Approaches to optimize the unnecessary caesarean section in Bangladesh

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The World Health Organization (WHO) projects that between 10% and 15% of all births will have medically justifiable CS rates. Globally, WHO estimates that 6.2 million CSs are performed each year without medical justification. The determination to proceed with or forgo a CS can be understood as the result of weighing three key categories of influence: demand-side factors, supply-side factors, and clinical factors. Each of these categories contributes uniquely to the ultimate decision of whether to perform a CS, highlighting the multifaceted nature of this healthcare challenge. Within each input, there is also, often, a complex interplay. For example, there is a local narrative of mothers seeking an elective CS being "too posh to push", inextricably linking household socioeconomic factors and maternal preferences. On the supply side there are issues of the policy within the healthcare facility (private hospitals prefer CSs) and an interplay with time management and maximizing the efficiency of the facility. Bangladesh's CS has been on the rise; according to the most recent survey, it was 45%, far higher than the WHO recommendation. The private sector interacts with the high rates of CS in Bangladesh; MOH Bangladesh has little control over this sector. To optimize the CS rate, the nation must first recognize that needless CS is an issue and take all necessary action to address it." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-340/v1", "name": "Approaches to optimize the unnecessary caesarean section in Bangladesh" } } ] } Home Browse Approaches to optimize the unnecessary caesarean section in Bangladesh ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Rahman A, Hasan ASM, Dewan F et al. Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.12688/f1000research.162420.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Opinion Article Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] Aminur Rahman https://orcid.org/0000-0003-1434-3883 1 , Abu Sayed Mohammad Hasan https://orcid.org/0000-0002-6821-3892 2 , Farhana Dewan 3 , Sakina Afroz 4 , Mahbub Elahi Chowdhury 1 , Daniel Reidpath 5 Aminur Rahman https://orcid.org/0000-0003-1434-3883 1 , Abu Sayed Mohammad Hasan https://orcid.org/0000-0002-6821-3892 2 , [...] Farhana Dewan 3 , Sakina Afroz 4 , Mahbub Elahi Chowdhury 1 , Daniel Reidpath 5 PUBLISHED 27 Mar 2025 Author details Author details 1 Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, 1205, Bangladesh 2 Health Specialist, UNFPA, Bangladesh, Dhaka, 1212, Bangladesh 3 Obstetrical and Gynaecological Society of Bangladesh (OGSB), Bangladesh, Dhaka, Bangladesh 4 Shaheed Suhrawardy Medical College and Hospital, Bangladesh, Dhaka, Bangladesh 5 Queen Margaret University, Musselburgh, Scotland, UK Aminur Rahman Roles: Conceptualization, Investigation, Resources, Writing – Original Draft Preparation Abu Sayed Mohammad Hasan Roles: Writing – Review & Editing Farhana Dewan Roles: Writing – Review & Editing Sakina Afroz Roles: Writing – Review & Editing Mahbub Elahi Chowdhury Roles: Writing – Review & Editing Daniel Reidpath Roles: Investigation, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract In cases where vaginal delivery is not feasible and the mother's or the child's health is in danger, a Caesarean section (CS) is medically warranted. The World Health Organization (WHO) projects that between 10% and 15% of all births will have medically justifiable CS rates. Globally, WHO estimates that 6.2 million CSs are performed each year without medical justification. The determination to proceed with or forgo a CS can be understood as the result of weighing three key categories of influence: demand-side factors, supply-side factors, and clinical factors. Each of these categories contributes uniquely to the ultimate decision of whether to perform a CS, highlighting the multifaceted nature of this healthcare challenge. Within each input, there is also, often, a complex interplay. For example, there is a local narrative of mothers seeking an elective CS being "too posh to push", inextricably linking household socioeconomic factors and maternal preferences. On the supply side there are issues of the policy within the healthcare facility (private hospitals prefer CSs) and an interplay with time management and maximizing the efficiency of the facility. Bangladesh's CS has been on the rise; according to the most recent survey, it was 45%, far higher than the WHO recommendation. The private sector interacts with the high rates of CS in Bangladesh; MOH Bangladesh has little control over this sector. To optimize the CS rate, the nation must first recognize that needless CS is an issue and take all necessary action to address it. READ ALL READ LESS Keywords Caesarean Section, Maternal health, Bangladesh, Government regulation, Private Sector Corresponding Author(s) Aminur Rahman ( [email protected] ) Close Corresponding author: Aminur Rahman Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Rahman A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Rahman A, Hasan ASM, Dewan F et al. Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.12688/f1000research.162420.1 ) First published: 27 Mar 2025, 14 :340 ( https://doi.org/10.12688/f1000research.162420.1 ) Latest published: 16 Jan 2026, 14 :340 ( https://doi.org/10.12688/f1000research.162420.3 )  There is a newer version of this article available. Suppress this message for one day. Introduction CS is justifiable when vaginal delivery is not possible due to medical conditions like labor dystocia, fetal malpresentation, abnormal or indeterminate fetal heart rate, suspected fetal macrosomia, etc. that can put the life of the mother and baby at risk. Though WHO expects that medically justified CS rates would not exceed 10%-15% of all births, 1 in Bangladesh, CS rates have risen dramatically from 11% in 2011 to 45% in 2022. 2 There is, however, no evidence of a dramatic increase in the medical need for CS. The increase appears to be driven by convenience and economic upliftment. The current rates are so high, that they have recast CS as a form of “normal delivery”, and urgent action is required to address the situation. Parturition is a natural physiological phenomenon. In specific situations, cesarean section may be necessary to safeguard the health of the woman and the infant. Even though the procedure itself carries inherent risks, the balancing of risks and harms means that too low a CS rate contributes to Introduction Caesarean section is warranted when vaginal birth is unfeasible owing to medical issues such as labor dystocia, fetal malpresentation, abnormal fetal heart rate, suspected fetal macrosomia, among others, that may jeopardize the lives of the mother and infant. Vaginal delivery is a normal, physiological phenomenon. In some situations, Caesarean section may be necessary to safeguard the health of the women and the infant. 3 Despite the inherent hazards associated with the surgery, an excessively low Caesarean section rate results in heightened maternal and neonatal mortality and morbidity due to the risk-harm balance. In contrast, excessive usage (i.e., the use of CS without medical rationale) has not demonstrated advantages. Excessive usage inflicts harm by subjecting both mother and infant to unwarranted risks, while also squandering essential human and financial resources. 4 , 5 The World Health Organization estimates that 6.2 million Caesarean sections are conducted annually without medical reason. 6 Consequently, the optimization of CS utilization represents a global problem and a public health dilemma. 7 , 8 Discussion Caesarean section is a significant surgical intervention, and before to its execution, the advantages must surpass the potential hazards. 9 , 10 Current research suggests that neonates born via Caesarean section are at an increased risk of hypothermia, respiratory insufficiency, and necessitate admission to the critical care unit throughout the neonatal period. There is an elevated life-course risk of chronic conditions such as obesity, asthma, and atopic disorders. 11 The hazards are significantly heightened if the Caesarean section is conducted before to 39 weeks of gestational age or electively before the onset of labor. Mothers who undergo Caesarean sections exhibit elevated incidences of postpartum hemorrhage, infection, and an increased likelihood of miscarriage and stillbirth in future pregnancies. 12 Certain nations have a dual challenge concerning Caesarean section (CS) service, characterized by the detrimental effects of both unaddressed demand for CS and the delivery of hazardous CS procedures. Other nations encounter a triple burden, which compounds the overutilization of Caesarean sections with their pre-existing double burden. 13 , 14 Considering the potential for substantial population growth in certain nations already experiencing the dual and triple burden of Caesarean sections (CS), it is likely that the overutilization of CS, unsafe administration of CS, and unmet demand for CS will pose considerable challenges to these countries in attaining their 2030 Sustainable Development Goals (SDGs). The most recent data from the Lancet CS series, encompassing over 99% of global births from 169 countries, indicates that the Caesarean section rate exceeds the recommended threshold in several nations. 15 The global CS rate exhibits an average yearly growth of 4.4%, as indicated by trend analysis of data from 150 countries spanning from 1994 to 2014. 16 The average yearly growth is significantly greater in emerging nations than in industrialized countries. 17 The prevalence of Caesarean sections without medical justification seems to be concentrated in lower-risk pregnancies (nulliparous, term, single, vertex presentation), which account for around 60% of all Caesarean section cases. 18 The study could not incorporate the indication-based CS rate, which may have provided further insights, as it was outside the scope of this work. Caesarean section in Bangladesh In Bangladesh, 65% of all deliveries take place in healthcare facilities: 45% in private hospitals, 18% in state hospitals, and 2% in NGO hospitals. 