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Journal of Health, Population and Nutrition
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Long-term effects of caesarean delivery on health and behavioural outcomes of the mother and child in Bangladesh
Mostafizur Rahman1,
Nuruzzaman Khan2,
Aminur Rahman1,
Mahmudul Alam3 &
Alam Khan4
Journal of Health, Population and Nutrition volume 41, Article number: 45 (2022) Cite this article
Medically unnecessary caesarean section (CS) is now an ongoing concern worldwide including in Bangladesh. This intensifies the occurrence of adverse maternal and child health outcomes. We investigated the associations of CS with some basic health and behavioural outcomes of the mothers and their children in Bangladesh.
We conducted a community-based case–control study from May to August 2019. A total of 600 mother–child dyads were interviewed using a structured questionnaire, 300 of them had CS, and 300 had vaginal delivery (VD) in their most recent live births. The exposure variable was the mode of delivery, classified as 1 if mothers had CS and 0 if mothers had VD. The outcome variables were a group of health and behavioural problems of the mothers and their children. Multivariate or multiple logistic regression model, separately for each health and behavioural outcome, was used to determine the effect of exposure variable on outcome variable after adjusting for possible confounders.
The mean age and weight of mothers were 25.1 years and 53.1 kg, respectively. Likelihoods of headache, after delivery hip pain, problem of daily activities, and breastfeeding problem were reported higher among mothers who had CS in their most recent live birth than mothers who had VD. Similarly, children who were born through the CS operation were more likely to report breathing problem, frequent illness, lower food demand and lower hours of sleeping.
The use of CS increases the risks of health and behavioural problems of the mothers and their children. Policies and programs to avoid medically unnecessary CS and increase awareness over its adverse effects are important.
Caesarean section (CS) is a surgical procedure in which a baby is delivered through an incision of the mother's abdomen. Ideally, this is recommended when the Vaginal Delivery (VD) would put a baby and/or his/her mother at risk and would not be saved without performing the CS. The World Health Organization (WHO) in 2004 recommended an upper limit of CS use should be 15%, with a further recommendation of 1–5% CS use is enough to avoidable unnecessary morbidity and mortality of mothers and their children [1, 2]. However, the number of CS is increasing globally, starting in early 1990 [3]. Around 21% of the total current world's births, ranging from 6% in low- and middle-income countries (LMICs) to 27% in developed region, are currently ended by CS [3]. At the regional level, the rate is higher in Eastern Asia (35%), Central America (38%), North America and Oceania (32%) [3, 4]. These rates would have been increased to around 50% by 2030 with a global prevalence of 29% CS- a recent projection found [4]. The reasons for these dramatic increases are multi-factorial and varied across countries' socio-economic conditions. However, maternal demographic and reproductive characteristics, including higher age mothers at the time of pregnancy, higher birth order, lower inter-pregnancy interval, higher household wealth quintile and higher educational status of the mothers and their partners are found most influential factors of performing CS in Bangladesh as well as other LMICs [5,6,7]. Professional practice style of the health care personnel, including unethical practice to motivate mothers to undergo CS for making money, has recently been addressed as other important contributors to the rising rate of CS in LMICs [8,9,10]. Moreover, mothers' homes distance from the nearest health care facility and quality and accessibility of the health care services available there are found as other important predictors of CS use in a recent study of Bangladesh [7].
There is evidence that the use of CS prevents nearly 187,000 maternal and 2.9 million neonatal deaths worldwide [4, 11]. However, along with these contributions in reducing maternal and child deaths, medically unnecessary CS can increase short- and long-term health risks of mothers and their children. The short-term risk includes infection, haemorrhage, visceral injury, placenta accrete, and placental abruption [12,13,14]. The long-term risk includes asthma and obesity [12]. Moreover, higher likelihoods of miscarriage, ectopic pregnancy, and stillbirths in the subsequent pregnancies are found among the mothers having CS [15,16,17,18,19,20]. Placental accrete, placental abruption, and uterine rupture are also found higher among mothers with a previous history of CS than VD [18, 21, 22]. However, the effects of CS on maternal and child physical and behavioural health problems following delivery have not been studied yet, in Bangladesh, as well as, in other LMICs. Therefore, in this study, an attempt has been made to examine the effects of CS on some basic physical and behavioural health problems of mothers and children. The findings of this study will inform the policymakers in making relevant policies and programs and will work as a basis for conducting relevant research in a larger setting in future.
