Caesarean Section rates in South Asian cities: Can midwifery help stem the rise?

Introduction: Caesarean section (CS) is a life-saving surgical intervention for delivering a baby when complications arise in childbirth. World Health Organization recommends a rate of CS from 10% to 15%. However, CS rates increased steadily in recent decades and have almost doubled from 12.1% in 2000 to 21.1% in 2015. Therefore, this has become a global public health problem. The main purpose of the scoping review article is to give an overview and analysis of the rising CS use in four South Asian countries: Bangladesh, India, Nepal and Pakistan. Methods: A scoping review was carried-out using several bibliographic electronic databases (MEDLINE, EMBASE, SCOPUS, CINAHL and Web of Science), organizational websites and open access journal databases. Literature was searched from December 2011 to December 2018 for articles reporting hospital-based CS rates. Inclusion criteria were primary studies conducted in institutional setting in Bangladesh, India, Nepal and Pakistan and published in the English language. Results: We have included 43 studies. Together these studies show that the rate of CS is increasing in all four countries: Nepal, Bangladesh, Pakistan and India. However, this is uneven with very low rates in rural and very high rates in urban settings, the co-existence of ‘Too Little Too Late & Too Much Too Soon’. Hospital based studies have shown that the CS rate is higher in urban and private hospitals. Age, education and socio-economic status of women, urban residence and distance from health facility are associated with CSs. CS is higher among highly educated affluent urban women in private hospitals in South Asian Countries. Conclusion: Rising CS rates in South Asian cities, particularly in specific groups of women, present a challenge to hospital staff and managers and policy-makers. The challenge is to avoid ‘Too Much Too Soon’ in otherwise healthy urban women and avoid ‘Too Little Too Late’ in women living in remote and rural area and in poor urban women.