Impact of COVID-19 on Health Seeking Behavior for Mental Health Issues among Post-Graduate Students

Problem Statement:

The mental health problem in Bangladesh is stark but invisible to most. People are surrounded by different mental health issues but don’t really realize it until or unless individuals are aware of mental health problems. Moreover that the pandemic situation showed us a mirror how severe the mental health can be. Coronavirus disease has impacted almost everyone’s life especially on mental health for students. According to a study, COVID-19 has increased the mental health problems mostly the stress and anxiety among the students. Also students had fear of getting infected of coronavirus, concentration difficulties on studies, disruption in sleeping patterns, social distancing and concerns for academic performance (Son, 2020). Similar to another report states that, students had stress on online learning, hygiene related issues, follow up the medications and getting paid with proper wages (Kecojevic, 2020). Although people are facing different mental health related issues, seeking healthcare is stigmatized even before the pandemic period. Studies reveals that due to social stigma, barriers, embracement, poor health literacy, social support, trust issues on providers and many other reasons people doesn’t show positive attitudes on health seeking behavior (Mitchell, 2017).

During the pandemic people had different experiences added along with the above mentioned factors. As per the research article inadequate transportation, cost, fear of getting infected and contact difficulties, maintaining confidentiality was also worked as factors for not seeking health care during pandemic period (Kahi, 2019). However, students who experienced very poor mental health status are more likely to seek for counseling services during COVID-19 (Liang, 2020).

The impact of pandemic on students, our future generation, cannot be neglect. The focused group for found literatures on health seeking behavior for mental health is college students, university students and others but not the postgraduate students. Less study has been conducted on this area of topic mainly in the context of Bangladesh. That is why to mitigate the gap research will play an important role. I want to come up with the idea of health seeking behavior for mental health especially among postgraduate students to know the insights of their barriers, reasons and other related factors. That is why I think novelty of this study is unique and research focusing on this issue is important.

Research Question

  • How has COVID-19 affected health seeking behavior for mental health issues among post-graduate students?

Specific Research Questions

  • What are the health seeking behaviors regarding mental health issues among postgraduate students?
  • What are the factors influencing health seeking behavior for mental health issues during Covid-19 among post graduate students?
  • What is the coping mechanism to deal with mental health issues among postgraduate students?
  • What were the challenges while seeking help regarding mental health issues among postgraduate students?

Method: 

The study will use qualitative design to collect data from postgraduates students enrolled in Qualitative Research Methods course at BRAC James P. Grant School of Public Health. Convenient sampling method will be use to select students from a group. For data collection, a semi-structured questionnaire is going to be used. The questionnaires will contain socio-demographic and mental health related questions. Data will be collected through online interviews via zoom, whatsapp, google meet from postgraduates’ students willing to provide information about their mental health issues during COVID- 19. The medium of the interview will be English. Data will be collected with the help of group peers. They have enough knowledge about the research topic. This research is going to be conducted under the supervision of Qualitative Research Methods Course advisors who are expertise in the field of research. The study will maintain the privacy and confidentiality of the participants by using an identification number instead of name. Consent will be taken from the study participants. Before taking the consent the goal of the study will be explained to the participants. They will be given the chance to ask any questions regarding the research if they have any. The participants also have the freedom to withdraw from the research any time they want.

Findings:

Health seeking behavior (HSB) and mental health issues is one of the critical fields in public health sector. People are surrounded by different mental health issues but don’t really realize it until or unless individuals are aware of mental health problems. Many of the individuals are stigmatized while seeking help from health professionals. Even the students are stigmatized and feel shame for seeking professional help in order to cope with their mental health issues. The present study examines the health seeking behavior regarding mental health issues among the postgraduate students. Prior study on health seeking behavior has investigated different components including mental health problems and its various affects on students. However, no study has focused previously about health seeking behavior on post-graduate students.

The total number of the sample size was 7 postgraduate students including 5 female and 2 male. Students enrolled for the course qualitative research method of MPH program at BRAC JPGPH are included in this study. Interviews were conducted following a semi-structured questionnaire. In this exploratory qualitative study, data matrix has been used to find out the association between different factors and health seeking behavior. The researchers of this study focused on coding by using Dedoose with some initial codes, later on added the sub codes for detail analysis purpose. Constantly comparing the data found from respondent, we developed links focusing on the research questions. Through a discussion session, the data were reviewed again along with the codes and sub-codes to ensure whether the data sufficiently narrated the phenomenon. Several main themes emerged after analyzing interviews including understanding health seeking behavior, coping mechanisms to deal with mental health issues and the challenges faced while seeking formal or informal help. The main theme or specific research question that has been focused in this paper is the health seeking behaviors regarding mental health issue among postgraduate students during COVID-19.

Anxiety, depression, fear, stress were prominent mental health issues during COVID-19. What we found from our study is the respondent wanted to cope with mental health issues by sharing problems with their friends/ family, involving in work and studies and by self consolation. Very few of our respondents seek help from professional and online platform. While coping with mental issues they faced social stigma and for health seeking behavior respondent faced social stigma, accessibility and financial challenges. However, we found that despite of facing challenges, they deal with their mental health issues by coping and seeking help from professionals and have a stable current mental health status.

Understanding Mental Wellbeing:

Analysis revealed few interrelated topics surrounding health seeking behavior (HSB) for mental health experienced by post-graduate students. Those are Understanding mental health well-beings, decision making, perception of HSB, different pattern of health seeking behavior.

The respondent of this study were asked to share their understanding on being mentally healthy. Most of the respondent stated mentally well-being means the condition of being stress-free and able to cope up with the ups and downs in life.

“[Researcher: what do you mean by mentally healthy?]….like life is not stable right? There are many ups and downs, to be able to cope with the positive and negative side of life. Yes I think that means we are mentally healthy….” (IDI-1)

umm.. May be having no sad or stress kind of emotions. Peace in mind, no worries, no stress, I guess that is it…….” (IDI-3)

At the beginning of the pandemic respondents have had fear, anxiety and stress, concerning for their family mainly for parents’ health, reported by the respondents. To continue their livelihood, few respondents were working outside even during the pandemic. They had stress and fear of getting infected by virus and also not to be the reason by being a carrier of virus for their family. Here is the statement of one of the respondent about his/her stress:

“I was in so much stress because of my family members, because I was working in a COVID-19 situation [….] and I was in contact with so many people [….] so much of stress [….] that I shouldn’t be the reason to affect my family.”(IDI-3)

Health Seeking Behavior:

Main part of the research was finding out whether respondent seek for any formal or informal help while facing mental issues. Health seeking behavior referred as going to psychiatrist for counseling, medications, NGO for special course or training, attending online programs like webinar. The analysis of the findings revealed that more than half of the respondent didn’t seek any professional help despite of facing mental health issues. Among the respondent only 2 student sought professional help.

“Yes, I did, I was sharing my problem, shared reasons of depression with a professional counselor. She is a psychiatrist, she gave some kind of counseling, offered medication and assignment. I took training from NGO for positive mindset building based on depression” (IDI_4)

Perception of Health Seeking Behavior:

In terms of seeking help from professional, respondent made the decision by themselves. Although more than half of the respondent did not go for HSB, all of them think HSB to be important regarding mental health. Also the respondent thinks that awareness should be raised regarding mental health.

“…..but I didn’t go because I didn’t feel that much of a need. That’s why. I think it would be better….. We should get some professional help to share our problems because not always sharing with our friends and family is enough.” (IDI_5)

“……everyone should seek for professional health counseling I guess. Some kind of stress level, some kind of distress can be canceled out talking to people close to us as well.” (IDI_3)

Among the 7 respondents, 2 respondents went for professional help and 5 did not go to seek any professional help. Among these 5, 2 people didn’t feel the necessity of this because their mental condition was not that serious. And one respondent, despite of being much stressed about personal life and workload, didn’t go for psychological counseling. And the rest two was very worried about what people will think of them. Even one respondent got stigmatized by highly educated family members. The important findings of the study, 2 respondent who sought professional help, they were not benefited by coping strategies. One of the respondents belonging from marginalized groups, went for professional help. And the other respondent was also stigmatized initially but then he took the help using digital platform.

Discussion:

Currently mental health issues are a prominent concern of public health sector as many people are facing at least one issue in their life. In our study, it was found that most of the respondents were facing some kind of mental health issues during COVID- 19 pandemic. Similar to a report state that, students experienced moderate to extreme level depression (52.2%), anxiety (58.1%), stress (24.9%) before COVID-19 and during COVID-19 the rate increased respectively following depression (62.9%), anxiety (63.6%), stress (58.6%). The prevalence rate was 8.6% higher during COVID-19 comparing to pre-COVID- 19 period (Islam, et.al, 2020).

Although students were facing mental health issues, most of them didn’t seek any formal or informal help from anywhere found in our research similarly mentioned in Kar et.al. (2020) literature, overall 35% students didn’t seek any help from professionals. According to study the main reason for the seeking low professional treatment were being stigmatized by surroundings and trusting more in informal sources (Kerebih et.al, 2017). Also another research reported that, social stigma was the major challenge to seek professional help which identified among Ethiopia residents. Social stigma towards mental health issues in Ethiopia has association with help seeking behavior (Mascayano et.al, 2015).

