Midwives could be game changers in curbing unnecessary C-sections

When Sanjida Khatun joined the Kazipur Upazila Health Complex in Sirajganj as a midwife in 2018, the facility would see only 20-25 childbirths a month. People used to avoid the hospital due to its inadequate facilities and rather go to private clinics. But they often fell victim to unnecessary Caesarean sections (C-sections) that cost large amounts of money.

The situation, however, has changed thanks to Sanjida and her three fellow midwives. Childbirths at the Kazipur Upazila Health Complex have now increased to 70-80 per month and almost all of them are normal deliveries.

"With our continuous efforts, changes are now visible. The rate of normal delivery has been on a gradual rise. In most cases, we do not see the necessity of C-sections but previously it would happen randomly, causing long-term complications for mothers and children," Sanjida told The Business Standard.

"We look after an expecting mother for 10 to 12 hours after she goes into labour. It is a long duty where we play an active role," added Nusrat Jahan, another midwife at Taraganj Upazila Health Complex in Rangpur.

"Most mothers give birth normally without any complications. In rare cases, we refer to doctors for C-sections," she told TBS, noting that her hospital now serves 20 such patients every month, which was only two-three before her appointment around five years ago.

Nusrat and Sanjida are just two of nearly 4,000 midwives who were appointed in 2018 as part of the government's efforts to promote normal childbirths. Although some other steps are also in place, midwives appear to be the game-changers.

They work at the hospitals and outside at a time to campaign for institutional deliveries, care for expecting mothers, help childbirths without C-sections, and manage complications in post-partum periods.

Experts believe trained and well-equipped midwives can play an important role in reducing maternal and infant mortality. The labour room facility at every hospital is crucial for that, they added.

"An effective way to reduce Caesarean deliveries is to appoint midwives, but most healthcare facilities, including medical college hospitals and district-level hospitals, have no midwife. Only upazila-level hospitals have midwives. It is very unfortunate," said Professor Ferdousi Begum, president of the Obstetrical and Gynaecological Society of Bangladesh.

"It is not possible for a gynaecologist to take care of a patient for about 10 hours before delivery. We need confident teams, including midwives, junior physicians and nurses, who can facilitate normal deliveries, antenatal and postnatal care at hospitals," she said and added that it is time to create and recruit midwives on a large scale.

Sources at the Directorate General of Nursing and Midwifery say processes are underway to recruit another 5,000 midwives soon. "A letter has been sent to the health ministry to this end. Some 1,500 midwives are expected to be recruited in the next one to two months and the rest will be recruited in phases," a senior official at the directorate, wishing to remain unnamed, told The Business Standard.

According to the United Nations Population Fund, as many as 8,646 midwives graduated from different educational institutions in Bangladesh over the last decade. Of them, 2,557 were deployed at government health facilities. In addition, 376 are currently working at various private hospitals. Around 400 midwives have also been deployed in the Rohingya camps in Cox's Bazar.

Midwives are now conducting 86% of the child deliveries in 407 upazila health complexes across Bangladesh, the organisation said.

Professor Ferdousi Begum believes midwifery education needs to be further promoted and graduate midwives need to be assured of jobs.

Simultaneously, necessary equipment such as ultrasonography machines and standard labour rooms are needed at all hospitals – be they private or public.

On rising C-sections, the health expert said it is alarming and unexpected. "We must make special and time-befitting efforts to reduce it. Mass awareness should be raised to this end."

According to the Bangladesh Demographic and Health Survey, the C-section rate jumped to 45% in 2022, which was 34% in 2017, 24% in 2014 and 18% in 2011. Among all C-sections, 84% happen in private hospitals and 14% in public facilities.

The World Health Organization always recommends that a country should accept a maximum of 10%-15% of C-section births, but anything higher is alarming. In Bangladesh, the unnecessary higher Caesarean deliveries are causing physical harm to mothers and financial losses to families, it warns.

Following a High Court order in 2019, the government prepared a guideline to promote normal deliveries and curb C-sections in the country, keeping a priority of midwives as an implementation resource.

"But, in reality, the rate of hiring midwives has been slow. We need more than 20,000 midwives if district-level hospitals and medical college hospitals are taken into consideration," said public health expert Dr Ishtiaq Mannan.

He has been working to create awareness about C-section deliveries for a long time. "Obviously, Caesarean section is a life-saving procedure; it is necessary to save the lives of mothers in some cases, at most 15%. But our C-sections are unnecessarily high. It is not meant for curbing maternal mortality rate by any means," he added.

The policy, known as "Bangladesh National Guidelines and Technical Standards and Operating Procedures for Promotion of Normal Delivery, Ensuring Life-saving Interventions and Prevention of Unnecessary Caesarean Sections", says certified midwives and functional labour rooms should be made mandatory for private hospitals and clinics intending delivery care.

It also promotes a standard record-keeping and reporting system at hospitals.

When contacted, Directorate General of Health Services Program Manager for Maternal Health Dr Azizul Alim told The Business Standard that the directorate has started implementing the guidelines at all public and private hospitals since the Covid-19 pandemic.

"Caesarean deliveries have increased in the country in the face of a surge in institutional deliveries. So, we are emphasising labour rooms everywhere. Training modules to increase normal delivery also are being prepared," he said, adding that the hospital wing of the directorate is working with them to reduce Caesarean deliveries in private hospitals.