Reducing unnecessary caesarean sections: an action research from a semi-urban hospital in Dhaka, Bangladesh

BackgroundCaesarean section (CS) rates in Bangladesh have risen dramatically, with some facilities reporting rates above 90%. Overuse of CS is associated with increased maternal and neonatal risks, underscoring the need for practical, evidence-based interventions to reduce unnecessary procedures. The objective of this study was to assess whether a package of evidence-based maternity practices, combined with routine monitoring, could reduce CS rates in a semi-urban hospital in Dhaka, Bangladesh. MethodsWe conducted a pre-post (two-period) evaluation using consecutive deliveries sampled in two independent time windows. The intervention was implemented at the Centre for Women and Child Health (renamed to Ashulia Women and Children Hospital as of 2022) between May 2017 and February 2019. Data were collected in two phases: baseline (n=1,116) and endline (n=1,252). A set of 11 practices was introduced to promote safe normal vaginal delivery, including antenatal counselling, improved labour monitoring, and promotion of vaginal birth after caesarean. Deliveries were classified according to the Robson Ten Group Classification System. Statistical analyses were performed using chi-squared tests. ResultsThe overall CS rate declined from 52% at baseline to 42% at endline (p<0.001), representing a 19% relative reduction. Significant decreases were observed in Robson Groups 2a (p=0.017), 2b (p<0.001), 4a (p<0.001), 4b (p<0.001), and 5 (p=0.004). The intervention increased the proportion of women entering spontaneous labour (Groups 1 and 3) and reduced repeat CS through successful implementation of vaginal birth after caesarean. No adverse trends in maternal or neonatal outcomes were identified. ConclusionImplementation of a structured package of evidence-based obstetric practices, supported by systematic monitoring with the Robson classification, effectively reduced unnecessary CS in this hospital setting. These findings provide practical evidence for reducing CS rates while maintaining safety in similar low-resource contexts.