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

Introduction: C-section rates in Bangladesh have risen sharply, with facility-based rates reaching 90%, raising concerns regarding unnecessary C-sections and associated maternal and neonatal risks. This study aimed to evaluate whether a targeted intervention package, monthly monitoring of C-section rates, and implementation of the Robson Ten Group Classification System could reduce C-section rates in a semi-urban hospital in Dhaka, Bangladesh. Methods: An action research was conducted at Ashulia Women and Children Hospital from May 2017 to February 2019. Data was collected from delivering mothers at the hospital in two phases, a baseline and endline phase. Data collected consisted of mode of delivery, indication for C-section, and six obstetric variables for Robson classification. A package of 11 evidence-based interventions was implemented to promote safe normal vaginal deliveries, including antenatal counselling, improved labour monitoring, and promotion of vaginal birth after caesarean. Statistical analyses were conducted using SPSS v26 and p-values compared through Pearson's chi-squared tests. Results: The overall C-section rate reduced significantly from 52% in Phase 1 (n=1,116) to 42% in Phase 2 (n=1,252; p<0.001), representing a 20% relative reduction. Reductions were observed across key Robson groups, including Groups 2a (p=0.017), 2b (p<0.001), 4a (p<0.001), 4b (p<0.001), and 5 (p=0.004). The intervention successfully increased the proportion of women in Groups 1 and 3 undergoing spontaneous labour. Promotion of vaginal birth after caesarean and improved induction practices contributed to the reduction in repeat and unnecessary C-sections in multiparous mothers with previous C-sections. Conclusions: A structured, evidence-based intervention package, integrated with Robson classification, can effectively reduce C-sections in a facility-based setting while maintaining maternal and neonatal safety. This study provides practical evidence for hospitals in similar low-resource settings to address this growing epidemic through targeted, data-driven strategies. Keywords: caesarean section, Robson classification, normal vaginal delivery, VBAC, action research, Bangladesh