Discussion. Three separate guidelines wereused for in-depth interview with post caesarean women, obstetriciansand Focus group discussions with pregnant women. (PDF 419 kb)Additional file 4: Demography data. Demographic details of studyparticipants. This excel sheet detail out the socio- demographiccharacteristics of all study participants including age in range, sex,education, religion, occupation, family income, cost of caesarean serviceetc.. (XLSX 20 kb)Additional file 5: Data display. Summary of study findings. The studyfindings are grouped under different color codes. (XLSX 26 kb)AbbreviationsCaesarean section: Caesarean; FWV: Family Welfare Visitor;icddr,b: International Centre for Diarrhoeal Disease Research Bangladesh;JPGSPH: James P Grant School of Public Health; NGO: Non-GovernmentalOrganization; NICE: National Institute for Health and Care Excellence;SBA: Skilled Birth Attendant; TBA: Traditional Birth Attendant; UHFWC: UnionHealth & Family Welfare CentreAcknowledgementsWe are thankful to all the study participants, hospital authorities, andresearch assistants. We also acknowledge James P Grant School of PublicHealth for their financial assistance, icddr,b Matlab hospital and HDSS officialsfor their support during data collection. Icddr,b is also grateful to thegovernment of Bangladesh, Canada, Sweden and UK for providing core/unrestricted support.FundingJPGSPH provided funding for this thesis research & some voluntary supportwas received from icddr,b Matlab hospital.Availability of data and materialsAll data generated or analyzed during this study are included in thispublished article and in the supplementary information files given with thisarticle with the file name (additional data_Tahmina_begum).Authors’ contributionsConception and research design: TB, LR Data analysis: TB, LR Datainterpretation: TB, LR, CE; JFR, IA, AR, MS. Drafting the manuscript: TB, LR, CE;JFR, IA, AR, MS. Language edit: LR, JFR. All authors read and approved thefinal manuscript.Authors’ informationAll the authors listed in this article have many years of clinical and researchexperience in maternal health.Ethics approval and consent to participateEthics approval was obtained from the Ethical Review Committee of theJames P Grant School of Public Health, BRAC University. Informed verbalconsent was obtained from all the participants and permission was obtainedfrom each hospital authority for accessing required hospital documents.Begum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 10 of 11Consent for publicationThe study participants gave the author permission to publish their researchviews regarding this specific research topic, provided that anonymity wasmaintained.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Health Systems and Population Studies Division, International Centre forDiarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh.2Department of Family Practice, University of British Columbia, Vancouver,BC, Canada. 3James P Grant School of Public Health, BRAC University, Dhaka,Bangladesh. 4Institute of Public Health University, Heidelberg, Germany.5Population Council, Washington, DC, USA.Received: 30 January 2018 Accepted: 23 August 2018References1. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. Theincreasing trend in caesarean section rates: global, regional and nationalestimates: 1990-2014. PLoS One. 2016;11(2):e0148343.2. Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, Shah N,Semrau K, Berry WR, Gawande AA. Relationship between cesarean deliveryrate and maternal and neonatal mortality. JAMA. 2015;314(21):2263–70.3. World Health Organisation: WHO Statement on Caesarean Section Rates. 2015.4. Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. Theglobal numbers and costs of additionally needed and unnecessarycaesarean sections performed per year: overuse as a barrier to universalcoverage. World Health Report. 2010;30:1–31.5. Lo JC. Patients’ attitudes vs. physicians’ determination: implications forcesarean sections. Soc Sci Med. 2003;57(1):91–6.6. Yazdizadeh B, Nedjat S, Mohammad K, Rashidian A, Changizi N, Majdzadeh R.Cesarean section rate in Iran, multidimensional approaches for behavioralchange of providers: a qualitative study. BMC Health Serv Res. 2011;11(1):159.7. Ajeet S, Jaydeep N, Nandkishore K, Nisha R. Women’s knowledge,perceptions, and potential demand towards caesarean section. Natl JCommunity Med. 2011;2(2):244–8.8. Anwar I, Nababan HY, Mostari S, Rahman A, Khan JA. Trends and inequitiesin use of maternal health Care Services in Bangladesh, 1991-2011. PLoSOne. 2015;10(3):e0120309.9. Feng XL, Xu L, Guo Y, Ronsmans C. Factors influencing rising caesareansection rates in China between 1988 and 2008. Bull World Health Organ.2012;90(1):30–39A.10. Stanton C, Ronsmans C. Caesarean birth as a component of surgical services inlow-and middle-income countries. Bull World Health Organ. 2008;86(12):A-A.11. Aminu M, Utz B, Halim A, Van Den Broek N. Reasons for performing acaesarean section in public hospitals in rural Bangladesh. BMC PregnancyChildbirth. 