Insidious Rise of Unnecessary C-Sections in Bangladesh and How to Reign it In: An Interview with Barrister Rashna Imam

rashna imam
Rashna Imam, a Bachelor of Civil Law (BCL) Scholar from the University of Oxford,  previously worked in Baker & McKenzie’s London Office as a corporate associate. She now practices law in the Supreme Court of Bangladesh. She is the Managing Partner of Akhtar Imam & Associates, a leading law firm ranked in Chambers & Partners. In 2018, she was selected from a large pool of nominees from around the world as Asia 21 Young Leader, in recognition of her work in establishing a legal framework for emergency medical services, reforming the archaic statutes inhibiting organ donation and challenging the failure of  Bangladeshi government to enforce fire and structural safety standards for buildings in Dhaka city.

When did you become aware that Bangladesh has an epidemic of unnecessary c-sections? Are there any personal experiences that motivated you to look into the matter?

Experiences of friends and family and newspaper reports in leading national dailies on the alarming rise in medically unnecessary c-sections, not to mention the campaign to stop unnecessary c-sections jointly launched by Save the Children, Bangladesh and ICDDRB motivated Bangladesh Legal Aid and Services Trust (BLAST), and myself, to look into the matter and seek judicial intervention to check the rise of this dangerous trend. 

How bad is the problem? Would you like to share any statistics that the public may not be privy to?

According to World Health Organisation (WHO), there is no justification for any country to have a c-section rate beyond 10 – 15%. Bangladesh has deviated from this internationally recognized benchmark by a massive margin.

Our c-section rate is at a whopping 31%; i.e., more than double of what WHO recommends. These numbers are reported by Bangladesh Maternal Mortality Survey of 2016, and implemented under the authority of the National Institute of Population Research and Training (NIPORT), a research wing of Ministry of Health and Family Welfare.

There seems to be a strong co-relation between higher levels of education and undergoing a c-section.  56% of the women who have completed either secondary and higher levels of education end up delivering their child via c-sections.  Source: Stop Unnecessary C-Sections. Accessed 5th August, 2019. 

Over 1 million c-sections take place in Bangladesh every year. We have one of the highest c-section rates in the world. The c-section rate in our country increased ten-fold between 2000 and 2016: from 2.7% to 31%.

Infographics published in Stop Unnecessary C-Section campaign website  further indicate that c-section delivery rate has almost doubled in private facilities (83%) compared to public facilities (35%).

In NGO hospitals, the rate is 39%, according to BMMS 2016. The Bangladesh Demographic and Health Survey 2014 revealed that despite the astronomic rise of c-sections in Bangladesh, maternal mortality ratio was still very high, i.e., 176 per 100,000 births. Compare those numbers to only 4 per 100,000 in Sweden where the C-section rate is 18%, and 7 per 100,000 in Netherlands where the c-section rate is 14%. The high maternal mortality ratio in Bangladesh, despite the rapid rise in c-sections, renders the medical necessity of these c-sections as an immensely dubious practice.

Let’s talk about the causes. Is the alarming rise in medically unnecessary c-sections entirely motivated by revenue generation or are there other reasons behind this? 

The distressing rise in medically unnecessary c-sections is a multi-factorial phenomenon. While one of the main reasons is revenue generation, other reasons include: shortage of accredited midwives to lead uncomplicated vaginal deliveries, convenience of doctors and families, little or no monitoring of hospitals and clinics by the relevant authorities and trepidation about childbirth pain.

The last reason – the dreaded prospect of enduring childbirth pain, may be the reason why urban women from high-income families opt for superfluous c-sections. This is partly due to ignorance about the health implications of a c-section coupled with the fact that they receive no physical or psychological training akin to Lamaze classes during pregnancy in the more developed parts of the world. Add to that the financial ability of urban women to pay for a c-section, and you end up with surplus c-sections.

On the other hand, rural women from low income families (who are almost always accustomed to hard physical labour) are physically more prepared for normal deliveries than urban women.

You have filed a public interest litigation on the issue. On behalf of whom did you file it and what orders have you sought and obtained from the court? Current stage?

I filed and moved a Public Interest Litigation (PIL) on behalf of BLAST, the petitioner; challenging the failure of the Ministry of Health, DG Health Services and Bangladesh Medical and Dental Council, who were the respondents; to regulate public and private hospitals and clinics and medical practitioners to prevent medically unnecessary c-sections.

