Improving safe vaginal deliveries using evidence-based practices at a semi-urban hospital in Dhaka, Bangladesh

Background Caesarean 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.

We 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.

The 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.

Implementation 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. Competing Interest Statement The authors have declared no competing interest. Funding Statement This study did not receive any funding. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Formal ethical approval for the study was obtained from the Ethical Review Committee of Centre of Woman and Child Health (approval number: CWCH/ERC/2017/010) on May 24, 2017. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes Intervention phase dates (training) were updated. Data Availability All data produced are available online at OPENICPSR with project ID 236841