However, to cope with mental health issues very few among our respondent used digital platform as a coping strategy. A study conducted among pharmacy student in Ireland mentioned the key benefits of webinar on a mindfulness course. The course organizes a calmer mind, stress reduction and recognition of thoughts as mental events (O’Driscoll, 2019).

Our study has been conducted with a small number of sample sizes that is why we had no gender differences seen in terms of mental health issues. But in the study on Ethiopia residents’ gender was found as a factor associated with professional help seeking behavior regarding mental health (Mascayano et.al, 2015). Similar to another study indicated gender as a significant predictor towards seeking formal psychological help. Additionally, cultural perspective also influences gender differences for getting professional psychological treatment (Nam, 2010).

The finding of our study also states that the respondent took decision by their own whether they have to seek professional help but the study conducted in Ethiopia residents, decision making on professional help influenced by family and friends. (Mascayano et.al, 2015).

However, respondent supports the professional health care for all whoever having severe mental health issues. Another study conducted among Chinese adults, around 80% respondent preferred to seek psychological help in serious cases, 72.4% agrees to seek help from medical organizations and only 12% knew about seeking help from professionals. (Yu et.al, 2015). Even though very few respondents seek for professional treatment in this study but everyone beliefs to seek formal/informal help for severe mental health issues which considers as an positive side in public health sector.

Limitations:   

The limitations of a study are its flaws or shortcomings. Since we conducted the IDI virtually we could not observe the respondents’ non verbal cues. As a first time researcher we were not familiar with Qualitative Research. As it was an international platform, it was difficult to understand the context of the respondents. We faced some issues of familiarization (like: country, profession regarding anonymity) as we interviewed our classmates. However, our sample size was small; our findings cannot be generalized for all postgraduate students.

The focus group discussion enlighten us with wider diversities including region, country, culture, religion, believes, occupation & definitely our main theme (health seeking behaviour). This research gave us the opportunity to look at the wider aspect of COVID-19 pandemic to all sectors, identifying the effect of pandemic on mental health & various health seeking behaviors. The online interview platform showed us a new ways of interviews settings. Also the in depth view of fragile structure of health seeking behavior regarding mental health taught us various aspects of world.

Conclusions 

Mental health issues gain ground during COVID-19 period. Following the study findings every respondent had at least one minor kind of mental health issue faced during pandemic. The rate of mental health seeking behavior was low. A few of the respondents with mental health issue looked to seek professional help and other respondent with minor mental health problems preferred self coping rather than professional help. Financial issues and social stigma were found to be the major challenges to seek professional help. Inadequate efforts of post graduate respondents to seek professional help, especially during a pandemic, could have long-term consequences on their mental health.

Recommendations 

Extensive research can be done on different pattern of health mental issues and seeking help during COVID -19. Better access to online webinars and counseling. Promote accessible and affordable approaches for professional help. Campaigns can be arranged for recreational activities and wellness.

 

 

 

 

References:

Islam MS, Sujan MSH, Tasnim R, Sikder MT, Potenza MN, van Os J (2020). “Psychological        responses during the COVID-19 outbreak among university students in Bangladesh.”           PLoS ONE 15(12): e0245083. doi:10.1371/journal.pone.0245083

Kar Sujita.Kumar., Yasir Arafat S.M., Kabir R., Sharma P., Saxena S.K. (2020). “Coping with     Mental Health Challenges During COVID-19.” In: Saxena S. (eds) Coronavirus Disease   2019 (COVID-19). Medical Virology: From Pathogenesis to Disease Control. Springer,      Singapore. https://doi.org/10.1007/978-981-15-4814-7_16

Kerebih, Habtamu; Abera, Mubarek; Soboka, Matiwos (2017). “Pattern of Help Seeking   Behavior for Common Mental Disorders among Urban Residents in Southwest Ethiopia.”  Quality in Primary Care.

Mascayano F, Armijo JE, Yang LH. “Addressing stigma relating to mental illness in low- and       middle-income countries.” Front Psychiatry. 2015;6:38.

Nam, Suk & Chu, Hui & Lee, Mi Kyoung & Lee, Ji & Kim, Nuri & Lee, Sang. (2010). “A Meta   analysis of Gender Differences in Attitudes Toward Seeking Professional Psychological          Help.” Journal of American college health: J of ACH. 59. 110-6.  10.1080/07448481.2010.483714.

O’Driscolla M., Byrnea S., Byrneb H., Lambertc S., Sahma LJ , 2019. “An online mindfulness      based intervention for undergraduate pharmacy students: Results of a mixed-methods feasibility study.” CurrPharm Teach Learn, Vol. 11(9):858-875.            https://pubmed.ncbi.nlm.nih.gov/31570123/

Yu, Y., Liu, Z. W., Hu, M., Liu, H. M., Yang, J. P., Zhou, L., & Xiao, S. Y. (2015). “Mental        Health Help-Seeking Intentions and Preferences of Rural Chinese Adults.” PloS            one, 10(11), e0141889. https://doi.org/10.1371/journal.pone.0141889

Caesarean Section Delivery among Ever-Married Women

Background
Cesarean section delivery has become very common surgical procedure in the world including in
Bangladesh. Cesarean section is a surgical procedure, use for childbirth when vaginal delivery can’t be
performed, suggested to save life of mother and baby in case of maternal complications during
pregnancy. Before maternal and child mortality rate was high. Every day there are hundreds of
maternal death reports due to complications of pregnancy (Carlo and Travers, 2016). Now the
mortality rate has significant decrease. The ratio was 322 in 1998 to 2001 and 194 in 2007 to 2010 by
considered as annual average rate of 5.6% decrease. Now it dropped to 14.1% from 2010 to 13.1% in
2016 (Arifeen et al., 2015; Sabnom and Islam, 2013). With the improvement of technology, surgery
delivery came as a new invention of science as a life savior for most of the women. Home delivery by
the unskilled nurse has been decreased with the modern devising. Studies figure out that over the past
few years, child birth became too “medicalized” because of some non- obstetrical factors rather than
obstetrical factors. These factors point out the concern for mother’s health and influence the families
(Bruekens, 2001; Khanday, 3013). Nowadays the unnecessary CS delivery is high in Bangladesh and it
is draining resources from both supply and demand sides. The overuse of technology in medical sector
is one specific reason behind this increasing rate. According to the report, the percentage of CS
delivery is increased up to 51% which can correlate with the term, epidemic of over-medicalization of
maternal health (Hasan, 2019; Bruekens, 2001). With the unnecessary numbers of CS delivery, women
are also facing some unwanted complications. Many women do their cesarean delivery because of
indicated causes in pregnancy, fear of unbearable labor pain, thinking about the safety of child, etc.
which leads to many unwanted complications. This study will explore the causes and the risk factors
associated with C-Section delivery among ever married women in Bangladesh.
Literature review
Cesarean section delivery is now a controversial affair worldwide. The alarming rate of CS is actually
surprising as it is high than the recommendation by WHO (2015). The rate has increased 6.7% to
19.1% from 1990 to 2014 all over the country. The less develop countries showed 14.6% absolute
increase in CS delivery where developed and least developed countries showed rose by 12.7% and
4.2% (Betran et al., 2016). 60% of all births take place in low income countries on the contrary only
37.5% of births come off in middle- and high-income countries but mostly the middle- and highincome countries give rise to CS rate globally. As per the estimation, among all 18.5 million annually
performed CS deliveries, among that one-third are unnecessary and without any medical indications
(Aminu et al., 2014). In Bangladesh the unnecessary CS rate is also high. According to the report, 7.7
out of 10 births are unnecessary. Overall, 860,000 unnecessary operations have been conducted last
year in Bangladesh. But the women who really need of CS delivery they couldn’t afford or access it
while child- birth (Gibbons et al., 2010; Maswood, 2019). The trend of CS delivery among Bangladeshi
women is increasing day by day. With globalization and advanced technology, the medical facilities
have improved almost in every urban areas of Bangladesh. Factors such as infertility, modern
reproductive techniques, and increased risk factors, age of women, psychology and biological safety for
offspring leads women towards cesarean section deliver (Khawaja et al., 2007; Radha et al., 2015;
Weaver et al., 2007). Having lack of medical knowledge and misconception about vaginal delivery,
works as an important and main factor for CS delivery (Azami et al., 2014). It is true that mortality rate
has been decrease after the invention of CS delivery but the natural childbirth is beneficial than
operational one. Psychological, physical and other related factors are associated with attitudes of labor
pain which influence the decision of mode of delivery (Zakeri et al., 2015).
In Bangladesh, almost 60% of childbirths take place at clinic and 65% of those deliveries are Csections (Doucleff, 2018). Only 33% of institutional deliveries has been done through CS in 2000 but it
rise up to 63% in 2014 (Haider, 2018).The rate of deliveries is higher in private hospitals (86.2%) than
the public hospitals (29.9%). According to research, private hospitals get financial benefits from
external agents for performing CS delivery (Aminu et al., 2014). Still mostly people prefer to do
delivery in private hospitals than in public because of their better service quality though the cost is high
but the outcome was found better in public hospitals (Andaleeb, 2000; Sabnom and Islam, 2013).
Delivery cost also depends on the mode of delivery.
Nine out of ten women favoring vaginal delivery prefers CS delivery if the costing is same for both
procedure (Ajeet et al., 2011). According to the report of 2010, about 10.3% of Total Health
Expenditure (THE) was due to delivery costs from where 6.9% caused by CS deliveries (Haider,
2018). People often receive treatments and other facilities lately due to the cost. In Bangladesh, 49.6%
population lives on less than US$1.25 per day and 40% of the population lives below the poverty line
(Klugman, 2010). Still people are doing CS deliveries as their perception is CS delivery can save
mothers and child’s birth without any complications even though for some people it is hard to afford.
There are insufficient data on women’s preferences for delivery mode, causes and factors associated
with complications through CS delivery. The study aimed to examine the causes of cesarean section
delivery specially highlighting among ever-married women in the three years preceding the survey.

