Child mortality in Bangladesh - why, when, where and how? A national survey-based analysis

Stakeholder engagement to introduce a standardised register for improved inpatient care of newborns and sick children in Bangladesh

Background

Despite a global decrease of 59% in under-five mortality rates from 1990 to 2021, child survival remains a pressing issue. This holds true for Bangladesh, as well. In response, the Government of Bangladesh introduced a standardised register for strengthening the inpatient management of newborns and sick children in 2021.

Methods

We employed a comprehensive four-phase stakeholder engagement process to implement an inpatient register for newborns and sick children. The first stage included identifying and prioritising potential stakeholders at the national and district levels. We identified eight organisations involved in newborn and child health and selected 24 participants from various other sectors for workshops aimed at raising awareness about the register's introduction. These stakeholders also participated in the register's design, development strategies planning, and implementation phases. These phases were led by the 'National Newborn Health and IMCI programme' with support from various partners. A technical working group reviewed existing registers and helped prepare training materials. Feedback from each workshop was crucial in finalising the register.

Results

The Government of Bangladesh has recognised the need for an indoor register for newborns and sick children, which was to be established in collaboration with development partners. This initiative can enhance the quality of care for sick children and increase service provider accountability. Due to its successful implementation, it will continue to be used in the Kushtia and Dinajpur districts, with plans for a nationwide scale-up. The Government has allocated funds in the next health sector programme for orientation and register printing. A strengths, weaknesses, opportunities, and threats (SWOT) analysis of the stakeholder engagement process highlighted strengths such as a context-specific approach and collaborative engagement, as well as challenges such as time resource requirements.

Conclusions

Implementing an inpatient register for newborns and sick children through stakeholder engagement can effectively improve child health care services. Aside from challenges such as resource intensiveness and stakeholder commitments, success depended on the organising authority's expertise in relationship building, budget allocation, time management, and workforce dedication. Therefore, strategic planning, staff recruitment, networking, and budgeting are crucial for successful stakeholder engagement and health care initiatives.

Introducing a standardised register for strengthening the inpatient management of newborns and sick children: Implementation research in selected health facilities of Bangladesh

Background

It is imperative to maintain accurate documentation of clinical interventions aimed at enhancing the quality of care for newborns and sick children. The National Newborn Health and IMCI programme of Bangladesh led the development of a standardised register for managing newborns and sick children under five years of age during inpatient care through stakeholder engagement. We aimed to assess the implementation outcomes of the standardised register in the inpatient department.

Methods

We conducted implementation research in two district hospitals and two sub-district hospitals of Kushtia and Dinajpur districts from November 2022 to January 2023 to assess the implementation outcomes of the standardised register. We assessed the following World Health Organization implementation outcome variables: usability, acceptability, adoption (actual use), fidelity (completeness and accuracy), and utility (quality of care) of the register against preset benchmarks. We collected data through structured interviews with health care providers; participant enrolment; and data extraction from inpatient registers and case record forms.

Results

The average usability and acceptability scores among health care providers were 73 (standard deviation (SD) = 14) and 82 (SD = 14) out of 100, respectively. The inpatient register recorded 96% (95% confidence interval (CI) = 95-97) of under-five children who were admitted to the inpatient department (adoption - actual use). The proportions of completed data elements in the inpatient register were above the preset benchmark of 70% for all the assessed data elements except 'investigation done' (24%; 95% CI = 23-26) (fidelity - completeness). The percentage agreements between government-appointed nurses posted and study-appointed nurses were above the preset benchmark of 70% for all the reported variables (fidelity - accuracy). The kappa coefficient for the overall level of agreement between these two groups regarding reported variables indicated moderate to substantial agreement. The proportion of newborns with sepsis receiving injectable antibiotics was 62% (95% CI = 47-75) (utility - quality of care). We observed some variability in the completeness and accuracy of the inpatient register by district and facility type.

Conclusions

The inpatient register was positively received by health care providers, with evaluations of implementation outcome variables showing encouraging results. Our findings could inform evidence-based decision-making on the implementation and scale-up of the inpatient register in Bangladesh, as well as other low- and middle-income countries.