2 The present Caesarean section rate in Bangladesh is 45%. Private hospitals constitute 85% of all Caesarean sections (CS), over which the Bangladeshi government exerts minimal control and monitoring. Efforts to decrease the Caesarean section rate in Bangladesh inevitably necessitate governmental engagement in the private sector. The decision to undertake or abandon a Caesarean section may be comprehended as the outcome of evaluating three primary areas of influence: demand-side considerations, supply-side factors, and clinical aspects 19 – 21 (refer to Figure 1 ). Each category individually influences the final conclusion regarding the performance of a CS, underscoring the complex nature of this healthcare issue. Each input frequently has a complicated interaction. For instance, a local narrative suggests that ladies opting for elective Caesarean sections are “too posh to push,” so intertwining socioeconomic issues with maternal preferences. The supply side has challenges related to healthcare facility policies, since private hospitals favour Caesarean sections, alongside considerations of time management and operational efficiency. Figure 1. Conceptual framework of factors associated with caesarean deliveries in Bangladesh adapted from Gosh et al. 21 Figure 1 clarifies the ramifications of the CS decision, highlighting four primary areas of impact: maternal health cost/benefit, neonatal health cost/benefit, patient economic burden, and institutional economic burden. This highlights the extensive ramifications of CS decisions, which extend beyond urgent medical factors to include long-term health effects and cost impacts for people and broader healthcare systems. In Bangladesh, private hospitals significantly contribute to the high incidence of Caesarean sections, mostly owing to their profit-driven model. These institutions usually prioritize rapid and efficient services, often resulting in the unnecessary frequency of conducting CS. In contrast to public hospitals, which may have budget constraints and delayed care, private hospitals provide timely surgical operations, typically seen by patients as a safer and more regulated choice for birthing. The presence of skilled surgeons and the adaptability of arranging consultations beyond standard government hours contribute to the higher frequency of Caesarean sections at private institutions. The convenience, along with enhanced socioeconomic conditions, enables an increasing portion of the population to bear the expenses of Caesarean sections, hence solidifying its choice over vaginal birth. Furthermore, some women and their families regard Caesarean sections as a safer alternative, swayed by the hygienic, well-equipped settings of private hospitals in contrast to the frequently congested and seemingly less sanitary surroundings of public hospitals. Nonetheless, these activities elicit considerable apprehension. The excessive utilization of Caesarean sections not only subjects’ women and infants to unwarranted surgical hazards but also burdens the healthcare system by reallocating resources that could be employed more efficiently in other areas. The absence of oversight in private hospitals intensifies this problem, since several facilities do not engage in the government's Maternal and Neonatal Health (MNH) initiatives, which prioritize evidence-based procedures and compliance with national and international health objectives. Having one Caesarean section significantly elevates the likelihood of undergoing a Caesarean section in any future pregnancy. Global evidences to reduce nonclinical caesarean sections Diana et al. 3 proposed, based on a review of literature, that two kinds of interventions can effectively lower the Caesarean section rate in a nation. A. Clinician-focused: a. Clinical practices: i. Trial of labor following Caesarean section and vaginal birth after Caesarean section (VBAC) ii. External cephalic version for breech presentation, iii. Judicious administration of oxytocin during labor augmentation, b. Nonclinical Approaches: i. Audit and feedback mechanisms for facility deliveries, ii. Clinical practice guidelines, iii. Head stop policies (consultation with another obstetrician regarding Caesarean section), iv. Financial incentives for healthcare providers. B. Patient-Centered Strategies: a. Prenatal Assistance: i. Continuous prenatal social support, ii. Prenatal public health education. b. Intrapartum Assistance: i. Continuous labor surveillance, ii. Non-pharmacological analgesic interventions for labor pain Cochrane and another meta-analysis examined and endorsed the aforementioned strategies under three specific interventions: i. For women and families, ii. For service providers, and iii. For organizations or facilities. The widespread implementation of partographs (Currently known as Labour Care Guide) has the potential to reduce the Caesarean section rate. 22 Conclusions The need for regulatory and educational interventions The high incidence of