Research questions:
1. What is the prevalence of C-section deliveries among ever-married women who gave birth in the
three years preceding the survey?
2. Examine the relationship between birth order and C-section delivery among ever-married women.
3. Examine the relationship between employment status and C-section delivery among ever-married
women.
4. What percentage of women had a C-section delivery just because of convenience?
5. What are the factors that influence C-section deliveries among ever-married women?
Missing values in the dataset:
For any research analysis, it is important to look at the missing data set. The dataset that has been taken
requesting from DHS had some missing values. At first the data which are necessary saved with keep
command and drop the other variables which are not required for this project. Afterwards executing
missing values command, the real dataset has been kept in this project for analysis.
Dispersion present in dataset:
Considering age of respondent at 1st birth (v212) as a quantitative variable with dispersion a boxplot
has been generated. The boxplot has a mean 18.6, median 18 and standard deviation 3.2. The range was
13-39.

Statistical analyses plan:
For statistical analysis, STATA has been used by giving command to generate necessary tables. At first,
a socio-demographic table of age (v013), division (v024), education level (v106), religion (v130), type
of residence (v025), wealth index (v190) etc. will be drawn stating frequency, percentage and 95%
confidence interval of each variable. The prevalence of C- section delivery will be shown in a pie chart
after taking frequency, percentages and 95% CI from STATA. The association between birth order
(bord_01) and employment status (v714) will be compared with socio-demographic variables such as
age, education level, wealth index and with other related variables to find out significance level. Then
the percentage of women had C-section just because of convenience that will be shown in another pie
graph to represent the data clearly. The factors associated for causing C-Section delivery among ever
married women will be find out through an adjusted and unadjusted odd-ratio table. The interpretation
will be written along with the table of statistical analysis.

Analysis and Interpretation:
In total 4932 women were included in the study. The age of the study participants ranged from 15-49
years. The highest c-section percentage was 25.6% in Dhaka and lowest in Barisal 5.71%. People from
rural (73.19%) areas are more in number than urban (26.81%) to conduct c-section delivery. The
percentage of education level with secondary (49%) and Islamic religious people (91.87%) is high.
Regarding respondent’s employment status, non-working women are high in number (62.74%).
According to the wealth index, 20.65% poorest participants’ responses were recorded.

Percentages of prevalence of C-section delivery:

Figure 1 shows the prevalence percentages of csection delivery with 95% confidence interval.

Birth Order and C-section Delivery: From the chi-square test we found the p-value which shows age,
education, types of residence, wealth index and BMI have relation with birth order but age influence
the birth order more. Among the listed birth order 1, women with secondary education level (50.37%)
is the usual factor identified. Birth order 5 or higher is comparatively less associated than birth order 1.
Other variables are more or less likely contributed in the birth order of c-section delivery.

Employment Status and C-section Delivery: From the chi-square test we found the p-value which
shows age, education, types of residence, wealth index, BMI and other variables have relation with
employment status but wealth index influence the employment status most. It is found from the table
religion is not associated with employment status. Mostly the employed (58.61%) women had their
delivery in home. Women living in rural areas (69.61%) don’t work outside of the house. Women have
secondary education (47.25%) are more involved with work.

Factors Influencing C-Section Delivery: In logistic regression, BMI of the participants was found to
be as a significant predictor of CS delivery. Women with overweight and obese were more likely to
influence for their CS delivery compared with underweight. It was found that participants’ lives in
rural areas were at 0.52 times influenced for having CS delivery than who lives in urban areas and
when adjusted the influence of doing CS delivery was 0.90 times among the participants. However, It
was seen that the risk of being influenced for CS delivery was 0.49 times (CI: 0.46 – 0.52), p- value:
.000) greater among ones who are not working. When the adjusted risk increased to 0.79 times but
didn’t show significance. Same thing happened with age (30-49 years), secondary and higher
education, overweight BMI. The rest of the variables such as age (15- 29) years, primary education
didn’t show any significance in the test.

Conclusion & Recommendations:
The findings of this study showed that in rural areas C-section delivery is more practiced among ever
married women. Although the prevalence of the C-Section delivery is not higher the birth order
influenced by the education factor mostly. Employed women are more likely to do their deliveries in
home than unemployed women and the rural women are more employed than urban areas. The
participants are unaware of the reasons of C-Section delivery. Obese in Body Max Index (BMI) were
found most significant predictor when adjusted and unadjusted. Women’s age, education, and
employment status influenced the C-Section delivery. The study recommends generalized awareness
raising campaign targeting prospective mothers and couples to use antenatal check-up during
pregnancy and to increase knowledge about pregnancy danger signs needing emergency obstetric care.
Professional integrity and ethics training should be strengthening for health care providers to exercise
medically oriented protocol in recommending CS delivery.

References:
Aminu, M., Utz, B., Halim, A. et al. (2014). Reasons for Performing a Caesarean Section in Public
Hospitals in Rural Bangladesh. BMC Pregnancy Child birth, 14, 130, doi.org/10.1186/1471
2393-14-130
Arifeen, Shams & Hill, Kenneth & Ahsan, Karar & Jamil, Kanta & Nahar, Quamrun & Streatfield,
Peter (2015). Maternal Mortality in Bangladesh. Obstetrical & Gynecological Survey, 70,74
75, doi.org/10.1097/01.ogx.0000461895.7873 4.18
Azami, Aghdash S., Ghojazadeh, M., Dehdi- lani, N., Mohammadi, M., & Asl Amin Abad, R. (2014).
Prevalence and Causes of Cesarean Section in Iran: Systematic Review and Meta- Analysis.
Iranian journal of public health, 43(5), 545-555. pubmed.ncbi.nlm.nih.gov/26060756/
Betran, A. P., Ye, J., Moller, A. B., Zhang, J., Gulmezoglu, A. M., & Torloni, M. R. (2016). The
Increasing Trend in Caesarean Section Rates: Global, Regional and National Esti- mates:
1990-2014. PloS one, 11(2), e0148343. doi.org/10.1371/journal.pone.0148343
Bruekens, P. (2001). Over-medicalization of maternal care in developing countries. In Brouwere VD
and Lerberghe WV (ed.). Safe Motherhood Strategies: A Review of the Evidence. Antwerp:
ITG Press, 17, pp.1-5. www.researchgate.net/publication/242075892_Over
medicalisation_of_Maternal_Care_in_De veloping_Countries
Carlo WA, Travers CP. (2016). Maternal and neonatal mortality: time to act, 2016. J Pediatr (Rio J),
92: 543-5, www.scielo.br/scielo.php?script=sci_arttex t&pid=S002175572016000700543
Doucleff, Michaeleen, (2018). Rate Of C- Sections Is Rising At An ‘Alarming’ Rate, Report Says.
National Public Radio. Retrieved from – www.npr.org/sections/goatsandsoda/2018/10/12/
656198429/rate-of-c-section-is-risingat-an-alarming-rate
Gibbons,Luz; Belizan, Jose M., Jeremy A Lauer, Ana P Betran, Mario Merialdi and Fernando
Althabe, (2010). The global numbers and costs of additionally needed and
unnecessary caesarean sections performed per year: overuse as a barrier to universal
coverage. World Health Organization (WHO). www.who.int/healthsystems/topics/financi
ng/healthreport/30C-sectioncosts.pdf
Haider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM. (2018) Ever increasing
Caesarean section and its economic burden in Bangladesh. PLoS ONE, 13(12): pp.1-13.
doi.org/10.1371/journal.pone.0208623
Hasan, Md. Kamrul (2019).C-sections up by 51% in Bangladesh in two years. Dhaka Tribune,
Retrieved from- http://www.dhakatribune.com/bangladesh/nation/2019/06/21/csections-up
by-51-in-bangladesh- says-reprt
Khanday, Zulufkar Ahmad (2013). Review on Medicalisation: A critical appraisal with special
reference to India, Intern. J. of Medical Sociology and Anthropology, 2(2), pp.66-75.
www.academia.edu/6223034/Review_on_Medicalisation_A_critical_appraisal_with_specia
_refe rence_o_India
12
Khawaja M, M Al-Nsour and M Khawaja (2007). Trends in prevalence and determinants of caesarean
delivery in Jordan: Evidence from three demographic and health surveys 1990- 2002, World
Health and Population, 9(4), 17- 28. https://doi.org/10.12927/whp.2007.19395
Klugman, Jeni (2010). The Real Wealth of Nations: Pathways to Human Development. UNDP-HDRO
Human Development Report 2010-20th Anniversary Edition, pp.1-234
ssrn.com/abstract=2294686
Maswood, Manzur H (2019). Caesarean births boom in Bangladesh. New Age Bangladesh.
www.newagebd.net/article/76766/caesarean- births-boom-in-bangladesh
Radha, K.; Devi, G. Prameela; R, V. Manjula; P. A. Chandrasekharan, (2015). Study On Rising
Trends Of Caesarean Section (C- Section): A Bio-Sociological Effect. J. of Dental and
Medical Sciences (IOSR-JDMS), 10-13. https://doi.org/10.9790/0853-14821013
Sabnom, R., & Islam, M. (2013). Cost and outcome of caesarean section in a public and private
hospital in Dhaka city. Bangladesh Journal of Medical Science, 12(3), 276-281,
doi.org/10.3329/bjms.v12i3.15424
WHO Statement on Caesarean Section Rates (2015). Department of Reproductive Health and
Research: World Health Organization (WHO) www.who.int/mediacentre/news/release
s/2015/caesarean-sections/en/
Zakeri, Hamidi M., Latifnejad Roudsari, R., & Merghati Khoei, E. (2015). Vaginal Delivery vs.
Cesarean Section: A Focused Ethno- graphic Study of Women’s Perceptions in The North of
Iran. International J. of community based nursing and midwifery, 3(1), 39-50.
pubmed.ncbi.nlm.nih.gov/25553333/

