Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh

BACKGROUND: Globally, Caesarean section (CS) rates are mounting and currently exceed the safe upper limit of 15%. Monitoring CS rates using clinical indications and obstetric sub-group analysis could confirm that women in need have been served. In Bangladesh, the reported CS rate was 31% in 2016, and almost twice that rate in urban settings. Delivering in the private healthcare sector was a strong determinant. This study uses Robson Ten Group Classification System (TGCS) to report CS rates in urban Bangladesh. The clinical causes and determining factors for CS births have also been examined. METHODS: This record linkage cross-sectional survey was undertaken in 34 urban for-profit private hospitals having CS facilities during the period June to August 2015. Data were supplied by inpatient case records and operation theatre registers. Descriptive analyses were performed to calculate the relative size of each group; the group-specific CS rate, and group contribution to total CS and overall CS rate. CS indications were grouped into eleven categories using ICD 10 codes. Binary logistic regression was performed to explore the determinants of CS. RESULTS: Out of 1307 births, delivery by CS occurred in 1077 (82%). Three obstetric groups contributed the most to overall CS rate: previous CS (24%), preterm (23%) and term elective groups (22%). The major clinical indications for CS were previous CS (35%), prolonged and obstructed labor (15%), fetal distress (11%) and amniotic fluid disorder (11%). Multiple gestation, non-cephalic presentation, previous bad obstetric history were positive predictors while oxytocin used for labour induction and increased parity were negative predictors of CS. CONCLUSIONS: As the first ever study in urban private for-profit health facilities in Bangladesh, this study usefully identifies the burden of CS and where to intervene. Engagement of multiple stakeholders including the private sector is crucial in planning effective strategies for safe reduction of CS.