Determinants and socioeconomic disparities in caesarean section in Bangladesh

The increasing use of caesarean sections (CS) in low and middle-income countries has become a major public health concern because of its impact on health and equity. In Bangladesh, the prevalence of CS reached 45% in 2022, well-above the WHO recommendation of 10–15%. Previous research using the Bangladesh Health and Demography Survey (BDHS) for 2017-18 highlighted rising inequality; however, updated evidence is needed to understand recent trends and determinants. The analysis utilized BDHS 2022 data, which covered 3,257 births in the two years preceding the survey. Determinants of CS were investigated using complex sampling and multilevel logistic regression models, while socio-economic inequalities were quantified by the concentration index (CI) and further explained by the Wagstaff-type decomposition analysis. The overall prevalence of CS was 69.3%, with substantial disparities. CS was higher among educated women (77.6%), overweight women (76.9%), 1st or 2nd birth orders (71–74%), those receiving ≥ 4 ANC visits (72.4%), and deliveries in private/NGO facilities (81.5%). Multi-level analysis identified maternal age, BMI, birth order, place of delivery, household wealth, and region as significant predictors. Women in the richest quintile had 87% higher odds of CS (AOR = 1.868, 95% CI: 1.085–3.215), while delivery in private facilities sharply increased the likelihood (AOR = 8.231, 95% CI: 5.930-11.426). The CI was 0.0535, indicating pro-rich inequality, primarily explained by place of delivery (13.7%), maternal education (11.8%), ANC visits (15.0%), and regional variations. The use of CS in Bangladesh remains disproportionately concentrated in affluent and educated women, underlining the uneven access and overuse of CS. Strengthening public obstetrics and regulating private sector practices is essential to promote equity and health equity.