Noted obstetrician Rowshan Ara Begum’s career spanned over four decades. She graduated from Mymenshingh Medical College in 1974. Lately she was Obstetrics and Gynaecology professor at Holy Family Red Crescent Medical College and Hospital. She was president of Obstetric and Gynaecological Society of Bangladesh, a leading organisation of obstetricians and gynaecologists in the country, in between 2014-16. She shares her thoughts with New Age staff correspondent Manzur H Maswoodabout the obstetric care situation in Bangladesh, the growing trend of caesarean births and how it could be curbed for the betterment of both mothers and newborn.
Back in 1993, when a good number of mothers were dying in the countryside of Bangladesh every day due to complicated deliveries but without any caesarean interventions, Bangladesh government wanted to change the scenario. In support with some international nongovernment organisations, the government trained gynaecologists and anaesthesiologists to send them to the rural areas so that they can provide emergency obstetric cares including caesarean section when needed to the marginalised rural mothers.
‘The noble step of making available C-section to save thousands of mothers worked and started to show in the steady fall in the maternal deaths rate in Bangladesh. But that was the beginning of a rise of caesarean section deliveries in Bangladesh, Rowshan Ara Begum argued.
‘C-section has now turned endemic. Irrespective of whether it was needed or unnecessary for mothers, it is being performed. Though C-section is a lifesaving intervention for mothers in danger while giving birth to child, she said.
Rowshan Ara said having a C-section done when there is no medical reason behind it, puts mothers and babies at unwanted risk. Unnecessary C-section increase the likelihood of infections, excessive bleeding, organ damage and blood clots as well as increasing the recovery time for mothers.
But natural births on the other hand, enable mothers and babies to have physical contact sooner, with breastfeeding beginning earlier. When babies travel through their mother’s birth canal, they also receive a measure of good bacteria, which boost their immune system, she said.
Unregulated mushrooming of private health facilities contributed to the increase of the number of C-section in Bangladesh, Rowshan Ara believed.
Private clinics were now set up at upazilas, districts and countryside and they were meant to provide exclusively the C-section services only, which was a dangerous trend, she said.
A section of doctors were responsible for the increasing rate of C-section, she said, adding, more financial incentive from C-section motivated the doctors to go for C-section while wealthy mothers also went for C-section as they were unwilling to endure the pain during childbirth.
Rowshon Ara urged the mothers to endure the pain of child delivery for the sake of their health and to benefit the newborn.
She said now a painless delivery method of childbirth was introduced and wealthy mothers across Bangladesh preferred C-section over normal delivery, though it was not really beneficial for both the mother and child in the end.
For the method, doctors administer pain killers to the mothers but though it makes the mother not feel any pain during delivery, the mother could neither feel when she was ready to deliver, nor understand the readiness of her child, she explained.
In such cases, the babies are pulled out using machines which may harm the babies including causing their deaths.
Pulling of babies in such way might make the baby unable to breathe and sustain injuries in the head or other organs, Rowshan Ara said.
She said a low cost gas known as Entonox that reduced the pain could be inhaled by mothers when they feel excessive pain during natural delivery.
Rowshan Ara said the decision to opt for a C-section depended on the condition of mothers and babies. If the mother’s health condition was good, if her delivery canal had no complications and if the child’s condition and position in the womb was alright, then a C-section was not necessary.
But without considering the above issues, taking a decision in favour of C-section whimsically might be dangerous, she said.
She suggested that the government should fix the fees of C-section to rein in the errant doctors performing C-sections.
She said the labour room protocol, formulated by the Obstetric and Gynecological Society of Bangladesh and endorsed by the government last week, would help to check the rampant use of C-section.
The doctors have to follow the labour room protocol that stipulates certain conditions upon which the doctors would decide if the mothers really needed a C-section or normal delivery was good for her, Rowshan Ara said, adding the government have to ensure a mechanism so that the doctors follow the labour room protocol.
Rowshan Ara said C-section was increasing globally but C-section in developed countries and even in Sri Lanka has a positive impact, decreasing maternal deaths.
Though application of C-section procedure is increasing in Bangladesh, the rate of maternal deaths was not decreasing, she added.
Countries like Sri Lanka, Thailand and United States have high C-section rate but the maternal mortality rate is low in those countries. Sri Lanka’s C-section rate is 35 and maternal mortality rate is 30 per 100,000 live births while USA’s C-section rate is 33 and maternal mortality rate is 14. Whereas in Bangladesh, the high rate of C-section has no correspondence whatsoever with the reduction in maternal deaths, as it is now 196 per 100,000 live births, Rowshan Ara pointed out.
She said Sri Lanka has 100 per cent delivery at health facilities, but in Bangladesh, the rate of delivery at hospitals is only 47 per cent.
The trend of resorting to C-section procedure is much higher at private hospitals in Bangladesh which proves that families who have the ability to bear the expenses go for C-section.
‘About 83 per cent birth in private hospitals are performed through C-section. But such practice has little or no impact on maternal deaths. It proves that the poor and the marginalised mothers who are really in need of C-section to save their lives remain outside the ambit of such services,’ Rowshan Ara said.
She said antenatal care and nutrition of mothers were crucial during pregnancy as lack of proper antenatal care and malnutrition made mothers vulnerable and led to C-section.
She said early marriage and early pregnancy (pregnancy before at least 20 years of age) created complications that often led to C-section.
Rowshan Ara underscored the need for midwifery and trained traditional birth attendants if the country was to experience a decrease in the use of emergency C-section procedure.
She said Bangladesh has merely 1,000 trained midwives, whereas the country was in need of at least 20,000.