A community-based retrospective case–control study was conducted from May to August 2019. The study was conducted in seven communities of the Rajshahi District of Bangladesh, covering both the village and suburban area. Around 60,000 people live in our study area whereas the community health workers reported 2560 live births within three years before the survey was conducted as part of the immunization program. We used this list as the sampling frame. We first divided this list as per the delivery methods (CS vs. VD). Data were then collected from 600 mother–child dyads in total, covering an equal number of CS (n = 300) and VD (n = 300). Our included sample was three times higher than the standard sample size required for this study as determined using the standard formula for required sample size calculation [23]. The samples were selected randomly by using the list and continued up to the inclusion of 300 mother–child dyads in each of the CS and VD group. Data were collected through face-to-face interviews by using a standard questionnaire, which was first developed in the English language and later translate to Bengali (the native language of Bangladesh). Eight Bachelor of Science (B.Sc.) students collected data under the supervision of the principal investigator, the first author of this paper, who also trained properly all data collectors before starting data collection.
Exposure variable
The main exposure variable was the mode of delivery (CS vs. VD) that mothers used in their most recent live birth. Other exposure variables considered were maternal age of birth, place of residence, wealth quintile, education status of the mothers and their partners, number of children ever born, and mothers' body mass index. These variables are found as important determinants of CS in national-level studies of Bangladesh [7, 24] as well as other LMICs.
We considered a range of maternal and child health outcomes as outcome variables. Mothers' health outcomes were headache (pain in the head or neck), after delivery hip pain (pain in the buttock or lower back), problem of daily activities (problems associated with daily work including cooking and walking), suffering physical problems (problems in any organ of the body including eye problem, backbone problem), and breastfeeding problem (women reported they were faced problem during breastfeeding). The type of physical health problems that women faced was also explored and the relevant variable was classified as no problem, eye problem, backbone problem. Breathing problem (problem during breath), frequent illness (measured by at least once quarterly), behavioural characteristics (classified as obstinate, restless, and quiet), food demand (5–6 times in a day for children under 2 years old and 4–5 times a day for the children above 2 years is considered as normal), sleeping hours (40% times a day is considered normal) were considered as child health outcomes. The relevant data were collected by asking the mothers about their health problems after the most recent delivery to the survey date. Child data were also collected from them by asking a separate set of questions. Precautious measures were taken to reduce the recall bias. As part of this, all respondents were asked to show the relevant health cards where available. If the health care cards were not available, respondents were asked several follow up questions to ensure respondents reported correct answers, as such, to reduce the recall bias.
We used mean and standard deviation to describe participants' characteristics. The Pearson's Chi-squared (χ2) test was used to find the significance of the difference of maternal and child health outcomes across methods of delivery (CS vs. VD). Association between outcome variables with methods of delivery was determined after adjusting for socio-demographic characteristics of the mothers. Multivariate logistic regression was used for this purpose if the outcome variable were dichotomous (yes, no). Multiple logistic regression model was used if the outcome variables had more than two categories. All results are reported as Odds Ratio (OR) and its 95% confidence interval (95% CI). All analyses were performed using the Statistical Package for Social Science (SPSS) version 20.0.
The Institutional Animal, Medical Ethics, Biosafety and Biosecurity Committee (IAMEBBC) of the Institute of Biological Science, University of Rajshahi, Bangladesh, reviewed and approved this study (approval number is 78/318/IAMEBBC/IBSc). Informed verbal consent was obtained from the study participants after exploring the objectives of this study. The confidentiality of the participants was ensured as well.
The mean age of the mothers was 25.1 years and the mean weight was 53.14 kg (Table 1). A majority of the respondents had primary education (mean year of education was 5.40 years) and they had at least two children (mean number of children ever born was 1.9) at the time of the survey conducted. The mean age of marriage was around 16 years.
Table 1 Background characteristics of the respondents
The self-reported health problems among the mothers and their children across modes of delivery (CS vs. VD) are presented in Tables 2 and 3, respectively. Adverse mothers and child health outcomes were found higher among the mothers who performed CS and children born by CS. These differences were to be statistically significant at less than 5% level.