Causes and Complications of Cesarean Section Delivery among Women in Cox’s Bazar, Bangladesh

Abstract

Unnecessary cesarean section (CS) delivery is a major problem in Bangladesh and it is draining resources from both supply and demand sides. Many women do their cesarean delivery because of indicated causes in pregnancy, afraid of unbearable labor pain, thinking about the safety of child, etc. which leads to many unwanted complications. The purpose of this research was to investigate the preferences and causes of cesarean section delivery and to characterize the outcomes after cesarean section delivery. This cross-sectional study was conducted by using a semi-structured questionnaire among women who delivered in selected hospitals in Cox’s Bazaar, Bangladesh. The total number of the sample was 273 women with calculated mean age of 26.72 years. In this study the key reasons found for doing CS delivery were mother’s age, occupation, higher education, history of cesarean delivery, recommendation of doctor’s, afraid of normal delivery and concern about baby’s health. Results showed that 48.7% women faced complications and 50.3% participants didn’t face any complication after CS delivery. The most frequent complications were pus, 22% and obesity,13.9% among the participants and breakdown of membrane, 28.2%, excess bleeding, 19.4% extreme pain, 19% and prolonged labor, 18.3% were found as the main causes indicated by the doctors for cesarean delivery. The prevalence of CS found much higher than the anticipation of WHO. The Causes of cesarean delivery lead to the complications with various factors which effects women health directly and indirectly. It is necessary to reduce the rate of cesarean delivery by spreading awareness among the mothers about the risks and providing training, workshops to overcome the scare of normal delivery.

Keywords: Causes, Complications, Cesarean section (CS) delivery, Perception, and Prevalence.

 

Introduction

Cesarean section delivery has become very common surgical procedure in the world including in Bangladesh. Cesarean delivery is a surgical process, use for childbirth when delivery through vagina can’t be performed, suggested to save mothers’ lives and baby in case of maternal complications during pregnancy. Before maternal and child mortality rate was high. Every day there are hundreds of maternal death reports due to complications of pregnancy [9]. Now the mortality rate has significant decrease. The ratio was 322 in 1998 to 2001 and 194 in 2007 to 2010 by considered as annual aver- age rate of 5.6% decrease. Now it dropped to 14.1% from 2010 to 13.1% in 2016 [4] [31]. With the improvement of technology, surgery delivery came as a new invention of science as a life savior for most of the women. Home delivery by the unskilled nurse has been decreased with the modern devising. Studies figure out that over the past few years, child birth became too “medicalized” because of some non- obstetrical factors rather than obstetrical factors. These factors point out the concern for mother’s health and influence the families [8] [18]. Nowadays the unnecessary CS delivery is high in Bangladesh. The overuse of technology in medical sector is one specific reason behind this increasing rate. According to the report, the percentage of CS delivery is increased up to 51% which can correlate with the term, epidemic of over-medicalization of maternal health [8] [14]. With the unnecessary numbers of CS delivery, women are also facing some unwanted complications. This study will explore the causes and also investigate the risk factors of complications associated with different factors.

Cesarean section delivery is now a controversial affair worldwide. The alarming rate of CS is actually surprising as it is high than the recommendation by WHO (2015). The rate has increased 6.7% to 19.1% from 1990 to 2014 all over the country. The less develop countries showed 14.6% absolute increase in CS delivery where developed and least developed countries showed rose by 12.7% and 4.2% [7]. 60% of all births take place in low income countries on the contrary only 37.5% births come off in high and middle-income countries but mostly the high and middle-income countries give rise to CS rate globally. As per the estimation, among all 18.5 million annually performed CS deliveries, among that one-third are unnecessary and without any medical indications [2]. In Bangladesh the unnecessary CS rate is also high. According to the report, 7.7 out of 10 births are unnecessary. Overall, 860,000 unnecessary operations have been conducted last year in Bangladesh. But the women who really need of CS delivery they couldn’t afford or access it while child- birth [11] [22]. The trend of CS delivery among Bangladeshi women is increasing day by day. With globalization and advanced technology, the medical facilities have improved almost in every urban areas of Bangladesh. The basic obstetric care emergency services were introduced in the sector of public health care by the Ministry of Health and Family Welfare (MOH&FW). These policies have improved the infant and maternal mortality rate including morbidities. However, this improved health care led to CS deliveries following by unintended complications [28]. Now women get better antenatal care during their pregnancy. In developing countries, the demand of CS delivery is increasing with the economic and educational advancement. Educated women are found more likely to do CS delivery in order to avoid labor pain.

Also, other factors such as infertility, modern reproductive techniques, and increased risk factors, age of women, psychology and biological safety for offspring leads women towards cesarean section deliver [19] [26] [33]. Having lack of medical knowledge and misconception about vaginal delivery, works as an important and main factor for CS delivery [5]. It is true that mortality rate has been decrease after the invention of CS delivery but the natural childbirth is beneficial than operational one. Fear of labor pain impels women to do CS delivery. According to report, women who have already done CS delivery said normal delivery is more painful than CS [1]. Psychological, physical and other related factors are associated with attitudes of labor pain which influence the decision of mode of delivery [36]. Risk of dying during delivery or delivery related issues among women is 100 times higher in Bangladesh than any other developed countries. As a result, 75% babies die within the first week after their mother’s death [16].

In Bangladesh, almost 60% of childbirths take place at clinic and 65% of those deliveries are C-sections [10]. Only 33% of institutional deliveries has been done through CS in 2000 but it rise up to 63% in 2014 [12]. The delivery rates are higher in private hospitals (86.2%) than the public hospitals (29.9%). According to research, private hospitals get financial benefits from external agents for performing CS delivery [2]. Still mostly people prefer to do delivery in private hospitals than in public because of their better service quality though the cost is high but the outcome was found better in public hospitals [3] [30].

Delivery cost also depends on the mode of delivery. Nine out of ten women favoring vaginal delivery prefers CS delivery if the costing is same for both procedure [1]. According to the report of 2010, almost 10.3% of Total Health Expenditure (THE) was due to the cost of deliveries from where 6.9% caused by CS deliveries [12]. People often receive treatments and other facilities lately due to the cost. In Bangladesh, population around 49.6% lives on less than US$1.25 per day and about 40% of the population lives below the poverty line [20]. Still people are doing CS deliveries as their perception is CS delivery can save mothers and child’s birth without any complications even though for some people it is hard to afford. There are insufficient data on delivery preferences of women, causes and associated factors with complications via CS delivery. The study aimed to examine the main reasons and complications of CS delivery specially highlighting women’s perception of cesarean delivery in Cox’s Bazar, Bangladesh.

Methods and Materials

Study design: This study followed cross sectional design to collect data from women who were 18 years or older and have done their CS delivery in the selected government hospital and clinical sites of Cox’s Bazar.

Sampling method: Purposive sampling method was used to selected women from hospitals and clinics who have conducted CS delivery. Study sample size was calculated using 23% reported CS prevalence rates (NIPORT, 2016), 5% absolute precision and 95% confidence level. Using the formula as below the desired sample size was calculated to be 272.

n = Z21-a/2 p (1-p)/d2

Data collection: For data collection, a semi-structure questionnaire was used and divided into four sections. The first section contained socio-demographic questions such as age in years, occupation, education, income etc. The second part of questionnaires had indication of CS delivery includes excess bleeding, respiratory problem, history of previous surgery, causes of cesarean, etc. Third part focused on the perception of women like fear of normal delivery, decision making process, affordability etc. Finally, the fourth and last part of the questionnaire was focus on complications of cesarean. Data collection was done via face to face interviews from women, willing to share information about their delivery. The medium of the interview was Bengali. Data collection completed with the help of research assistants. They had adequate knowledge regarding the research goal. This research has been conducted under the super- vision of Public Health Department advisors who are expertise in this research field. Study was approved by the Ethical Review Committee (ERC) of Asian University for Women. This study strictly maintained the confidentiality and privacy of participants tagged with a number of identification instead of name. Verbal consent was taken from participants after explaining the goal of research. Participants had freedom to ask any questions related to the research if they had any along with the freedom of withdrawal from the research any moment they wanted.

