Caesarean section (CS) can be a lifesaving operation when a woman or her babyfaces complications before or during labor and delivery, and it is an essential intervention included in emergency obstetric care. The rate of caesarean delivery is increasing in countries worldwide, and Bangladesh is no exception. Between 1999and 2010, the CS rate in Bangladesh increased from 0.7 percent to 12 percent, andin urban areas the rate is almost 16%. While the increase in CS suggests increasedaccess to life-saving emergency obstetric care for more women in Bangladesh, italso brings with it the potential for several unintended consequences that require better understanding. BRACs community based maternal and child health program,known as Manoshi, aims at reducing maternal and child mortality and illness inurban slums of Bangladesh. Manoshi uses its delivery centres throughout the urbanslums for normal safe delivery and it refers complicated cases to referral facilities.Data provided by Manoshi program personnel indicate that 53% of women whodelivered in the hospital and 23% of all women in the Manoshi program in Dhakacity underwent CS delivery in 2010.This study documented several causes and consequences of caesarean deliveriesin the urban slums of Dhaka City. The specific study aims were to documentthe supply and demand side factors associated with CS; document the short-termmedical, economic, and social consequences of CS for women and their families;and to document the cost of CS to the Manoshi program and to CS recipientsand their households. This was an observational, survey- and record review-based,mixed retrospective/prospective classical case-control design using women whounderwent cesarean section (CS) delivery as cases and normal vaginal delivery(NVD) as controls. Data collection was carried out in two phases; in the first phasedata was collected from May to October 2011 at the facility level and second phasedata collection was carried out between July and December 2011 in the communitylevel. A total of 732 women (n=342 in control and n= 390 in the case groups) wereinterviewed in the facility and among them 669 women were successfully followedup in Phase 2 data collection at the community level. Women were selected fromsix purposively selected facilities that included public sector, private not-for-profit,and private for-profit facilities. Descriptive and multivariate analyses were done tointerpret the study findings.The mean age of participants was 24 years and the mean age at first pregnancy forNVD group and CS group were 18.8 years and 19.2 years respectively, with 10% (NVD) and 8% (CS) respondents reporting first pregnancy at 15 years or younger.The rate of preterm birth (< 37 weeks GA) was 8.5% in the NVD control group and4.6% in the CS case group. About 67% of respondents were from public facilityand 30% from private not-for-profit facilities while only 3% were from privatefor-profit facility.Almost one-half of the women reported no pregnancy-specific antepartumcomplications. CS cases were more likely than NVD controls to have experiencedsevere headache and blurring of vision (OR=1.84, 95% CI [1.04-3.26]). The mostcommon reason for referral by Manoshi was prolonged labour (36%), followedby premature rupture of membranes after 37 weeks gestational age before labouronset (12%), previous CS (10%), malpresentation (7%), postdate (6%), andpre-eclampsia or pre-eclampsia-like symptoms (5%) where the most commonintrapartum complications reported by the women were prolonged labour (23%),and high blood pressure (7%). From the medical record review, the most commonindications for CS were documented as: fetal distress (38%), previous CS (20%),postdate (18%), oligohydramnios (14%), malpresentation (11%), prolonged labour(8%), and obstructed labour (7%).Among women who were indicated as “postdate” in either the referral indicationand/or the CS indication, slightly more than 80% were at a self-reported gestationalage less than 42 weeks. Thirty-one percent (31%) of women were referred by BRAC for “prolonged labour” if 12 hours since their self-reported time of onsetof labour pain had not yet elapsed. Seventy-seven percent (77%) of CS caseswith previous CS, 51% with postdate, and 35% with pre-eclampsia included indocumented medical indication for CS did not undergo any trial of labour (TOL) atterminal birth facility (TOL self-reported). Additionally, 70% of CS cases referredfor prolonged labour, 73% referred for obstructed labour, 55% referred for fetaldistress, and 50% with bleeding per vagina still underwent TOL after arriving atthe facility, before CS. Seventy-three percent (73%) CS cases referred for previousCS, 37% referred for pre-eclampsia and 32% referred for “rupture of membranes”or PROM did not undergo any TOL before CS delivery.Only 24% of women reported postpartum complications in hospital with severelower abdominal pain (5%), excessive bleeding (4%), and convulsions or fits (4%)being the most common. CS cases were less likely to have experienced excessivebleeding (OR: 0.167, 95% CI [061-.456]), but more likely to have experiencedcoryza/cough (OR: 22.600, 95% CI [2.804-182.141]). The mean length of hospitalstay for the NVD group was 31 hours (SD = 34hours) and for CS group was 101 hours (SD = 89 hours). The mean time to first breastfeeding for NVD group was162 minutes (SD = 430, range 5 – 96 hours), and for CS group was 293 minutes(SD = 527, range 20 – 96 hours). CS cases were more likely to experience woundinfection or possible wound infection symptoms than NVD controls [33% vs.11%] (OR 3.78, 95%CI [2.51-5.72]) as postnatal complications at follow-up. CScases were more likely than NVD