caesarean sections in Bangladesh, especially among private facilities, necessitates immediate intervention. The government must enforce regulatory measures to align private healthcare providers with the norms of public institutions. This may encompass compulsory involvement in MNH programs, compliance with clinical protocols, and routine evaluations of CS practices. Public education initiatives are essential. Women and their families must to be apprised of the possible hazards linked to unnecessary caesarean sections and the advantages of vaginal birth when medically appropriate. Enhancing the engagement of qualified midwives and advocating for active, health-conscious lives among women of reproductive age may further diminish the necessity for elective caesarean sections. In accordance with the United Nations Sustainable Development Goals (SDGs), specifically SDG-3, Bangladesh should prioritize the reduction of superfluous caesarean section rates as an integral component of its overarching plan to enhance maternal and new born health. The incorporation of skilled midwives during birthing may result in a decrease in caesarean section births. By tackling the economic, clinical, and policy-related variables that contribute to elevated caesarean section rates, the nation may strive for more fair and safe delivery practices, therefore enhancing health outcomes for both women and children. The authors of the Lancet series and FIGO policy statement call for increased research on strategies aimed at decreasing the incidence of needless caesarean sections. They concede that the initial step towards success is the acknowledgment of the issue at the national level. 23 Ethics and consent Ethical approval and consent were not required. Data availability No data are associated with this article. Acknowledgements Support from Library, icddr, b. References 1. WHO: WHO Statement on caesarean section rates: Executive summary.2015. 2. National Institute of Population Research Training (NIPORT): Bangladesh Demographic and Health Survey.2022. 3. Diana V, Tipandjan A: Emergency and elective caesarean sections: comparison of maternal and fetal outcomes in a suburban tertiary care hospital in Puducherry. Int. J. Reprod. Contracept. Obstet. Gynecol. 2016; 5 (9): 3060–3066. 4. National Institute of Population Research Training (NIPORT): Bangladesh Demographic and Health Survey, 2017-2018: key indicators. Dhaka, Bangladesh: NIPORT; 2018. 5. National Institute of Population Research and Training (NIPORT): Bangladesh Demographic and Health Survey 2014: Key Indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International.; 2015. 6. Gibbons L, Belizán JM, Lauer JA, et al. : The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World health report. 2010; 30 (1): 1–31. 7. Koblinsky M, Anwar I, Mridha MK, et al. : Reducing maternal mortality and improving maternal health: Bangladesh and MDG 5. J. Health Popul. Nutr. 2008; 26 (3): 280–294. PubMed Abstract 8. Begum T, Nababan H, Rahman A, et al. : Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh. PLoS One. 2019; 14 (8): e0220693. PubMed Abstract | Publisher Full Text | Free Full Text 9. World Health Organization: Appropriate technology for birth. Lancet. 1985; 2 : 436–437. 10. Molina G, Weiser TG, Lipsitz SR, et al. : Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA. 2015; 314 (21): 2263–2270. Publisher Full Text 11. van den Berg A , van Elburg RM , van Geijn HP , et al. : Neonatal respiratory morbidity following elective caesarean section in term infants. A 5-year retrospective study and a review of the literature. Eur. J. Obstet. Gynecol. Reprod. Biol. 2001; 98 (1): 9–13. Publisher Full Text 12. Keag OE, Norman JE, Stock SJ: Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018; 15 (1): e1002494. PubMed Abstract | Publisher Full Text | Free Full Text 13. Walker R, Turnbull D, Wilkinson C: Strategies to address global cesarean section rates: a review of the evidence. Birth. 2002; 29 (1): 28–39. PubMed Abstract 14. Khawaja M, Kabakian-Khasholian T, Jurdi R: Determinants of caesarean section in Egypt: evidence from the demographic and health survey. Health Policy. 2004; 69 (3): 273–281. PubMed Abstract | Publisher Full Text 15. Boerma T, Ronsmans C, Melesse DY, et al. : Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018; 392 (10155): 1341–1348. Publisher Full Text 16. Betran AP, Ye J, Moller AB, et al. : The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One. 2016; 11 (2): e0148343. PubMed Abstract | Publisher Full Text | Free Full Text 17. Betran AP, Ye J, Moller AB, et al. : Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob. Health. 2021; 6 (6): e005671. Publisher Full Text 18. Montoya-Williams D, Lemas DJ, Spiryda L, et al. : What are optimal cesarean section rates in the US and how do we get there? A review of evidence-based recommendations and interventions. J Womens Health. 2017; 26 (12): 1285–1291. PubMed Abstract | Publisher Full Text | Free Full Text 19. Standard HB: 2 out of every 5 babies are born thru C-section, situation alarming: BBS. Buiseness Standard.2024. 