Data analysis: Data were analyzed through descriptive statistics based on mean, percentage, frequencies, and standard deviation. In order to identify risk factors binary and multiple logistic regressions was performed in odds ratios (ORs) with 95% confidence interval (95%CI), furthermore, chi-square test was conducted to study association in between the qualitative variables. All p-values in this study were two-tailed and ≤ 0.05 was set as statistical significance. Statistical analysis was done calculating on IBM SPSS version 23 computer software in association with MS Excel.

Results:

 

In total 273 women were included as study participants. Participants’ age ranged from 18-40 years with the mean age of 25.48 years. Among them 48% of the respondents have 45”-5 height and relatively fewer percentages (14.3%) was observed in 55- 57. 56.4% women weight between 51-60 kg. 42.1% women said they had bachelor or above level education and 52.4% received education till higher secondary and 5.5% women received no education. Among the participants, 24.9% worked for paid job, 59% women were housewife and 16.1% women were regular student. Regarding their husband’s occupation, 62% worked as a government employee, 33% did private employee, 9.5% were day laborer, 31.1% were businessman, 2.1% were farmer and 1.5% were transport workers. About 30.8% women have 15-35 thousand income in their family, 29.7% have 36-55 thousand income, 9.5% earn 56-85 thousand and 30% participants didn’t answer the question.

 

Obstetric and non- obstetric medical causes of CS delivery: The set of factors affecting CS delivery due to medical causes has shown in Fig 1. Some of the medical factors within the causes studied in this research are previous cesarean (27.30%), depression (45.40%), prolonged labor (29.30%), respiratory (47.30%) and multiple pregnancies (2.60%) found as the main medical reasons for CS delivery. Fig 2, includes doctor’s recommendation (61.20%), fear of normal delivery (63.40%), baby’s safety (95.20%), own decision (38.80%) and affordability (48.0%).

Percentages of causes leading to CS delivery

Figure 3 shows the frequency of causes which led to CS delivery. Among the participants 18.30% faced prolonged labor, 28.20% had breakdown of membrane, 19.40% had excess bleeding, 19% had extreme pain, 11.70% respondents crossed the delivery date, 1.80% said their baby’s size was too large, 1.50% respondents had fetal distress.

Regression analysis

In binary logistic regression, education of the respondents was found as a significant predictor of CS delivery. Women with higher secondary education and illiterate were less likely to take decision for their CS delivery compared with B.A and above education. The history of patient’s previous surgery also shows significant result which means this factor drive them to take decision for CS delivery. Besides, the respondent’s medical history of having respiratory appears significance and was found association along CS delivery. It was also found that respondents reported having no respiratory was at 3.44 times at risk of experiencing CS delivery than who had respiratory and when the risk adjusted of doing CS delivery was 4.90 times between the respondents with no respiratory problem. However, It was observed that the risk of doing CS delivery was 0.16 times greater (CI: .09 – .29, p- value: .000) among ones who have fear of normal delivery. When the risk adjusted, it increased to 0.58 times but didn’t show significance. Same thing happened with age (25-30 years), fear of normal delivery depression and number of children. Other variables such as weight, education didn’t show any significance in the test.

Association of complications and risk factors: The relationship between types of complications and socio demographic variables has shown in Table 2. Women 18-24 years aged are more likely to get pus (50%) and become obese (55.3%). Others aged between 25-30 years mostly suffers from incision (48%) and swelling (57.1%). Women aged with 31-40 years old have less a case to become pregnant that is why the complications percentage seems less than other participants. Women who have 51-60 kg weight have more complications than others. Among the listed complications pus is the usual factor for service holders’ women (46.8%), housewife (37.1%) and students (16.1%). For incision complications housewives (60%) have more cases than service holder and students. Housewives (42.1%) and students (39.5%) become obese after delivery than service holders (18.4%). 7.1% service holders, 78.6% housewives and 14.3% students have observed swelling in their CC cut. Women received education till higher secondary, B.A and above faces more complications than uneducated women.

Percentages of complications faced after CS delivery: Fig 4 shows the percentages of complications among participants faced after CS delivery and the percentages are 22.0% pus, 8.80% incision, 13.90% obesity, 4.00% swelling and 51.30% with no complications.

From the chi-square test we found the p-value which shows age, weight and education have no relation with types of complications but occupation influence the types of complications after CS delivery. Among the listed complications pus is the usual factor for service holders’ women (46.8%), housewife (37.1%) and students (16.1%). For incision complications house- wives (60%) have more cases than service holders and students. Housewives (42.1%) and students (39.5%) become obese after delivery than service holders (18.4%). 7.1% service holders, 78.6% housewives and 14.3% students have observed swelling in their CC cut. Women received education till higher secondary, B.A and above faces more complications than uneducated women. From the chi-square test we found the p-value which shows age, weight and education have no relation with types of complications but occupation influence the types of complications after CS delivery.

Cesarean section delivery cost distribution: Figure 5 summarizes the expenditure of CS delivery. Among the participants 52% spend 15-25 thousand, 28.20% spend 26-35 thousand, 5.90% spend 36-50 thousand and others around 13.90% participants didn’t answer the question.

The lowest amount is 15 thousand and 50 thousand is the highest cost of CS delivery. 49% participants could bear the cost because they had savings, 16.8% took loan and 34.1% could cover the cost from their salary. Among the participants 52% said they didn’t have affordability to pay the cost of CS delivery but they hardly managed it and 48% said they didn’t find any difficulties to pay or arrange money for CS delivery.

Discussion:

This study aimed to identify the causes and complications of CS delivery in Bangladesh. In this study, complications were reported by 48.7% of the women which is much higher compared to the study conducted in 2014 by Bangladesh Demographic and Health Survey with 23% prevalence rate [25]. World Health Organization (WHO, 2015) recommends CS rate should be 10% to 15% of all births per country but the percentage found in this study is 50.9% which is much higher than the recommendation by WHO [35]. Another report stated that in Bangladesh the percentage has increased up to 51% due to unnecessary CS delivery [6]. The recent data showed that, more than 60% of the world’s nations have overused the CS procedure within 169 countries [34]. According to the CNN report, all over the region the prevalence of CS delivery in Central Africa and West is 4.1%, 6.2% in Southern Africa and Eastern, 29.6% in the North Africa and Middle East, about 18% in South Asia, 28.8% in the Pacific and East Asia, 44.3% in Caribbean and Latin America, 27.3% in Central Asia and Eastern Europe, 32% in North America and 26.9% in Western Europe [15]. The percentage of CS delivery varied differently in different regions for various reasons such as cultural, educational and economic differences.

 

The result of this study highlighted that depression and respiratory problem were the prime reasons for obstetric medical factors. Others reasons included previous cesarean delivery, prolonged labor, multiple pregnancies were among the least common medical factors. On the other hand, non-obstetric causes like baby’s safety were the priority for all the parents which led to CS delivery. It was strongly perceived by the participants that CS delivery would save the life and health of child. But CS delivery caused complications for neonatal also. Studies showed that, respiratory disorder was higher among the newborn with cesarean delivery. Not only preterm infants but also near-term babies suffer from severe respiratory distress syndrome caused by surfactant deficiency [29]. However, the experts recommend that without any emergency and obstetrical indications, no cesarean should perform for the sake of newborns health [27].

For conducting CS delivery doctors justified at least one cause under certain complicated situation. According to BDHS- 2014 report, to avert labor pain (3.2%), and during mal presentation (41.5%), cord prolapsed (2.6%), premature baby (1.7%), multiple births (0.2%), preeclampsia (2.9%), failure to progress in labor (21.1%), diabetes (0.5%), convenience (5.8%), less pressure on baby’s brain (9.7%) and other complications (38.6%) doctors mentions proposed to undergo Cesarean Section delivery [13]. However, without any complications also some CS deliveries were performed.

Higher educated but housewives aged between 18-24 years were more likely to do CS delivery. The service holder women mostly take their own decision but housewives considered their doctors recommendation. Similarly, in other studies, it’s alleged that educated and pregnant woman mostly afraid of labor pain and other complications of vaginal delivery. Women with higher education, highest socioeconomic status, age, have access to facilities and mostly deliver a baby boy underwent CS delivery [17] [21] [24]. But the individual contribution factors were also important to CS delivery. These factors would help us to figure out the consequences of CS delivery in order to make awareness and promote health policy.

Women conducted cesarean delivery for one or two times suffers from pus, incision, obesity, swelling more than the women who did normal delivery for their first child. Percentage of becoming obese is higher than other complications among them. The complications were higher among the higher educated women aged 18-24 years old. Surprisingly, the housewives face more complications than service holder women. The percentage of pus (46.8%) observed higher than the other complications among the service holders. This study also found out that 51.3% women faced no complications after CS delivery.

Family income was also influenced CS delivery. From the study, it has been found out that, economically affluent participants were more likely to do CS delivery than others. Those who couldn’t afford they spent their salary, took loan or used their savings. Most of the participants reported costing 15-25 thousand taka, while only 5.90% participants mentioned they spent 36-50 thousand for CS delivery. Perhaps, they had better treatment facilities in private hospitals during delivery. It is assumed that the socio demo- graphic and economic factors were associated with the increase rate of cesarean delivery [32].

Women’s life style affected by the CS delivery because complications were related to both physical and psychological concerns. This research focused on medical complications after CS delivery not the others factors. But other studies indicated that after cesarean birth women faces additional stress, less satisfaction with birth experience, guilt, anxiety, and loss of self- esteem [23]. Maternal care was really important to avoid the complications of CS delivery. The study limitations included having possibility of recall bias in reporting the reasons of CS delivery properly and also lack of generalizability because the study was conducted only in one city of Bangladesh.

