Why have caesarean sections become the dominant form of delivery for women accessing public hospitals in Bangladesh? A mixed-methods study in eight district hospitals of Bangladesh to understand factors influencing C-section consent and to explore opportunities for optimizing C-section rates.

  • Sathyanarayanan Doraiswamy

Student thesis: Doctoral ThesisDoctor of Health (DHealth)


Introduction: Caesarean sections (C-sections), as with any other surgery, are not risk-free, have higher costs associated with them, and, potentially, can convert the usual physiological birthing process into one that is medically intensive, thus undermining the capability of women to deliver normally. In 2014, official C-section rates in Bangladesh touched 24%, which is an 8-fold increase from 2001 and well above the acceptable range of standards set by WHO at a population level.

Study aim: The research aims to study factors influencing decision-making for C-sections in public sector hospitals of Bangladesh with a focus on physician-patient communication in both emergency and elective C-section contexts.

Methodology: A multi-method approach of observation of physician-patient interactions in labour situations and in-depth narrative interviews of physicians and women who underwent primary emergency and elective C-sections as a complementary study design were used to provide a holistic picture in studying the decision-making process in caesarean section.

Results: By observing 306 labour situations and interviewing 16 physicians and 32 women who underwent emergency and elective C-sections, the study was able to establish that communication between the physician/other health care providers and the woman in the labour situation was both minimal in extent and limited in nature. The consent form has been rendered as an artefact in the process, making the form itself irrelevant in the background of what happens around it. The study finds that there are factors that prime the patient and the physician in favour of C-section, even before the clinical encounter, and there is very little evidence of any remodelling of these primed decisions during the encounter to change course.

Conclusions: The clinical encounter, and the poor communication that was found to happen during it, risks setting up a vicious cycle, exaggerating the existing priming into a dominant form of practice with the consequence of further increasing C-section rates in Bangladesh. The findings call for a set of carefully designed evidence-based behavioural interventions targeting the physicians, patients and the health system to better govern C-section decision-making in Bangladesh and hence to influence the C-section rate.
Date of Award2020
Original languageEnglish
Awarding Institution
  • University of Bath
SupervisorAlan Buckingham (Supervisor)


  • Caesarean
  • Bangladesh
  • Decision Making
  • Communication
  • Public sector

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