Despite enormous improvements in maternal and child health in Bangladesh over the years, CS rates have risen to unprecedented levels in both rural and urban areas (2, 8). There are two main reasons for CS: (i) medical necessity, meaning CS is required to save a life, and (ii) elective surgery, meaning an unnecessary CS that is usually performed to control delivery. One of the potential reasons for the high rate of CS deliveries in Bangladesh may be elective CS, which is associated with a tendency toward profit-making. One previous study reported that physicians and the breadwinner of the pregnant woman’s family are the primary decision-makers behind CS delivery and that pregnant women are often excluded from that decision-making process (9). Thus, women are probably not aware that an unnecessary CS can result in increased risk of infection, potential complications in subsequent pregnancies, and prolonged recovery times (10). Previous evidence has shown that a combination of sociocultural factors, such as education, social class, and religion, and medical factors, such as pregnant women’s high blood pressure and/or diabetes, contributes to this increasing CS rate (2). Research has also indicated that, although protocols and guidelines for CS are available in healthcare facilities, they are not being followed due to pressures from external agents who are present in public hospitals and who want to benefit financially by facilitating the transfer of patients to private hospitals (11).

Given the different reasons for CS, it is also important to mention that private healthcare facilities contribute to the greater part of CS in Bangladesh (12). Approximately 3.6 million babies are born each year in Bangladesh, and 50% of deliveries are institutional. Among these deliveries, two-thirds occur in private facilities (83% private facilities vs. 35% government facilities) (13). The financial benefits gained by private hospitals constitute the main reason for encouraging pregnant women and their families to undergo CS delivery rather than examinations of pregnant women’s physical condition (7, 10). One study claimed that highly educated women and their husbands tend to prefer CS without hesitation compared to less educated couples, especially in urban areas (5). One reason could be that educated couples have no economic barriers, meaning they can avoid vaginal delivery complications without being informed about the consequences of an unnecessary CS.

Considering the physical and financial burdens of unnecessary CS, evidence-based recommendations could help change the scenario in Bangladesh. One study recommended a health reform to reassess the role of private healthcare facilities and redefine the responsibilities of private healthcare providers (14). Another study from Iran stressed that, while reducing CS rates is complex and time-consuming, key factors include informing mothers and families about the benefits of normal delivery, strong government regulations, and strict supervision of healthcare workers (15). A study from Brazil suggested that improving healthcare facilities, including hospital electronic medical records, data management systems, and standardized prescription systems, aids in making informed decisions, thereby increasing the rate of vaginal births in private healthcare facilities from 2010 to 2015 (16). A global systematic review found that, in some countries, financial incentives for service providers and legislatively imposed practice guidelines for physicians could control CS rates to some degree (17). These studies mentioned that reducing CS rates cannot be achieved through a single, quick intervention. Instead, achieving effective outcomes requires a comprehensive, context-specific approach and considerable time. Additionally, a systematic review strongly suggested the need for regulatory strategies aimed at reducing unnecessary CS procedures that could be effective across both public and private institutions (17). There is also evidence indicating that responsible medical leadership is crucial in reducing unnecessary CS procedures, alongside the introduction and implementation of strong regulations (3).

To reduce unnecessary CS rates, the government could track and report the annual rate of unnecessary CS and its costs. Including this information in the policy-making process could play a pivotal role in building awareness about unnecessary CS delivery. Increasing the number of trained midwives serving across the country is important to ensuring that unnecessary CS can be avoided, unless of course pregnant women experience physical complications (2). It is also necessary to involve pregnant women in the decision-making process and inform them of the benefits and risks of a CS (10). Moreover, community-level awareness programs and proper sensitization of mothers and families should continue to enhance their knowledge of the implications of unnecessary CS deliveries (5). Additionally, adopting a global standard like Robson’s classification system, which categorizes CS cases based on obstetric parameters such as pregnancy history and gestational age, could be incorporated into policies and regulations to help midwives and physicians make the right decisions (6, 18). The government could incorporate appropriate guidelines for CS into policy and regulations to ensure that no hospital, whether public or private, performs unnecessary CS procedures (5, 11). Healthcare regulatory bodies could develop a national guideline for use of CS that healthcare providers are obliged to follow.

WHO recommends CS delivery based on the mother’s physical condition and the position of the fetus, but these recommendations are not always followed by healthcare providers in Bangladesh. In this regard, the government could expand social and community movements to create awareness, particularly among pregnant women, of the negative immediate and long-term consequences of unnecessary CS delivery. Awareness and education efforts could also be focused on the benefits of vaginal delivery, such as faster recovery, low cost, and benefits to the baby (17, 19). However, CS can be used to save lives in certain cases, for instance, to deal with adverse situations like uterine rupture, pelvic pain, abnormal placentation, ectopic pregnancy, and many more (5, 8, 20). Based on the above opinion and evidence-based statement concerning why the rate of CS is increasing rapidly, particularly in Bangladesh, a tailored strategy that considers the different perspectives of healthcare providers and pregnant women and that utilizes the Robson Ten Group Classifications could be applied to reduce unnecessary CS.