Disparities in the maternal healthcare continuum among Bangladeshi women: evidence from nationally representative surveys

INTRODUCTION

Utilisation of maternal healthcare is low, and it consistently decreases across antenatal to postnatal period in Bangladesh. However, there is paucity of knowledge in Bangladesh to understand gaps and associated factors in seeking continuum of maternal healthcare along the pathway. Therefore, we aimed to assess the trend in socioeconomic and demographic factors and wealth inequity in maternal CoC using the Bangladesh Multiple Indicator Cluster Survey (MICS).

METHODS

We performed a secondary analysis on nationally representative data from the last two MICS survey, carried out in 2012-13 and 2019. The study included women of reproductive age (15-49 years) with a live birth within two years preceding the survey. Total of 7,950 and 9,183 respondents were identified from these two surveys, respectively. We used multivariable logistic regression and concentration index to examine the covariates and inequity, respectively, in the utilisation of CoC.

RESULTS

Utilisation of ≥4 antenatal care, skilled delivery, and postnatal care for both mother and newborn increased from 13 percent in 2012-13 to 25 percent in 2019 survey. Moreover, wealth inequity persists favouring the rich in utilisation of CoC in Bangladesh. Women belonging to wealthier quintile, urban areas, and non-Muslim families, with higher education, a household head with higher education, media use, and fewer children were most likely to avail complete CoC in both the surveys.

CONCLUSION

Overall utilisation of maternal CoC increased between 2012 and 13 and 2019, however, women in Bangladesh still lack the CoC with persistent wealth inequality. Integrated provision of ANC, delivery by SBA, and PNC should be introduced, comprising both private and public health facilities, and targeting women in poor and rural communities. Efforts should also focus on women's education, autonomy, fertility rate, and exposure to media.

Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh

BACKGROUND

Informal and unregulated rural medical practitioners (RMPs) provide healthcare services to about two-thirds of people in Bangladesh, although their service is assumed to be substandard by qualified providers. As the RMPs are embedded in the local community and provide low-cost services, their practice pattern demands investigation to identify the shortfalls and design effective strategies to ameliorate the service.

METHODS

We conducted a cross-sectional study in 2015-16 using a convenient sample from all 64 districts of Bangladesh. Personnel practising modern medicine, without any recognized training, or with recognized training but practising outside their defined roles, and without any regulatory oversight were invited to take part in the study. Appropriateness of the diagnosis and the rationality of antibiotic and other drug use were measured as per the Integrated Management of Childhood Illness guideline.

RESULTS

We invited 1004 RMPs, of whom 877 consented. Among them, 656 (74.8%) RMPs owned a drugstore, 706 (78.2%) had formal education below higher secondary level, and 844 (96.2%) had informal training outside regulatory oversight during or after induction into the profession. The most common diseases encountered by them were common cold, pneumonia, and diarrhoea. 583 (66.5%) RMPs did not dispense any antibiotic for common cold symptoms. 59 (6.7%) and 64 (7.3%) of them could identify all main symptoms of pneumonia and diarrhoea, respectively. In pneumonia, 28 (3.2%) RMPs dispensed amoxicillin as first-line treatment, 819 (93.4%) dispensed different antibiotics including ceftriaxone, 721 (82.2%) dispensed salbutamol, and 278 (31.7%) dispensed steroid. In diarrhoea, 824 (94.0%) RMPs dispensed antibiotic, 937 (95.4%) dispensed ORS, 709 (80.8%) dispensed antiprotozoal, and 15 (1.7%) refrained from dispensing antibiotic and antiprotozoal together.

CONCLUSIONS

Inappropriate diagnoses, irrational use of antibiotics and other drugs, and polypharmacy were observed in the practising pattern of RMPs. The government and other stakeholders should acknowledge them as crucial partners in the healthcare sector and consider ways to incorporate them into curative and preventive care.

Application of a count regression model to identify the risk factors of under-five child morbidity in Bangladesh

BACKGROUND

Bangladesh has seen a significant decline in child mortality in recent decades, but morbidity among children <5 y of age remains high. The aim of this analysis was to examine trends and identify risk factors related to child morbidity in Bangladesh.

METHODS

This analysis is based on data from four successive cross-sectional Bangladesh Demographic and Health Surveys for the years 2007, 2011, 2014 and 2017-18. Several count regression models were fitted and the best model was used to identify risk factors associated with morbidity in children <5 y of age.

