We explored a concerning trend in childbirth practices in Bangladesh. From 1999/2000 to 2017/18, there was a striking 42% increase in babies being born in hospitals, which is positive at first glance. However, when we looked closer, we found that CS deliveries increased by 30% during the same period. What is even more worrying is that the majority of this surge in hospital births was due to a substantial increase in CS performed in healthcare facilities. In 1999/2000, 30% of institutional deliveries involved CS, but by 2017/18, this had risen dramatically to 66%. Private healthcare facilities have emerged as major contributors to this rise in CS delivery, accounting for 80% of the country’s total CS delivery in 2017/18, compared to 45.5% in 1999/2000. Conversely, the rate of CS in government healthcare facilities dropped significantly from 49.7% in 1999/2000 to 15.5% in 2017/18. The situation becomes even more alarming when we examine district-level and wealth quintile-based variations. Women in border and hilly districts, as well as those in the poorest wealth quintile, reported significantly lower rates of CS delivery. In many cases, these rates fell below the 15% level. Conversely, in certain selected districts, and among women from affluent households, the reported usage of CS exceeded 80%. Our findings revealed no clear link between having a CS and neonatal mortality in Bangladesh, although the district-level Figure 2 suggests that neonatal mortality was higher in districts where CS rates were also higher. These findings raise concerns and warrant further research on the increasing use of CS and their effectiveness in improving child health outcomes in Bangladesh.

Since the 2000s, the Bangladesh government has prioritized increasing institutional deliveries and access to other maternal healthcare services [29]. This aligns with global goals like the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) and is common among LMICs [30]. However, despite significant efforts, progress has been limited. It is also important to acknowledge, ensuring universal coverage of institutional delivery, in line with the SDGs, is not practical for Bangladesh, as healthcare facilities cannot accommodate them all. As demonstrated by this and other studies in Bangladesh, half of all deliveries still occur outside formal healthcare facilities without skilled personnel present [31–34]. This study highlights another concerning trend: the rise in institutional deliveries is likely to be driven by an increase in CS use. While we cannot definitively say what proportion of these CS are unnecessary without further data, global evidence suggests a substantial proportion is likely to be provider-induced [35, 36]. This indicates that many women are choosing or being encouraged to undergo CS at healthcare facilities [29]. Whatever the reasons are, they are concerning. Women who choose CS mainly come from affluent wealth quintiles, urban areas, and are educated, or a combination of these factors [15]. This also indicates a pathway where the increasing demand for CS among this advantaged group is driving up its accessibility price, indicating that a segment of women cannot afford these services despite being in greater need due to the ongoing evidence of pregnancy complications in this group where CS is more warranted [15, 37]. The very high rate of CS among richer and urban women, along with a deficit of CS delivery among poorer women, supports this conclusion. Encouragement of CS delivery by healthcare facilities is linked with financial gains rather than its necessity [15]. This is the main reason for the rapid surge of CS in private healthcare facilities over the years, while public healthcare facilities observed a decline in CS, as seen in both this and other studies [15, 17, 29, 31, 33, 34]. However, whatever the direction, both indicate poor maternal and child health due to the unnecessary use of CS as well as an unmet need for CS [15, 17].

Concerns about the rising CS rate in Bangladesh surfaced in the early 2010s. National Safe Motherhood Guidelines and the Maternal Health Voucher Scheme were developed in response, followed by initiatives like enhanced skills training for healthcare professionals, public awareness campaigns, and financial incentives for promoting vaginal delivery [30, 38]. However, these programs yielded limited success in curbing the CS surge, coinciding with the increasing role of private healthcare facilities in providing CS [15]. Since 2020, the government has implemented a mandatory CS audit, requiring healthcare facilities to document the reasons for every CS performed [30]. This study reveals significant district-level variations in CS rates. The underlying reasons for these disparities are likely related to healthcare access, socioeconomic conditions, and cultural preferences [15, 17, 29]. Regions with better healthcare access and higher socioeconomic status tend to have higher CS rates, while rural and economically disadvantaged areas may experience lower rates due to accessibility and affordability challenges [15, 17]. Community awareness also play a role, with more informed populations potentially opting for CS based on health considerations [29]. Despite these diverse underlying factors, of the overall results suggest that universal policies and programs are a major drawback and indicate the need for more targeted approaches. Segmented policies tailored to specific local needs and contexts could be a more effective way to address the issue of unnecessary CS in Bangladesh. However, the country lags far behind in achieving this target.

While previous observations linked rising CS rates to lower neonatal mortality [39–41], Bangladesh’s current trend presents a puzzling contradiction. Despite a recent surge in CS deliveries, there is no clear association with reduced child mortality. Rather, there is an overall trend that districts with relatively high CS delivery rates tend to have elevated neonatal mortality. This suggests that the increased CS uptake may not be contributing to the intended goal of lowering child deaths. Potential explanations for this discrepancy could lie in two areas. First, advancements in the quality of maternal healthcare might be independently contributing to the decline in neonatal mortality, even as CS rates rise [42]. Second, the rise in CS use is mostly concentrated among women from affluent families, where neonatal mortality is generally low [15, 17, 29]. Since women from resource-poor families have higher neonatal deaths and they use CS much less than women from affluent households, the CS rate has a little or negative gradient [15–17, 29, 31]. These indicate a complex interplay among maternal healthcare services, CS rates, and neonatal mortality and warrant further research.

The findings of this paper have significant policy implications, particularly concerning the notable variations in CS rates among districts. It highlights deficits in CS use among women from resource-poor households in many districts, indicating that a one-size-fits-all approach to CS control may not be effective and could potentially worsen maternal and child health outcomes by limiting access for those in genuine need. The recommended approach is to shift focus towards promoting justified CS use, especially in private healthcare facilities where the majority of CS deliveries occur. This entails moving beyond the government’s objective of providing CS to enhance child health. The primary goal should be to ensure appropriate and justified CS utilization. In this endeavor, public healthcare facilities, despite their decreasing contribution to overall CS deliveries, can play a crucial role. By strengthening their capacity to provide high-quality, justified CS when needed, they can offer a safe and equitable alternative to private facilities, ultimately improving maternal and child health outcomes for all.