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Background: Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician-patient communication leading to informed-consent for the operation., Methods: We conducted a mixed-method study using structured observations with the Option Grid Collaborative's OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis., Results: In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician-patient communication in the context of labour situations, the OPTION5 mean scores were low (5-25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication., Conclusions: Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

Background: The Global Network for Women's and Children's Health Research (Global Network, GN) has established the Maternal Newborn Health Registry (MNHR) to assess MNH outcomes over time. Bangladesh is the newest country in the GN and has implemented a full electronic MNH registry system, from married women surveillance to pregnancy enrollment and subsequent follow ups., Method: Like other GN sites, the Bangladesh MNHR is a prospective, population-based observational study that tracks pregnancies and MNH outcomes. The MNHR site is in the Ghatail and Kalihati sub-districts of the Tangail district. The study area consists of 12 registry clusters each of ~ 18,000-19,000 population. All pregnant women identified through a two-monthly house-to-house surveillance are enrolled in the registry upon consenting and followed up on scheduled visits until 42 days after pregnancy outcome. A comprehensive automated registry data capture system has been developed that allows for married women surveillance, pregnancy enrollment, and data collection during follow-up visits using a web-linked tablet-PC-based system., Result: During March-May 2019, a total of 56,064 households located were listed in the Bangladesh MNH registry site. Of the total 221,462 population covered, 49,269 were currently married women in reproductive age (CMWRA). About 13% CMWRA were less susceptible to pregnancy. Large variability was observed in selected contraceptive usage across clusters. Overall, 5% of the listed CMWRAs were reported as currently pregnant., Conclusion: In comparison to paper-pen capturing system electronic data capturing system (EDC) has advantages of less error-prone data collection, real-time data collection progress monitoring, data quality check and sharing. But the implementation of EDC in a resource-poor setting depends on technical infrastructure, skilled staff, software development, community acceptance and a data security system. Our experience of pregnancy registration, intervention coverage, and outcome tracking provides important contextualized considerations for both design and implementation of individual-level health information capturing and sharing systems.