RESULTS

According to the results of the trend analysis, the prevalence of non-symptomatic children increased and the prevalence of fever, diarrhoea and acute respiratory infections (ARIs) decreased over the years. The Vuong's non-nested test indicated that Poisson regression could be used as the best model. From the results of the Poisson regression model, child age, sex, underweight, wasted, stunting, maternal education, wealth status, religion and region were the important determinants associated with the risk of child morbidity. The risk was considerably higher among women with a primary education compared with women with a secondary or greater education in Bangladesh.

CONCLUSIONS

This analysis concluded that child morbidity is still a major public health problem for Bangladesh. Thus it is important to take the necessary measures to reduce child morbidity (particularly fever, diarrhoea and ARI) by improving significant influencing factors.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method

Background

Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh.

Methods

We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh.

Results

Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh.

Conclusions

This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Levels and trends in mortality and causes of death among women of reproductive age in Bangladesh: Findings from three national surveys

Background

Information on the mortality rate and proportional cause-specific mortality is essential for identifying diseases of public health importance, design programmes, and formulating policies, but such data on women of reproductive age in Bangladesh is limited.

Methods

We analysed secondary data from the 2001, 2010, and 2016 rounds of the nationally representative Bangladesh Maternal Mortality and Health Care Survey (BMMS) to estimate mortality rates and causes of death among women aged 15-49 years. We collected information on causes of death three years prior to each survey using a country-adapted version of the World Health Organization (WHO) verbal autopsy (VA) questionnaire. Trained physicians independently reviewed the VA questionnaire and assigned a cause of death using the International Classification of Diseases (ICD) codes. The analysis included mortality rates and proportional mortality showing overall and age-specific causes of death.

Results

The overall mortality rates for women aged 15-49 years decreased over time, from 190 per 100 000 years of observation in the 2001 BMMS, to 121 per 100 000 in the 2010 BMMS, to 116 per 100 000 in the 2016 BMMS. Age-specific mortality showed a similar downward pattern. The three diseases contributing the most to mortality were maternal causes (13-20%), circulatory system diseases (15-23%), and malignancy (14-24%). The relative position of these three diseases changed between the three surveys. From the 2001 BMMS to the 2010 BMMS and subsequently to the 2016 BMMS, the number of deaths from non-communicable diseases (e.g. cardiovascular diseases and malignancies) increased from 29% to 38% to 48%. Maternal causes led to the highest proportion of deaths among 20-34-year-olds in all three surveys (25-32%), while suicide was the number one cause of death for teenagers (19-22%). Circulatory system diseases and malignancy were the two leading causes of death for older women aged 35-49 years (40%-67%).

Conclusions

There was a gradual shift in the causes of death from communicable to non-communicable diseases among women of reproductive age in Bangladesh. Suicide as the primary cause of death among teenage girls demands urgent attention for prevention.

Influencing factors associated with maternal delivery at home in urban areas: a cross-sectional analysis of the Bangladesh Demographic and Health Survey 2017-2018 data

BACKGROUND

The associated factors and patterns of giving birth in home settings of rural areas have been extensively studied in Bangladeshi literature. However, urban areas still need to be explored, particularly with recent data. Therefore, the authors aimed to investigate the influential determinants of delivery at home in urban areas of Bangladesh.

MATERIALS AND METHODS

In this study, 1699 urban-dwelling women who had given birth within the previous 60 months of the survey and lived in urban areas were used. The secondary data were extracted from the latest Bangladesh Demographic and Health Survey 2017-2018. Descriptive statistics and logistic regression were applied along with the association among selected variables were examined by the Chi-square test.

RESULTS

Findings depict that 36.49% of women who lived in urban areas of Bangladesh delivered at home, whereas, 63.51% delivered at different govt. and private health care facilities. Women who lived in Chittagong [adjusted odds ratio (AOR) = 2.11, 95% CI 1.24-3.60], Barisal [AOR = 2.05, 95% CI 1.16-3.64] and Sylhet [AOR = 1.92, 95% CI 1.08-3.43] divisions have more likelihood to deliver at home (36.85%). Urban women following Christian religion [AOR = 10.71, 95% CI 1.32-86.68] have higher odds of delivering child at home (0.47%). Urban women having three or more children before her latest delivery (22.37%) and who are employed (29.37%) have more likelihood to deliver at home. However, women aged between 25 and 34 years (43.50%), who have higher education (25.90%), play the role of household head (9.06%), have parity of more than two births (2.24%), and read daily newspapers (68.69%) had a lower chance of delivery at home. Furthermore, women from wealthier families (89.12%) and more antenatal care (ANC) visits (94.93%) were less likely to have a delivery at home.