20. Nahar Z, Sohan M, Hossain MJ, et al. : Unnecessary Cesarean Section Delivery Causes Risk to Both Mother and Baby: A Commentary on Pregnancy Complications and Women's Health. Inquiry. 2022; 59 : 469580221116004. PubMed Abstract | Publisher Full Text | Free Full Text 21. Ghosh S: Increasing trend in caesarean section delivery in India: Role of medicalisation of maternal health. Bangalore, India: 2010. 22. Chen I, Opiyo N, Tavender E, et al. : Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst. Rev. 2018; 9 (9): Cd005528. PubMed Abstract | Publisher Full Text 23. Visser GHA, Ayres-de-Campos D, Barnea ER, et al. : FIGO position paper: how to stop the caesarean section epidemic. Lancet. 2018; 392 (10155): 1286–1287. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 27 Mar 2025 ADD YOUR COMMENT Comment Author details Author details 1 Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, 1205, Bangladesh 2 Health Specialist, UNFPA, Bangladesh, Dhaka, 1212, Bangladesh 3 Obstetrical and Gynaecological Society of Bangladesh (OGSB), Bangladesh, Dhaka, Bangladesh 4 Shaheed Suhrawardy Medical College and Hospital, Bangladesh, Dhaka, Bangladesh 5 Queen Margaret University, Musselburgh, Scotland, UK Aminur Rahman Roles: Conceptualization, Investigation, Resources, Writing – Original Draft Preparation Abu Sayed Mohammad Hasan Roles: Writing – Review & Editing Farhana Dewan Roles: Writing – Review & Editing Sakina Afroz Roles: Writing – Review & Editing Mahbub Elahi Chowdhury Roles: Writing – Review & Editing Daniel Reidpath Roles: Investigation, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 16 Jan 2026, 14:340 https://doi.org/10.12688/f1000research.162420.3 version 2 Revised Published: 28 Nov 2025, 14:340 https://doi.org/10.12688/f1000research.162420.2 version 1 Published: 27 Mar 2025, 14:340 https://doi.org/10.12688/f1000research.162420.1 Copyright © 2025 Rahman A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Rahman A, Hasan ASM, Dewan F et al. Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.12688/f1000research.162420.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 27 Mar 2025 Views 0 Cite How to cite this report: Halim A. Reviewer Report For: Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.5256/f1000research.178619.r373948 ) The direct URL for this report is: https://f1000research.com/articles/14-340/v1#referee-response-373948 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Apr 2025 Abdul Halim , Centre for Injury Prevention and Research Bangladesh (CIPRB), Dhaka, Bangladesh Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.178619.r373948 The article seems to be a literature review – it could rather a systemic review with data from meta-analysis methods which has not been included. However, the quoted information based on the reference looks convincing. ... Continue reading READ ALL The article seems to be a literature review – it could rather a systemic review with data from meta-analysis methods which has not been included. However, the quoted information based on the reference looks convincing. “ The explanation of the proposed framework is not clear from the descriptive in the articles, the explanation of the proposed framework linkage should be more detailed. The Conceptual framework of factors associated with caesarean deliveries could be better presented triangulating the major areas of factors and associating factors in the framework and the result into causing increased C-section. However, The article is good based on its timeliness, the breadth and the discussion, It could be better if the paper ends with indications on future research to bring in detail the cause and remedy of increasing trend in C-section. I recommend the paper may be considered for indexing. Is the topic of the opinion article discussed accurately in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Are arguments sufficiently supported by evidence from the published literature? Partly Are the conclusions drawn balanced and justified on the basis of the presented arguments? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: maternal and neonatal health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Halim A. Reviewer Report For: Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.5256/f1000research.178619.r373948 ) The direct URL for this report is: https://f1000research.com/articles/14-340/v1#referee-response-373948 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 02 Dec 2025 Aminur Rahman , Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, 1205, Bangladesh 02 Dec 2025 Author Response Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Competing Interests: I have no competing interests. Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Competing Interests: I have no competing interests. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 02 Dec 2025 Aminur Rahman , Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, 1205, Bangladesh 02 Dec 2025 Author Response Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Competing Interests: I have no competing interests. Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. Competing Interests: I have no competing interests. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 27 Mar 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 3 (revision) 16 Jan 26 Version 2 (revision) 28 Nov 25 read Version 1 27 Mar 25 read Abdul Halim , Centre for Injury Prevention and Research Bangladesh (CIPRB), Dhaka, Bangladesh Senapathige Nilan Kalidasa Rodrigo , General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Rodrigo S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Jan 2026 | for Version 2 Senapathige Nilan Kalidasa Rodrigo , General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka 0 Views copyright © 2026 Rodrigo S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Points that must be addressed to make the article scientifically sound The article is already scientifically sound as an opinion piece; however, to further strengthen it, the following points should be addressed: Clarify evidentiary versus interpretive statements Clearly distinguish between evidence-based findings and contextual or experiential observations, particularly regarding private sector behavior and patient preferences. Strengthen support for supply-side arguments Where possible, include additional empirical references specific to Bangladesh or similar settings on provider incentives and private sector practices. Expand explanation of the conceptual framework Provide a clearer narrative description of Figure 1, explicitly linking the framework to the proposed interventions. Minor language refinement Some sections would benefit from editorial polishing to avoid repetition and improve clarity, particularly in the introduction. Overall recommendation This is a timely and relevant opinion article that addresses an important maternal health challenge in Bangladesh. With minor revisions to strengthen evidentiary support and clarify conceptual arguments, the article makes a valuable contribution to the literature and is suitable for indexing and dissemination. Is the topic of the opinion article discussed accurately in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Partly Are arguments sufficiently supported by evidence from the published literature? Partly Are the conclusions drawn balanced and justified on the basis of the presented arguments? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise obstetrics and gynaecology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Rodrigo SNK. Peer Review Report For: Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.5256/f1000research.192249.r443945) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-340/v2#referee-response-443945 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Halim A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Apr 2025 | for Version 1 Abdul Halim , Centre for Injury Prevention and Research Bangladesh (CIPRB), Dhaka, Bangladesh 0 Views copyright © 2025 Halim A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The article seems to be a literature review – it could rather a systemic review with data from meta-analysis methods which has not been included. However, the quoted information based on the reference looks convincing. “ The explanation of the proposed framework is not clear from the descriptive in the articles, the explanation of the proposed framework linkage should be more detailed. The Conceptual framework of factors associated with caesarean deliveries could be better presented triangulating the major areas of factors and associating factors in the framework and the result into causing increased C-section. However, The article is good based on its timeliness, the breadth and the discussion, It could be better if the paper ends with indications on future research to bring in detail the cause and remedy of increasing trend in C-section. I recommend the paper may be considered for indexing. Is the topic of the opinion article discussed accurately in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Are arguments sufficiently supported by evidence from the published literature? Partly Are the conclusions drawn balanced and justified on the basis of the presented arguments? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise maternal and neonatal health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 02 Dec 2025 Aminur Rahman, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, 1205, Bangladesh Thanks for your comments. I have updated my conceptual figure by uploading a new version. I have also added a paragraph on future research to my revised submission. View more View less Competing Interests I have no competing interests. reply Respond Report a concern Halim A. Peer Review Report For: Approaches to optimize the unnecessary caesarean section in Bangladesh [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :340 ( https://doi.org/10.5256/f1000research.178619.r373948) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-340/v1#referee-response-373948 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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