The findings of this study showed that those who did CS delivery for the first time were more likely to do it for the second time because they thought they were not capable to do vaginal delivery anymore. Also, the women who did normal delivery for their first child had specific health issues mentioned by doctors to perform cesarean section for their second delivery or next child. Women’s age, education, and occupation significantly predicted decision making of CS delivery, which a number of health complications to mothers. The aver-age cost of CS delivery was not affordable for most families yet people are doing CS delivery for the sake of their baby’s safety and doctor’s suggestion. The study recommends generalized awareness raising campaign targeting prospective mothers and couples to use antenatal check-up during pregnancy and to increase knowledge about pregnancy danger signs needing emergency obstetric care. Professional integrity and ethics training should be strengthening for health care providers to exercise medically oriented protocol in recommending CS delivery.

Acknowledgements:

I am grateful to all the participants who took part in the study. I am deeply grateful to AUW for giving me the opportunity to conduct this research and thankful to the research assistants for help during data collection process.

Conflict of Interest:

The author(s) declare there is no conflict of interest.

References:

[1]. Ajeet, Saoji; Nayse, Jaydeep; Kasturwar, Nandkishore, Relwani, Nisha (2011). Women’s       Knowledge, perceptions and Potential Demand towards Cesarean Section. National       Journal of Community Medicine, 2 (2), pp.1-5 www.njcmindia.org/uploads/2-2_244 248.pdf.

[2]. Aminu, M., Utz, B., Halim, A. et al. (2014). Reasons for performing a caesarean section in     public hospitals in rural Bangladesh. BMC Pregnancy Childbirth, 14, 130.        doi.org/10.1186/1471-2393-14-130

[3]. Andaleeb, Syed. (2000). Public and private hospitals in Bangladesh: Service quality and         predictors of hospital choice. Health policy and planning. 15. 95-102.       10.1093/heapol/15.1.95.

[4]. Arifeen, Shams & Hill, Kenneth & Ahsan, Karar & Jamil, Kanta & Nahar, Quamrun &           Streatfield, Peter (2015). Maternal Mortality in Bangladesh. Obstetrical &      Gynecological Survey. 70. 74-75. 10.1097/01.ogx.0000461895.78734.18.

[5]. Azami, Aghdash S., Ghojazadeh, M., Dehdilani, N., Mohammadi, M., & Asl Amin Abad, R. (2014). Prevalence and Causes of Cesarean Section in Iran: Systematic Review and      Meta-Analysis. Iranian journal of public health, 43(5), 545–555.

[6]. Bangladesh: 51 percent Increase in “Unnecessary” C-Section in Two Years (2019). Save the               Children 100 years. Retrieved from- www.savethechildren.net/news/bangladesh-51-            cent-increase-%E2%80%9Cunnecessary%E2%80%9D-c-sections-two-years

[7]. Betran, A. P., Ye, J., Moller, A. B., Zhang, J., Gulmezoglu, A. M., & Torloni, M. R. (2016).   The Increasing Trend in Caesarean Section Rates: Global, Regional and National    Estimates: 1990-2014. PloS one, 11(2), doi.org/10.1371/journal.pone.0148343

[8]. Bruekens, P. (2001). Over-medicalization of maternal care in developing countries. In Brouwere VD and Lerberghe WV (ed.). Safe Motherhood Strategies: A Review of the   Evidence. Antwerp: ITG Press, 17, pp.1-5

[9]. Carlo WA, Travers CP. Maternal and neonatal mortality: time to act (2016). J Pediatr (Rio     J),92:543-5.Retrieved from-www.scielo.br/scielo.php?script=sci_arttext&pid=S0021 75572016000700543

[10]. Doucleff, Michaeleen (2018). Rate Of C-Sections Is Rising At An ‘Alarming’ Rate, Report  Says. National Public Radio. Retrieved from www.npr.org/sections/goatsandsoda/2018/10/12/656198429/rate-of-c-sections-is-rising            at-an-alarming-rate   

[11]. Gibbons,Luz; Belizan, Jose M., Jeremy A Lauer, Ana P Betran, Mario Merialdi and  Fernando Althabe. (2010). The global numbers and costs of additionally needed and    unnecessary caesarean sections performed per year: overuse as a barrier to universal          coverage. World Health Organization (WHO).            www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

[12]. Haider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM (2018) Ever    increasing Caesarean section and its economic burden in Bangladesh. PLoS ONE, 13(12):      pp. 1-13, doi.org/10.1371/journal.pone.0208623

[13]. Hasan, F., Alam, M.M. & Hossain, M.G. (2019). “Associated factors and their individual     contributions to caesarean delivery among married women in Bangladesh: analysis of          Bangladesh demographic and health survey data.” BMC Pregnancy Childbirth, 19 (433),             1-9, doi.org/10.1186/s12884-019-2588-9

[14]. Hasan, Md.Kamrul (2019).C-sections up by 51% in Bangladesh in two years. Dhaka Tribune, Retrieved from- www.dhakatribune.com/bangladesh/nation/2019/06/21/c      sections-up-by-51-in-bangladesh-says-report

[15]. Howard, Jacqueline (2018). “C-section deliveries nearly doubled worldwide since 2000,       study finds.” CNN Health. Retrieved from- edition.cnn.com/2018/10/11/health/c-section          rates- study-parenting-without-borders-intl/index.html

[16]. Kamal S. M. (2013). Preference for institutional delivery and caesarean sections in    Bangladesh. Journal of health, population, and nutrition, 31(1), 96–109.       doi.org/10.3329/jhpn.v31i1.14754

[17]. Khan, Nuruzzaman & Islam, M. Mofizul & Rahman, Mijanur. (2018). Inequality in   utilization of    cesarean delivery in Bangladesh: a decomposition analysis using        nationally representative data. Public Health. 157. 111-120. 10.1016/j.puhe.2018.01.015.

[18]. Khanday, Zulufkar Ahmad (2013). Review on Medicalisation: A critical appraisal with         special reference to India International. Journal of Medical Sociology and Anthropology,           2(2), pp.66-75.

[19]. Khawaja M, M Al-Nsour and M Khawaja (2007). Trends in prevalence and determinants of caesarean delivery in Jordan: Evidence from three demographic and health surveys 1990         2002, World Health and Population, 9(4), doi:10.12927/whp.2007.19395

[20]. Klugman, Jeni (2010). The Real Wealth of Nations: Pathways to Human Development.        UNDP-HDRO Human Development Report 2010 — 20th Anniversary Edition, pp.1-234    Retrieved from- ssrn.com/abstract=2294686

[21]. Manyeh, A.K., Amu, A., Akpakli, D.E. et al. (2018). Socioeconomic and demographic         factors             associated with caesarean section delivery in Southern Ghana: evidence from         INDEPTH Network member site. BMC Pregnancy Childbirth, 18 (405), 1-9.       doi.org/10.1186/s12884-018-2039-z

[22]. Maswood, Manzur H (2019). Caesarean births boom in Bangladesh. New Age Bangladesh.            www.newagebd.net/article/76766/caesarean-births-boom-in-bangladesh

[23]. Miovech, S. M., Knapp, H., Borucki, L., Roncoli, M., Arnold, L., & Brooten, D. (2013).      Major   concerns of women after cesarean delivery. Journal of obstetric, gynecologic, and          neonatal nursing: JOGNN, 23(1), 1–11. doi.org/10.1111/j.1552-6909.1994.tb01850.x

[24]. Mia, Mohammad Nahid; Mohammad Zahirul Islam, Md Razib Chowdhury, Abdur   Razzaque, Brian Chin, M.Shafiqur Rahman (2019). “Socio-demographic, health and           institutional determinants of caesarean section among the poorest segment of the urban        population: Evidence from selected slums in Dhaka, Bangladesh.” SSM – Population    Health, 8, 1-7, doi.org/10.1016/j.ssmph.2019.100415.

[25]. National Institute of Population Research and Training (NIPORT), Mitra and Associates,     and ICF International. 2016. Bangladesh Demographic and Health Survey 2014. Dhaka,     Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF    International, 120-122, Retrieved from- dhsprogram.com/pubs/pdf/FR311/FR311.pdf

[26]. Radha, K.; Devi, G.Prameela; R,V.Manjula; P.A.Chandrasekharan (2015). Study On Rising Trends Of Caesarean Section(C- Section): A Bio-Sociological Effect. Journal of Dental          and Medical Sciences (IOSR-JDMS), PP 10-13, DOI: 10.9790/0853-14821013

[27]. Rafiei, M., Saei Ghare, M., Akbari, M., Kiani, F., Sayehmiri, F., Sayehmiri, K., & Vafaee,    R. (2018). Prevalence, causes, and complications of cesarean delivery in Iran: A          systematic review and meta-analysis. International journal of reproductive biomedicine   (Yazd, Iran), 16(4), 221–234.