Table 2 Mothers' physical health problems by mode of delivery
Table 3 Child health problems by mode of delivery
We run a series of multivariate logistic regression models to examine the effects of CS on different maternal and child health outcomes (Table 4). We found mothers who had CS than VD reported a 3.57 (95% CI, 2.34–4.62) times higher likelihood of headache and 3.26 times (95% CI, 2.80–4.24) higher likelihood of hip pain. Mothers who had CS operations in their most recent pregnancies were 2.68 times (95% CI, 1.90–3.87) more likely to report the problem in daily activities than their counterparts who had VD. The likelihood for backbone pain (OR, 3.58, 95% CI, 2.12–4.70) was found higher among mothers having CS than VD. Moreover, mothers who had CS were more likely to report the problem in breastfeeding (OR, 3.19, 95% CI, 2.90–4.20) than mothers who had VD.
Table 4 Odds ratio of mothers' and children's health problems among mothers who have performed caesarean delivery either vaginal delivery
The children of the mothers who had CS were reported 2.62 times (95% CI, 1.90–3.67) higher odds of breathing problem after delivery than the children of the mothers who had VD. Around 5 times (OR, 5.10; 95% CI, 3.90–6.20) higher likelihood of frequent illness was also found among children born by CS than VD. In addition, children of mothers who had CS than VD were reported a higher odd of quite behaviour (OR, 1.93, 95% CI, 1.01–2.89). The likelihoods of normal food demand and normal sleeping hour were found to be 55% (OR, 0.45, 95% CI, 0.12–0.98) and 31% (OR, 0.69, 95% CI, 0.20–1.00) lower, respectively, among children whose mothers had CS than the children whose mothers had VD.
Through this study, we determined the effects of CS on the health and behavioural problems of mothers and their children. We reported a higher likelihood of health and behavioural problems among mothers who had CS and children who were born through CS. As far we know this observation is first in Bangladesh, as well as in other LMICs. Policies and programs from the governmental level to prevent medical unnecessary CS are important.
The use of CS was found associated with improvement in maternal and child health outcomes up to 1985, when the rates of CS were around 10–15% [25]. However, when the rates were crossed to 15% in the earlier part of 1990, it becomes a concern, since, such increasing rates of CS were showed no evidence of further improvements in maternal and child health [25, 26]. Even such increasing rates of CS, which are mostly performed without medical necessity, are found associated with obstetric complications and associated maternal and neonatal morbidities and mortalities [27]. A 14 years follow-up study in Canada of more than 2 million women found a 3 times higher risk of mortality from obstetric complications, including blood clots and heart attacks among the mother performed CS unnecessary [28]. Similarly, a higher likelihood of respiratory distress, metabolic and immune diseases are found among children born by CS than VD [28, 29]. There is also evidence that many of these adverse outcomes take a long time to recover and sometimes it stays lifelong [4, 19, 20, 29].
We found higher adverse health and behaviour problems are more common among the mothers who had CS as well as among their children. More than 83% of the mothers who had CS reported headaches and hip pain. These adverse outcomes are associated with anaesthesia. During CS, the doctor inserts a needle in the mother spinal area for administrating the pain medication. However, insertion punctures cover the spinal cord which leads to spinal fluids seepage and causes post-surgery headache [30,31,32]. Mothers suffering from this problem are mostly recovered within a week after delivery [31]. However, in some cases, the problem can stay longer period and could influence women daily activities and other associated physical health problems. This study also reported their higher likelihoods among the mothers who had CS than VD, which was similar to the findings of a study conducted in Australia [33]. Using post-partum care following the CS is important to overcome these complications. However, this is a further challenge in Bangladesh and other LMICs as post-partum care use is very low and many women consider these adverse outcomes are only for short time with no effective remedy [34].
We found CS mothers are more likely to face problems in exclusive breastfeeding—a similar finding reported in other LMICs [35,36,37,38]. The reason is lower earlier skin contact of mothers and children soon after delivery [39]. Mothers earlier return to the formal work, which is common among CS mothers as they are usually educated and belong to higher socioeconomic status, should be another predictor of lower exclusive breastfeeding following the CS [35, 39]. Importantly, lower exclusive breastfeeding is responsible for several adverse health outcomes of children, including frequent illness, lower food demand, and higher nutritional disorders that we also found in this study as similar to a previous study [35]. Researchers of a recent nationally representative study in Bangladesh concluded lowering exclusive breastfeeding is associated with increased infectious diseases among children, including diarrhoea and acute respiratory infection [40]. In addition, in this study, breathing problems, quite behavioural characteristics, and lower sleeping hours were found following the CS than VD. These adverse outcomes should be considered as consequences of lower exclusive breastfeeding that we found in this study.