CONCLUSION

Despite significant progress in women and reproductive health in Bangladesh, the proportion of delivery in the home in urban areas is alarming and should be emphasized more. The authors believe the identified factors will help design interventions and policy development on this issue.

Cohort profile: Bangladesh Cook Stove Pregnancy Cohort Study (CSPCS)

PURPOSE

The Cook Stove Pregnancy Cohort Study (CSPCS) was designed to assess the effects of biomass fuel use on household air pollution (HAP) as well as the effects of HAP (fine particulate matter, PM_2.5) on birth outcomes and acute lower respiratory infection (ALRI) among infants in Bangladesh.

PARTICIPANTS

We recruited 903 women within 18 weeks of pregnancy from rural and semiurban areas of Bangladesh between November 2016 and March 2017. All women and their infants (N=831 pairs) were followed until 12 months after delivery and a subset have undergone respiratory and gut microbiota analysis.

METHODS

Questionnaires were administered to collect detailed sociodemographic, medical, nutritional and behavioural information on the mother-child dyads. Anthropometric measurements and biological samples were also collected, as well as household PM_2.5 concentrations.

FINDINGS TO DATE

Published work in this cohort showed detrimental effects of biomass fuel and health inequity on birth outcomes. Current analysis indicates high levels of household PM_2.5 being associated with cooking fuel type and infant ALRI. Lastly, we identified distinct gut and respiratory microbial communities at 6 months of age.

FUTURE PLANS

This study provides an economical yet effective framework to conduct pregnancy cohort studies determining the health effects of adverse environmental exposures in low-resource countries. Future analyses in this cohort include assessing the effect of indoor PM_2.5 levels on (1) physical growth, (2) neurodevelopment, (3) age of first incidence and frequency of ALRI in infants and (4) the development of the respiratory and gut microbiome. Additional support has allowed us to investigate the effect of in utero exposure to metals on infant neurodevelopment in the first year of life.

Shah Alam H, Saberin A, Ahmed S, Banik G, Kabir ANME, Ahmed A, Chisti MJ, Cunningham S, Dockrell DH, Nair H, Arifeen SE, Campbell H. Introducing pulse oximetry for outpatient management of childhood pneumonia: An implementation research adopting a district implementation model in selected rural facilities in Bangladesh

BACKGROUND

Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services.

METHODS

The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel.

FINDINGS

We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children.

INTERPRETATION

This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs.

FUNDING

This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research.

Success and time implications of SpO2 measurement through pulse oximetry among hospitalised children in rural Bangladesh: Variability by various device-, provider- and patient-related factors

Background

Hypoxaemia is one of the strongest predictors of mortality among children with pneumonia. It can be identified through pulse oximetry instantaneously, which is a non-invasive procedure but can be influenced by factors related to the specific measuring device, health provider and patient. Following WHO's global recommendation in 2014, Bangladesh decided to introduce pulse oximetry in paediatric outpatient services, ie, the Integrated Management of Childhood Illness (IMCI) services in 2019. A national committee updated the existing IMCI implementation package and decided to test it by assessing the pulse oximetry performance of different types of assessors in real-life inpatient settings.

Methods

We adopted an observational design and conducted a technology assessment among children admitted to a rural district hospital. Eleven nurses and seven paramedics received one-day training on pulse oximetry as assessors. Each assessor performed at least 30 pulse oximetry measurements on children with two types of handheld devices. The primary outcome of interest was obtaining a successful measurement of SpO2, defined as observing a stable (±1%) reading for at least 10 seconds. Performance time, ie, time taken to obtain a successful measurement of SpO₂ was considered the secondary outcome of interest. In addition, we used Generalized Estimating Equation to assess the effect of different factors on the pulse oximetry performance.

Results

The assessors obtained successful measurements of SpO₂ in all attempts (n = 1478) except one. The median time taken was 30 (interquartile range (IQR) = 22-42) seconds, and within 60 seconds, 92% of attempts were successful. The odds of obtaining a successful measurement within 60 seconds were 7.3 (95% confidence interval (CI) = 3.7-14.2) times higher with a Masimo device than a Lifebox device. Similarly, assessors aged >25 years were 4.8 (95% CI = 1.2, 18.6) times more likely to obtain a successful measurement within 60 seconds. The odds of obtaining a successful measurement was 2.6 (95% CI = 1.6, 4.2) times higher among children aged 12-59 months compared to 2-11 months.