[28]. Rahman MM, Haider MR, Moinuddin M, Rahman AE, Ahmed S, Khan MM (2018)            Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh     Demographic and Health Survey 2014 Data. PLoS ONE, 13(9): e0202879.   doi.org/10.1371/journal.pone.0202879

[29]. Roth-Kleiner, Matthias & Wagner, Bendicht & Bachmann, Denis & Pfenninger, Jurg.           (2003). Respiratory distress syndrome in near term babies after C-section. Swiss medical weekly, 133, 283-288,

[30]. Sabnom, R., & Islam, M. (2013). Cost and outcome of caesarean section in a public and       private hospital in Dhaka city. Bangladesh Journal of Medical Science, 12(3), 276-281,           doi.org/10.3329/bjms.v12i3.15424

[31]. Sujan, Moudud Ahmmed (2019). Maternal causes behind 13pc deaths. The Daily Star,         Retrieved from-www.thedailystar.net/backpage/bangladesh-maternal-mortality-rate-is         thirteen-percent-survey-says-1759075

[32]. Vieira, G. O., Fernandes, L. G., de Oliveira, N. F., Silva, L. R., & Vieira, T. (2015). Factors associated with cesarean delivery in public and private hospitals in a city of northeastern     Brazil: a cross-sectional study. BMC pregnancy and childbirth, 15, 132.     doi.org/10.1186/s12884-015-0570-8

[33]. Weaver, Jane.J., Statham, H. and Richards, M. (2007), Are There “Unnecessary” Cesarean   Sections? Perceptions of Women and Obstetricians about Cesarean Sections for         Nonclinical Indications. Wiley Online Library, 34: 32-41. doi:10.1111/j.1523           536X.2006.00144.x

[34]. Weule, Genelle (2018). “The countries where more than half of babies are delivered via        caesarean.” Science News. Retrieved from- www.abc.net.au/news/science/2018-10-       15/countries-where-more-than-half-babies-born-by-c-section/10370302

[35]. WHO Statement on Caesarean Section Rates (2015). Department of Reproductive Health     and Research: World Health Organization (WHO).Retrieved from            apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jsessioni            B6B0787D65D99F3480571527BD17DB82?sequence=1

[36]. Zakeri, Hamidi M., Latifnejad Roudsari, R., & Merghati Khoei, E. (2015). Vaginal   Delivery vs. Cesarean Section: A Focused Ethnographic Study of Women’s Perceptions    in The North of Iran. International journal of community based nursing and            midwifery, 3(1), 39–50.

The Impact of Online Learning on the Education of University Students from Bangladesh, the Philippines and Vietnam during Covid 19 Pandemic

Introduction

The highly infectious COVID-19 hit the ground of China at the end of 2019. Soon, it became a global pandemic forcing humankind to stay behind locked doors, thus minimizing in-person interactions. Since then, a lot of initiatives have been taken. Lockdowns were the foremost effective means to prevent the spread of this virus. However, after almost two years fighting with this virus, many establishments have resumed work either online or in-person with proper preventive measures. The education system is no different. The pandemic forced the rapid and total closure of all academic systems, resulting in notable effects on the methods of learning. From primary to university students, everyone has been affected remarkably. University is the place to groom students for their careers through academics, extra-curricular activities, and practical work. Thus, COVID-19 has had a significant impact on university students’ learning. The change in instructional methods from the traditional offline classroom set-up to computer-based remote learning was one of the most important educational alterations that students had to deal with (Sharma et al., 2021). Internet-based classes were previously used in part-time academics, however online learning was hardly used previously (Drasler et al., 2021). Though there were some obvious benefits, still one research found that students’ level of satisfaction went down to 27% (Drasler et al., 2021). Students were concerned about their social, personal and academic growth. Issues that were identified by both students and educators included (a) absence of social communication and efficient laboratory work, (b) students’ and teachers’ lack of online knowledge (Drasler et al., 2021), (c) distractions faced at home (noise) (Barrot et al., 2021) and (d) challenges with access to the internet, computers or smartphones (Adnan & Anwar, 2020). To combat these effects students have adopted a couple of coping strategies such as finding a calmer place to attend and participate in class, discussing with the family, seeking help from classmates, faculties and instructors, studying at night while the family is asleep, using backup internet, joining online support groups, using resources available at home and consulting with teachers as needed (Barrot et al., 2021). Still, it has been found that students wanted the traditional method of teaching to be back as soon as possible (Drasler et al., 2021). While in this lockdown, online learning has allowed the education system to continue, there are certain advantages and disadvantages that need to be addressed. Students of developing countries have been the main focus for this study as there is a scarcity of research on the impact of COVID-19 on their learning progress, the challenges they face, and the way they adapt with these challenges amid the scarcity of resources available for online learning.

In this qualitative analysis we looked at the changes the students have experienced due to online classes, the benefits they got, the challenges they faced and how they are coping with those challenges in three developing countries: Bangladesh, the Philippines and Vietnam. Our aim was to see the impact of online learning on the overall education experience of university students in those three countries.

Objectives. The general objective of this study is to describe the impact of online learning on the education of university students from Bangladesh, the Philippines and Vietnam, during the COVID-19 pandemic. Specifically, it aimed to achieve the following.

  1. Identify the major differences in learning observed by students from Bangladesh, the Philippines and Vietnam in the university education system between the pre-pandemic and pandemic periods.
  2. Explore the main benefits and challenges students have experienced regarding learning and wellbeing during the pandemic.
  3. Enumerate the coping strategies used by the students to address these challenges.

Methodology  

Study design and settings

This study was a qualitative study conducted to attain a better understanding about the impact of online learning on the education of the university students during the COVID-19 pandemic from three (3) different countries (Bangladesh, the Philippines and Vietnam).

Sampling strategy

The research was conducted in 3 different countries through a diverse group of student researchers of the BRAC JPGSPH MPH program. Convenient sampling was implemented, considering a few criteria as follows: (a) nationality, (b) age, (c) religion, (d) sex, (e) institution type (public/private), (f) education level (2nd/3rd/4th year), (g) study major, and (h) place of residence during the lockdown (urban/rural). In total, sixteen (16) university students were involved. 1st year university students were excluded as they did not have any exposure to offline classes in the university prior to the pandemic.

Data collection technique and procedure

A group of 6 interviewers collected data from 16 respondents. A semi-structured guideline was developed as a tool for interviewers to guide the conversation and keep the interview on track. Appointments were set with the interviewees prior to the interview. Interviewees were asked to accomplish a Google form-based screening questionnaire and consent form beforehand. Virtual in-depth interviews (IDIs) via Zoom and Google Meet applications were conducted to facilitate two-way communication and encourage interviewees to open up more comfortably. Verbal permission for recording was taken at the start of the conversation proper. No note-taker was present during the online interviews.

Data analysis process

After collecting the data, transcription was done verbatim. Transcripts were then read for familiarization.  Codes were then set according to the study objectives and interview questions. Each researcher coded his own transcript on a shared Google sheet. For data verification, reading and coding was done on each other’s transcripts and a series of discussions with group members was conducted. After identifying the main themes, key findings were listed down and examined for any emerging patterns. Finally, the findings were summarized and any similarities and differences with existing literature were noted.

Ethical considerations

The study was approved by BRAC JPGSPH’s Epidemiology of Infectious Diseases Professors and Teaching Fellows. A consent form containing the contact details of the corresponding investigator was electronically submitted by participants before they were asked any research related questions. Verbal permission was sought before recording. Participants had full freedom to withdraw from the study at any time. Privacy and confidentiality was maintained using identification numbers. Interviewers answered any research-related questions asked by the respondents. Data was securely stored and destroyed after transcription.

Results and Discussion

Demographics

The participants of this qualitative study were 16 full-time undergraduate students studying in different public (8 students) and private (8 students) universities from Bangladesh, Philippines and Vietnam. The participants were from two sex categories- 9 males students, and 7 female students aged 21 to 25 years old. We had participants from both urban (10) and rural (6) residential areas practicing 6 different religion categories where 43.8% were Muslim, 25% practiced no religion, and others were Roman Catholic, Hindu or Christian. Students were from 11 different majors (Medicine, BS Public Health, Doctor of Dental Medicine, Medical Science, Pharmacy, BSc in Physiotherapy, Management, Marine science, Mechanical Engineering, Event Management and Business Administration). At the time of the study, most students were studying in the final year of their course.

Theme 1: Major Changes Pre- and Post-COVID

With the shift to online learning, students perceived significant changes in student assessment, which has led to noticeable effects on their learning and performance. One Bangladeshi pharmacy student shared:

“Now it is an open book exam… and I have to answer critically… My results are improving…” (IDI 202)Such changes were not limited to the learning materials provided and teaching methods used but also to the manner professors communicated with their students, as reflected in this statement:

“The major difference … that it’s the humor of the professors- because you don’t get to be excited, or you don’t get to be stimulated by… humor.” (IDI 101)

Overall, Vietnamese students generally enjoyed this shift to the online platform. In contrast, Filipino and Bangladeshi respondents felt negatively about the way they had to learn online:

“My personal learning curve was downhill, or it was not that steep. It was quite stagnant… I feel like we were given more exams, too.” (IDI 102)

Theme 2: Tools Used for Online Learning

Respondents made use of hardware and software applications to support learning in the virtual environment.  Laptops were deemed as best to use due to the wide screens and better video quality. Nevertheless, some respondents also tapped on the portability of mobile phones. As one pharmacy student from Bangladesh shared:

“During exams, a laptop was more useful as we needed to type. But during quizzes or classes where I just needed to post small responses and comments, I used a mobile phone…” (IDI_202)     

The combined use of (a) learning management systems (LMS), (b) teleconferencing platforms, and (c) less commonly, messaging applications, together supported optimal online learning. The LMS run by schools kept the learning experience systematic and student-friendly:

“…So, everything would be arranged in there, the videos and the lectures would be uploaded in there… So, it was very… very helpful during that time because it helped us keep our learning organized.” (IDI_101)

Real-time communication with professors and fellow students was possible through the use of conferencing and instant messaging applications, as highlighted by a Vietnamese respondent:

“We interact with each other on (Microsoft) Teams. If the professor changes the class schedule, the notice will be sent via Facebook Group.” (IDI_303)

Students favored online applications that were free of cost, versatile, had robust security and allowed collaborations with fellow students. However, whenever faced limitations in terms of technology, application features or even material content, university students were able to adapt using suitable online alternatives. One dentistry student from the Philippines noted:

“Some were not able to open Zoom or had internet problems. So, what we’d do is during… group work, we would just do it somehow synchronously… on Google Sheets, Google Docs, Google Slides.” (IDI 104) 

Overall, these findings highlight the pragmatism, ingenuity and resourcefulness of university students in the choice and use of the technologies made available to them while learning online.