This study has several strengths and some limitations. To our knowledge, this is the first study of its kind that considered CS and a range of adverse health and behavioural outcomes of mothers and their children. The associations were adjusted with the range of confounders' factors which make this study findings more precise and should be used for policymaking in Bangladesh as well as in other LMICs. However, our relationship is correlational only rather than causal. Moreover, the data for this study were collected for some selected communities; therefore, the associations reported should not be representative to all areas of Bangladesh. In addition, data were collected by asking respondents a series of relevant questions. Relevant health care cards were also checked. However, instead of these pre-cautious measures, recall bias is still a major issue for this study. However, any such errors is likely to be random.
The use of CS increases the risk of several adverse health and behavioural outcomes of the mothers and their children. The risks of headache, after delivery hip pain, the problem of daily activities, suffering physical problems, and breastfeeding problem were found higher among mothers who had CS in their most recent pregnancies than mothers who had VD. In addition, children born by the CS reported a higher risk of breathing problems, frequent illness, and quite behavioural characteristics. Lower risk of normal food demand and lower sleeping hours were also found among children born by CS than children born by VD. Policies and programs to prevent unnecessary CS and ensure frequent health check-ups of the mothers and their children following the CS operation are important.
The ethical review broad impose restriction to share this data publicly. However, data can be made available upon reasonable request to the corresponding author and approval from the ethical review broad.
LMICs:
Low- and middle-income countries
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We acknowledge the support of the Department of Population Sciences and Human Resource Development, University of Rajshahi, Bangladesh, where this study was conducted. We also acknowledge all mothers who were participated in this study.
This study is conducted without any financial support from any sources.
Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh
Mostafizur Rahman & Aminur Rahman
Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Trishal Mymensingh, Bangladesh
Nuruzzaman Khan
Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh
Mahmudul Alam
Department of Pharmacy, University of Rajshahi, Rajshahi, Bangladesh
Alam Khan
Mostafizur Rahman
Aminur Rahman
Rahman M designed the study, performed data analysis, and write the result section. Khan N writes the introduction and the discussion section and revised all versions of the manuscript. Khan A, Alam M and Rahman A critically revised the paper. All authors approved the final version of this manuscript.
Correspondence to Mostafizur Rahman.
The Institutional Animal, Medical Ethics, Biosafety and Biosecurity Committee (IAMEBBC) of the Institute of Biological Science, University of Rajshahi, Bangladesh, reviewed and approved this study (approval number is 78/318/IAMEBBC/IBSc). Informed verbal consent was obtained from the study participants after exploring the objectives of this study. Confidentiality of the participants was ensured as well.
Competing interest
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Rahman, M., Khan, N., Rahman, A. et al. Long-term effects of caesarean delivery on health and behavioural outcomes of the mother and child in Bangladesh. J Health Popul Nutr 41, 45 (2022). https://doi.org/10.1186/s41043-022-00326-6
Accepted: 23 September 2022
Caesarean delivery
Adverse health effects
Multivariate logistic regression model
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M.I.A., Spoon, Justice, Deerhunter Embrace CMJ 2007's Never-Say-Die Attitude
Black Kids, Yeasayer, No Kids, Dan Deacon live up to blog hype during Music Marathon shows in NYC.
NEW YORK — The CMJ Music Marathon is always a magical confluence of several hundred bands; scores of odd-size venues scattered all about the boroughs of NYC (and New Jersey too); air-tight, no-room-for-encores scheduling; clueless, map-clutching out-of-towners; and perilous, late-night subway rides deep into the heart of Lord-knows-where.
That this goes on for four never-say-die days and nights is a testament to the veracity of the fest's name: CMJ is not a sprint. It is 26.2 grueling, bloody miles of music. Nothing is easy. Tough choices need to be made. The wounded are left behind. That people actually seem to enjoy all of this is a testament not just to the will of the human spirit, but to the boundless energy of the pure-hearted, unspoiled music fan.