Conclusions

Our study indicated that assessors could achieve the necessary skills to perform pulse oximetry successfully in real-life inpatient settings through a short training module, with some effect of device-, provider- and patient-related factors. The National IMCI Programme of Bangladesh can use these findings for finalising the national IMCI training modules and implementation package incorporating the recommendation of using pulse oximetry for childhood pneumonia assessment.

Introducing pulse oximetry in routine IMCI services in Bangladesh: A context-driven approach to influence policy and programme through stakeholder engagement

Background

Pneumonia is the leading cause of under-five child deaths globally and in Bangladesh. Hypoxaemia or low (<90%) oxygen concentration in the arterial blood is one of the strongest predictors of child mortality from pneumonia and other acute respiratory infections. Since 2014, the World Health Organization recommends using pulse oximetry devices in Integrated Management of Childhood Illness (IMCI) services (outpatient child health services), but it was not routinely used in most health facilities in Bangladesh until 2018. This paper describes the stakeholder engagement process embedded in an implementation research study to influence national policy and programmes to introduce pulse oximetry in routine IMCI services in Bangladesh.

Methods

Based on literature review and expert consultations, we developed a conceptual framework, which guided the planning and implementation of a 4-step stakeholder engagement process. Desk review, key informant interviews, consultative workshops and onsite demonstration were the key methods to involve and engage a wide range of stakeholders. In the first step, a comprehensive desk review and key informant interviews were conducted to identify stakeholder organisations and scored them based on their power and interest levels regarding IMCI implementation in Bangladesh. In the second step, two national level, two district level and five sub-district level sensitisation workshops were organised to orient all stakeholder organisations having high power or high interest regarding the importance of using pulse oximetry for pneumonia assessment and classification. In the third step, national and district level high power-high interest stakeholder organisations were involved in developing a joint action plan for introducing pulse oximetry in routine IMCI services. In the fourth step, led by a formal working group under the leadership of the Ministry of Health, we updated the national IMCI implementation package, including all guidelines, training manuals, services registers and referral forms in English and Bangla. Subsequently, we demonstrated its use in real-life settings involving various levels of (national, district and sub-district) stakeholders and worked alongside the government leaders towards carefully resuming activities despite the COVID-19 pandemic.

Results

Our engagement process contributed to the national decision to introduce pulse oximetry in routine child health services and update the national IMCI implementation package demonstrating country ownership, government leadership and multi-partner involvement, which are steppingstones towards scalability and sustainability. However, our experience clearly delineates that stakeholder engagement is a context-driven, time-consuming, resource-intensive, iterative, mercurial process that demands meticulous planning, prioritisation, inclusiveness, and adaptability. It is also influenced by the expertise, experience and positionality of the facilitating organization.

Conclusions

Our experience has demonstrated the value and potential of the approach that we adopted for stakeholder engagement. However, the approach needs to be conceptualised coupled with the allocation of adequate resources and time commitment to implement it effectively.

Unnecessary Cesarean Section Delivery Causes Risk to Both Mother and Baby: A Commentary on Pregnancy Complications and Women’s Health

In Bangladesh, 3.6 million babies are born each year. But the country is now facing a quickly rising rate of cesarean section (C-section) utilization. Here about 50% of total deliveries are institutional. Among them, two-thirds are in private care facilities, where the rate of C-sections is very high (83%). The present C-section rate is 2.5 times higher than in the previous decades. In Bangladesh, many physicians from private facilities are recommending C-section regardless of the mother’s physical condition and the position of the fetus. Therefore, mothers are more likely to choose C-section delivery who receive antenatal care from a private facility. Moreover, several socio-economic and demographic factors might be responsible for these increased C-section deliveries. Also, many private hospitals prefer C-section delivery due to their profit-making tendency. The unnecessary C-section delivery causes risk to both mother and baby Also, the high prevalence of C-section in Bangladesh is putting women’s health at risk. Therefore, the government healthcare authorities should ensure proper utilization of C-section facilities and encourage people for normal births at any health facility. Also, they can develop a national guideline for the use of C-sections and normal delivery depending on the physical condition of the mother and fetus.