2014;14(1):130.12. Einarsdóttir K, Kemp A, Haggar FA, Moorin RE, Gunnell AS, Preen DB, StanleyFJ, Holman CAJ. Increase in caesarean deliveries after the Australian privatehealth insurance incentive policy reforms. PLoS One. 2012;7(7):e41436.13. Potter JE, Hopkins K, Faúndes A, Perpétuo I. Women’s autonomy andscheduled cesarean sections in Brazil: a cautionary tale. Birth. 2008;35(1):33–40.14. Bogren M, Begum F, Erlandsson K. The historical development of themidwifery profession in Bangladesh. J Asian Midwives. 2017;4(1):65–74.15. Bogren M, Doriswamy S, Erlandsson K. Building a new generation ofmidwifery faculty members in Bangladesh. J Asian Midwives. 2017;4(2):52–8.16. National Institute of Population Research and Training (NIPORT) MaA, andICF International. 2015.: Bangladesh Demographic and Health Survey 2014:Key Indicators. 2014.17. Keedle H, Schmied V, Burns E, Dahlen HG. The journey from pain to power:a meta-ethnography on women’s experiences of vaginal birth aftercaesarean. Women Birth. 2018;31(1):69–79.18. Rahman MM, Alam N, Razzaque A, Streatfield PK. Health and demographicsurveillance system – MATLAB. JHPN. 2014;46(124):22.19. Sanavi FS, Rakhshani F, Ansari-Moghaddam A, Edalatian M. Reasons forelective cesarean section amongst pregnant women; a qualitative study. JReprod Infertility. 2012;13(4):237.20. Wu S, Wyant DC, Fraser MW. Author guidelines for manuscripts reportingon qualitative research. J Soc Soc Work Res. 2016;7(2):000.21. Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: aguide for social science students and researchers. 2nd ed. Los Angeles:SAGE; 2014.22. Shenton AK. Strategies for ensuring trustworthiness in qualitative researchprojects. Educ Inf. 2004;22(2):63–75.23. World Health Organization: Process of translation and adaptation of instruments.http://www.who.int/substance_abuse/research_tools/translation/en/. 2009.24. Liamputtong P. Qualitative data analysis: conceptual and practicalconsiderations. Health Promot J Austr. 2009;20(2):133–9.25. Sarker BK, Rahman M, Rahman T, Hossain J, Reichenbach L, Mitra DK.Reasons for preference of home delivery with traditional birthattendants (TBAs) in rural Bangladesh: a qualitative exploration. PLoSOne. 2016;11(1):e0146161.26. Khan R, Blum LS, Sultana M, Bilkis S, Koblinsky M. An examination of womenexperiencing obstetric complications requiring emergency care: perceptionsand sociocultural consequences of caesarean sections in Bangladesh. JHealth Popul Nutr. 2012;30(2):159.27. Baksu B, Davas I, Agar E, Akyol A, Varolan A. The effect of mode of deliveryon postpartum sexual functioning in primiparous women. Int Urogynecol J.2007;18(4):401–6.28. Serçekuş P, Okumuş H. Fears associated with childbirth among nulliparouswomen in Turkey. Midwifery. 2009;25(2):155–62.29. Barrett G, Peacock J, Victor CR, Manyonda I. Cesarean section and postnatalsexual health. Birth. 2005;32(4):306–11.30. Dabiri F, Yabandeh AP, Shahi A, Kamjoo A, Teshnizi SH. The effect of modeof delivery on postpartum sexual functioning in primiparous women. OmanMed J. 2014;29(4):276.31. Yamasato K, Kimata C, Huegel B, Durbin M, Ashton M, Burlingame JM.Restricted episiotomy use and maternal and neonatal injuries: aretrospective cohort study. Arch Gynecol Obstet. 2016;294(6):1189–94.32. Koblinsky M, Anwar I, Mridha MK, Chowdhury ME, Botlero R. Reducingmaternal mortality and improving maternal health: Bangladesh and MDG 5.J Health Popul Nutr. 2008;26(3):280.33. Wiklund I, Edman G, Andolf E. Cesarean section on maternal request:reasons for the request, self-estimated health, expectations, experience ofbirth and signs of depression among first-time mothers. Acta ObstetGynecol Scand. 2007;86(4):451–6.34. Gamble J, Creedy DK, McCourt C, Weaver J, Beake S. A critique of theliterature on women’s request for cesarean section. Birth. 2007;34(4):331–40.35. Women’s NCCf, Health Cs: Caesarean section. 2011.36. Gholitabar M, Ullman R, James D, Griffiths M. Caesarean section: summary ofupdated NICE guidance. Bmj. 2011;343:d7108.37. American College of Obstetricians Gynecologists. ACOG Practice bulletin no.115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 Pt 1):450.38. Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med.2003;348(10):946–50.39. Vivilaki V, Antoniou E. Caesarean section: the underpinning choice?HealthSci J. 2008;2(2):83–8.40. Sikder SS, Labrique AB, Ali H, Hanif AA, Klemm RD, Mehra S, West KP,Christian P. Availability of emergency obstetric care (EmOC) among publicand private health facilities in rural Northwest Bangladesh. BMC PublicHealth. 2015;15(1):36.41. Ameh C, Msuya S, Hofman J, Raven J, Mathai M, van den Broek N. Status ofemergency obstetric care in six developing countries five years before theMDG targets for maternal and newborn health. PLoS One. 2012;7(12):e49938.42. World Health Organization. Bangladesh health system review. Manila: WHORegional Office for the Western Pacific; 2015.Begum et al. BMC Pregnancy and Childbirth  (2018) 18:368 Page 11 of 11


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items