Because unlike South By Southwest — the Marathon's bratty, down-South brother (which, in the minds of many, has surpassed the elder as the premier fest in the States) — CMJ is a musical festival for people who actually like music festivals and all the headaches and heartbreaks that come along with them. There is no Sixth Street (the Austin thoroughfare that hosts the majority of SXSW's action) to speak of, no label-sponsored cocktail hours at swank Texas hotels, no delicious Bar-be-que to demolish. SXSW is easy, sort of like an industry-wide booze cruise with bands playing on the pool deck. CMJ is complicated, a sometimes-miserable mess, with bands playing in apartments in Bushwick, Brooklyn.
But despite all that — or, perhaps, because of it — CMJ also offers rewards beyond your wildest dreams. If you're willing to put in the work, then the Marathon will deliver the goods, and the battles you fight along the way make the end results that much sweeter. Bands feel like tiny pearls, discovered only after hours of prying, swearing, sweating and bleeding. And for that fact alone, it's pretty great.
In that regard, CMJ 2007 was probably the pearliest in recent memory, though perhaps not for the reasons you'd expect. After all, the concept of "discovering" a band at any music fest is about as antiquated as the concept of fests themselves, thanks in no small part to the rise of taste-making blogs, yet there was something incredibly satisfying about witnessing acts like Black Kids and Yeasayer deliver sets that more than lived up to the hype surrounding them.
The former — a quintet from Jacksonville, Florida, that currently does not have a record (though it does have a record label: Almost Gold, the home of Peter Bjorn and John) — overcame an overly chatty crowd and a malfunctioning amp at the Annex on Thursday to deliver a herky-jerky set that sounded like the Cure on DFA Records. The latter, a bunch of Brooklyn weirdos with a predilection for droning electronics and delicate African melodies, owned Saturday night, washing through the borough's Glasslands art space like some sort of mythic flood, leaving the beards-and-glasses crowd soaked and awed in their wake.
Deerhunter, No Age and Dan Deacon — a trio of acts also not unfamiliar with blog love — kicked off the Marathon Wednesday night at the Bowery Ballroom with sets that were, in order: bizarre-yet-impactful; scarily spazzy; and, well, sweat-drenched. Earlier that day, Vampire Weekend shuffled their way through an afternoon set at the tiny Cake Shop, debuting a new track or two from their upcoming debut. And Los Angeles' Health howled, chanted and flailed their way to the top of a w-a-a-y packed noise-core bill (Japanther! AIDS Wolf! Sightings!) on Friday at the Knitting Factory.
But it wasn't all up-and-comers delivering the goods. There were also pearls to be found if you managed to brave the lines to see established acts like Spoon, Band of Horses and M.I.A. French DJ duo Justice had the crowd at newish venue Terminal 5 swaying and pumping, and the Meat Puppets — yeah, the Meat Puppets — were way too excited to be playing the tiny club Pianos. There was also a fair amount of hip-hop on display — truly one area in which CMJ trumps SXSW — from a feisty Wednesday night party at the sleek Hiro ballroom that featured Kanye West's DJ A-Trak and Chicagoans Kid Sister and the Cool Kids, to a fiery Saturday set by Brother Ali.
In the end, attempting to recap something as chaotic and hydra-headed as CMJ is nearly impossible. There is no unifying theme, ever, and the 2007 edition was even more fractious than any previous year. But, as we've tried to encompass in our on-air coverage, that's part of what makes the Marathon great: it's the searching, the scheduling, the "Holy sh--, I almost died, but I made it to Simian Mobile Disco's set!" that makes this unlike any music festival in the world. There's real danger here.
And will any of the bands we mentioned above even matter in a few years' time? Probably not, but that's nearly beside the point. You don't come to the Marathon to get discovered anymore — you come here to build upon a fleeting legend, to tough out roughly 47 different shows, to traverse shadowy alleyways, to party until the sun comes up and to wear yourself down. And perhaps the most amazing thing about CMJ is that the previous sentence applies to both the bands and the fans.
Check out our complete CMJ 2007 coverage, including reports, video and photos, in the You R Here blog.

redpajama_set_name: RedPajamaCommonCrawl