Theme 3: Benefits of Online Learning

Most students opined that two-way communication became easier while on online mode. This was especially true for shy students who were able to overcome their fear of asking questions by sending email messages. Learning also occurred more rapidly, without compromising effectiveness:

“Progress is faster than offline. Because in offline learning, if I have a question, I have to    go to class to meet the teacher to ask a question. In online class, I can ask by email, I just check your email or class group to see the answer. Besides, it is more convenient for teachers to answer individually in email than to answer the whole class in general.” (IDI_301)

Online learning allowed students to better manage their time. They would make routines, set alarms, and most importantly avoid traffic jams, thus saving time for other tasks:

“I can manage my time more easily between my studies, personal life, and internship.”      (IDI_304)

“Time waste is minimal in online classes. We can easily log in to the classes timely. (During) in-person classes, teachers are sometimes delayed due to traffic jams…
We were also late for our classes in the morning. But online (learning) was (just) at home… I don’t need any special preparation.” (IDI_201)

Online classes also worked to the advantage of students who had difficulties looking at the teacher’s slide screen from the back, taking down lecture notes, and concentrating well. Students could easily take screenshots, watch recordings later on, and understand any unclear topics:

“We can take the screenshots and after the class, we can easily read from that or see the     recorded versions.” (IDI_203)  

 

Theme 4: Main Challenges with Online Learning

Although online learning was the most popular way of gaining access to education during the pandemic, many challenges had also emerged among the students in all three countries. Network issues were a prominent concern among all respondents. Even though many students used both broadband and mobile data internet, poor or congested internet greatly hampered them during classes or exams:

“There are times that the internet is really bad. Actually, we have Wi-Fi here…
But somehow it cuts off… for how many hours, sometimes it’s during the time of your exam like that… even when you use mobile data… the signal is really bad.” (IDI_ 104)

Along with network issues, active participation was significantly reduced in all university students. Respondents from Bangladesh and the Philippines have also faced difficulties in concentration and understanding during online learning. Many of them expressed concern about practical classes not being conducted or even possible online:

 “We were greatly deprived of practical knowledge. Ward, lab and other activities were totally stopped. As a medical student I think, I didn’t get any practical knowledge through online classes. And I sincerely believe that this will affect my future career.” (IDI_201)

Finally, the students also experienced health related problems which adversely affected them and the way they learned. Eye strain, back pain, weight gain, stress were more common among the respondents from Bangladesh and the Philippines.

Theme 5: Coping Strategies

In this research, we found several strategies undertaken by the respondents- most frequently cited was keeping a good internet backup.

“I always have backup…like mobile data. As I use Wi-Fi which I lose when there is no electricity, I always buy mobile data so that even if I lose my Wi-Fi connection,
I can carry on with the mobile data.” (IDI_202)
 

Most of the students from public universities recorded their own classes, while in most of the private universities, classes were recorded and circulated later by university authorities:

“I will prepare a good internet, a stable place to study, and record the lecture carefully.” (IDI_303)

In this difficult time, when students faced the fear of COVID while continuing with their studies, their emotional health was compromised. Therefore, increasing physical activities, spending time with family members and doing religious practice were strategies mentioned by respondents to improve their physical, mental and emotional health:

“Due to the pandemic we could not go outside like before, so I played football once in a week or exercised at night when there were less people. But it is not a regular thing yet.” (IDI_202)

“ I spent more time with my family members. In addition, I increased my religious practices and took prayer regularly on time. These actually helped me to reduce my stress”  (IDI_201)

In a similar study, physical exercise was indeed found to significantly lower depression scores of home-quarantined Bangladeshi university students (Khan et al., 2020). Other strategies were undertaken at individual level such as making a routine, renovating the study room, seeking help from peers or psychiatrists for mental health issues, taking medications and controlling emotional eating. Couple of these strategies were also found in another study, for example, finding a calmer place to attend and participate in class, discussing with the family, seeking help from classmates, faculties and instructors, and using backup internet (Barrot et al., 2021).

Theme 6: Continuing Online Learning after the Pandemic

The opinion of the participants about continuing the online learning after the pandemic ends fell under three categories.

  1. No online learning anymore: Most of the respondents from both public and private universities from all 3 countries did not want to continue online learning after the pandemic ended:

“Definitely not. University life is more than just studying. No campus, no friends, no outing, no refreshment. This cannot be a life….”(IDI_208)

 

  1. Both online and offline learning: Some respondents wanted to continue online classes for specific subjects. This was more common among public university students from all countries:

“I feel like it should continue after the pandemic has stopped. Because it’s not like every person can attend offline classes every day. But if the classes are online, I can still see the recorded sessions, or I won’t miss the lectures. It will be really good for me….” (IDI_204)

III. Continue only online: Some public university students from urban areas in Vietnam and Bangladesh did not want to continue with offline classes anymore. However, one Vietnamese male public university student studying in public health had this to say:

 “Compared to studying online with offline, I prefer to study online because I don’t feel pressured to see my teacher standing in front of me. Studying online, if I’m scared, I can look elsewhere…”(IDI 302)

From a similar survey, most students (73%) wanted to continue their classes fully online in the future, while 68% wanted to have combined offline and online classes (McKenzie, 2021).

Challenges and Limitations

Since the study was performed in a limited population, findings may not be generalized for all university students. Owing to the ongoing political unrest in a fourth country, Myanmar, no Burmese respondent was included. Participant recruitment done through convenience sampling preferentially selected students who had reliable internet access. Since respondents were only taken from three developing countries, results might not be comparable with that in developed or less developed countries. With the ongoing pandemic, in-depth interviews had to be conducted virtually. Thus, though interviews were recorded, it was difficult to accurately observe and take note of all non-verbal cues from the respondents.

Conclusion and Recommendations

With the transition to online learning, COVID-19 has had a significant impact on the overall learning experience of selected university students from Bangladesh, the Philippines and Vietnam. Respondents preferred tools that made learning organized, convenient, and as close as possible to offline education. While they valued the time and effort saved with learning online, they still struggled with connectivity issues, yearned for more classroom interaction and often suffered from screen fatigue. Stable connectivity; maintaining physical, psychosocial and spiritual well-being; creating a conducive home learning environment, and ensuring adequate support from both family and teachers are keys to effective coping and the success of university students as they embrace the realities of online learning during this pandemic and beyond.

  

References

Adnan, M., & Anwar, K. (2020). “Online Learning amid the COVID-19 Pandemic: Students’      Perspectives.” Online Submission, 2(1), 45-51. Available at:            https://eric.ed.gov/?id=ED606496

Barrot, J.S., Llenares, I.I. & del Rosario, L.S. (2021). “Students’ online learning challenges           during the pandemic and how they cope with them: The case of the Philippines.” Educ Inf      Technol. Available at: https://doi.org/10.1007/s10639-021-10589-x

Drasler, V., Bertoncelj, J., Korosec, M., Pajk Zontar, T., Poklar Ulrih, N., & Cigic, B. (2021).        “Difference in the attitude of students and employees of the university of ljubljana      towards work from home and online education: Lessons from COVID-19 pandemic.”            Sustainability, 13(9), 5118. Available at: https://doi.org/10.3390/su13095118)

Khan, A. H., Sultana, M. S., Hossain, S., Hasan, M. T., Ahmed, H. U., & Sikder, M. T. (2020).    “The impact of COVID-19 pandemic on mental health & wellbeing among home    quarantined Bangladeshi students: A cross-sectional pilot study.” Journal of Affective     Disorders, 277, 121–128. Available at: https://doi.org/10.1016/j.jad.2020.07.135

Li, Cathy & Lalani, Farah (2020). “The COVID-19 pandemic has changed education forever.       This is how.” World Economic Forum. Available at:           www.weforum.org/agenda/2020/04/coronavirus-education-global-covid19-online-digital learning/

McKenzie, Lindsay (2021). “Students Want Online Learning Options Post-Pandemic.” Inside      Higher ED. Available at:    www.insidehighered.com/news/2021/04/27/survey-reveals   positive-outlook-online-instruction-post-pandemic

Sharma, A., Alvi, I. (2021). “Evaluating pre and post COVID 19 learning: An empirical study of learners’ perception in higher education.” Educ Inf Technol, Available at:            https://doi.org/10.1007/s10639-021-10521-3)