controls to score “positive” for major depressivedisorder screening, using the Edinburgh Postpartum Depression Scale and recentscore criteria updates, during the in-hospital interview but not at the follow-upinterview.Cases and controls showed a similar mean birth weight for neonates (2.8 kg), butlow birth weight status was more prevalent in NVD controls. CS case infants weremore likely than NVD control infants to experience fever ≥ 37.5°C, but less likelyto experience “absent cry” or “low birth weight” or failure to thrive. Apart fromstillbirths, we found 16 neonatal deaths before (n=7) or after discharging (n=9)from the hospital.More than 99% of women reported receiving antenatal care (ANC) with 96%attending 4 or more ANC visits. The majority (81%) of women wanted to havetheir delivery at a BRAC Manoshi delivery centre while 13% preferred at facilityand 6% preferred at home. CS cases were more likely than NVD controls to haveinitially wanted to deliver at a hospital rather than home or BRAC delivery centre(OR 3.36, 95% CI [2.04-5.55]). Seventy-six percent of women were referredfrom the BRAC delivery centre itself; 94% of women were referred by directobservation and the most common (64%) referring personnel from BRAC wasShasthya Karmi (SK). Fifty-eight percent of women reported that doctors were theprimary decision maker for their CS delivery.Sixty-eight percent of women experienced normal labor pain before delivery whileonly 8% reported medicine-induced labour pain. About 9% of women underwenta trial of labor at home and 10% women visited a facility other than their terminalfacility after leaving BRAC delivery centre. CS cases were more likely than NVDcontrols (22% vs 12%) to have spent 16 hours or more at home if they did not goto BRAC delivery centre. Forty percent of women spent less than an hour and 13%women spent more than 2 hours in transportation from home or BRAC to reach theterminal facility, if they did not visit another facility. Twenty-five percent of NVDsand 20% of CS cases had spent 8 to16 hours in BRAC delivery centre. In 24% ofNVD controls and 36% of CS cases, 4 to 8 hours elapsed before their delivery interminal facility. Seventy-six percent of CS cases who self-reported that they did not undergo any trial of labour at the terminal facility did not deliver within 2 hoursof arrival at the facility.Regarding cost of delivery at referral facilities, the highest costs (15,980 BDT)were incurred in private for-profit facilities, followed by NGO-not for-profit(9,410 BDT) and public facilities (7,775 BDT). Costs in private facility fornormal delivery were 3.2 times higher than the public facility. Multiple sourcesof funding were reported, the highest being household income (78%) followedby borrowing (69%), Manoshi help (63%). The proportion of costs shared byeach of these mechanisms was 39%, 42% and 14% respectively. Manoshi sharedhighest proportion of cost in public facilities (11%) followed by NGO (6.5%)and private facilities (1.3%). Households had to adopt several mechanisms atfollow-up to cope up with the delivery or post delivery expenditure and among themechanisms significantly higher proportion were: selling or mortgaging householdassets (p=0.005), borrowing money (p=0.001), postponing previous loan payment(p=0.032), decreasing recreational costs (p=0.026), purchasing fewer necessaryhousehold materials (p=0.018), and delaying or never seeking healthcare (p=0.019).Ten percent of families scored as having “moderate household hunger” or “severehousehold hunger” on the Household Hunger Scale.At follow-up interview, 12% percent of CS cases and 10% of NVD controlsreported their family status as “low” or “very low”, and 15% of CS cases and11% of NVD controls reported a worsening in their relationship with husbandssince before delivery. The most common behaviors of domestic abuse and neglectreported by women were: verbal abuse (21%); lack of emotional support (14%);lack of physical support (14%); and physical violence (9%). A total of 31% of CScases and 27% of NVD controls reported at least one of the listed behaviors ofabuse/neglect by their husband since delivery, the majority of whom reported thatthese behaviours had increased in frequency since before delivery. In addition, atotal of 14% of both CS cases and NVD controls reported at least one of the listedbehaviors of abuse or neglect by family members other than their husband sincedelivery.This study demonstrates the medical care and consequences, economicconsequences, and social consequences of NVD and CS in facilities afterreferral by BRAC Manoshi programme. The findings suggest the followingrecommendations for the Manoshi program. It should continue its efforts topromote frequent antenatal visits; ensure women have documentation of LMP andEDD as accurately as possible; encourage women not to trial or delay at home; ensure adequate training for Manoshi staff to appropriately refer women for morecommon problems; seek to deter the need for families to take drastic measuresto financially cope with delivery costs; make women aware about the increasedrisks associated with CS, especially those who have intention of doing caesareandelivery or delivering at a hospital; consider addressing the high positive screeningrates of postpartum depression and thoughts of self-harm in postpartum women;and consider programmatic interventions (e.g. promoting family members awareness) to deter and prevent abusive and neglectful behaviours towards womenin the postpartum period. Available from: https://www.researchgate.net/publication/265119205_Caesarean_Delivery_in_Urban_Slums_of_Dhaka_City_Indications_and_Consequences_No_18_January_2012