On 30th June 2019, we sought and obtained from the High Court Division of the Supreme Court of Bangladesh, the following directions on the respondents:

(i) Form a committee of relevant experts and stakeholders to formulate guidelines for prevention of medically unnecessary c-sections to be followed by public and private hospitals, clinics and medical practitioners.

(ii) Submit the guidelines so formed to the court within six months.

Will these guidelines be mandatory, that is, binding, or directory?

Once the guidelines are formulated and submitted to the court, we are going to pray that these are given the force of law until appropriate laws are enacted. If our prayer is granted, then these guidelines will be binding and their violation enforceable in a court of law. There are multiple judicial precedents in Bangladesh and India in which guidelines framed pursuant to court order, have been given the force of law until appropriate legislation is enacted.

The reaction to this petition has been overwhelmingly positive in social media, especially from young women in Bangladesh. What about the urban women who willingly opt for elective c-section?

Assuming that elective c-sections contribute to the alarming rise in a major way — even though I have not come across credible research or statistics to prove that is the case — we need to ask ourselves: Why do women in Bangladesh opt for medically unnecessary c-section when they do?

Ignorance of possible health complications arising from extraneous c-sections for the mother and baby is a major factor. Medical practitioners in Bangladesh hardly ever elaborate on the pros and cons of c-sections. Another reason is that pregnant women (especially those from urban areas and high income families) undergo little or no physical/psychological training of the kind that is given to pregnant women through structured educational programs in first-world nations.

If these issues are addressed, elective c-section rates are bound to go down as well. Despite all of that, if someone, who is fully informed of the possible health complications and has had the opportunity to receive physical and mental training for a normal delivery, chooses to deliver through c-section, it is her decision entirely.

How has the medical profession in Bangladesh reacted to this?

There are bad apples everywhere and the medical profession is no exception. Having said that, the reaction has been mixed. While there is a consensus on the alarming rise of medically unnecessary c-sections, opinions differ on whether judicial intervention is the right way to address the problem. The negative feedback that we got, I would like to believe, mostly arises from ignorance of the orders sought from and granted by the High Court. I would like to take this opportunity to clarify that the decision as to whether a c-section is medically unnecessary or not, will always lie on the doctor concerned.

The negative feedback that we got, I would like to believe, mostly arises from ignorance of the orders sought from and granted by the High Court. I would like to take this opportunity to clarify that the decision as to whether a c-section is medically unnecessary or not, will always lie on the doctor concerned.

 The point of the guidelines will be to raise awareness about the clinical indications that necessitate c-sections, both amongst the public and those associated with the medical profession; and to ensure training of doctors, secure training and deployment of midwives in all hospitals, introduce accountability in the maternal health care sector by imposing detailed record-keeping, and enforcing reporting obligations on hospitals and clinics for each c-section and imposing fines on or cancelling licences of hospitals for abnormally high c-section rates or rewarding hospitals for bringing down c-section rates.

Are Bangladeshi women especially vulnerable when it comes to accessing medical care in the private sector? 

Health services are almost entirely provider induced, in that we rely heavily on the advice of the expert. While c-sections of course affect only women and children, with regard to accessing health care services in general, both men and women are equally vulnerable due to zero accountability in the health sector in Bangladesh.

Despite the alarming incidence of medical negligence, court cases on medical negligence are few and far between. This is primarily due to the lengthy, protracted and expensive nature of civil suits for compensation and little to no chance of success due to evidentiary problems, given, among others; poor record-keeping practices in our hospitals and absence of a witness protection programme.

Of late, the constitutional courts of the Supreme Court of Bangladesh have come to the rescue by awarding compensation in glaring cases of medical negligence affecting the constitutionally protected right to life (broadly interpreted by the courts to include quality of life) but even those cases are plagued by evidentiary problems.

If the orders are granted by the court, to what extent do you think these would be successful in reducing the rate of medically unnecessary c-sections? What other measures are necessary and from whom?

If we are successful in obtaining a judgment sanctioning these guidelines and giving them the force of law until enactment of appropriate legislation, the guidelines would be the first step to establishing a specific legal framework for prevention of medically unnecessary c-sections in Bangladesh. What is required after that is a conjunctive effort from all stakeholders to disseminate, implement and enforce the said guidelines, raise public awareness, and train and motivate doctors and midwives. We can benefit by emulating the approach adopted by China and Brazil in addressing the same challenge. Both countries have been able to slow down the alarming rise in their c-section rates. 

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