Causal effect of private facility delivery on caesarean section in Bangladesh: an application of overlap weighting for estimation of the average treatment effect in the overlap population
Using overlap weighting on 2025 Bangladesh survey data to address covariate imbalance, this study finds that among women for whom either sector is a realistic option, delivery in a private for-profit facility substantially increases the probability of caesarean section compared to public or non-governmental facilities, suggesting that financial incentives rather than clinical need may drive the country's high C-section rates.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In Bangladesh, as in many parts of the world, the birth of a child is increasingly taking place inside a hospital or clinic rather than at home. This shift is generally seen as a positive step toward safer motherhood, yet it has brought a complex and growing problem: a sharp rise in the number of babies born via Caesarean section. While this surgical procedure is a vital, life-saving intervention when a mother or baby faces a genuine medical emergency, its use has surged far beyond what clinical necessity alone would dictate. In Bangladesh, nearly half of all births now occur through surgery, a rate among the highest in the world. This trend is not evenly spread; it is heavily concentrated in the private, for-profit health sector. The central question for doctors, policymakers, and families is whether this high rate reflects a population that is sicker and needs more surgery, or if the choice of a private facility itself drives the decision to operate. To answer this, researchers must untangle the web of factors that determine where a woman gives birth. Wealth, education, and where a woman lives in the country are so powerful that they almost entirely predict whether she will go to a private clinic or a public hospital. This creates a statistical hurdle: for the wealthiest women in the cities, there are almost no comparable women in the public system to compare them against, making it difficult to know what would have happened if they had chosen differently.
A team of researchers from the University of Dhaka set out to solve this puzzle using data from the 2025 Bangladesh Multiple Indicator Cluster Survey, a massive national study that captures the lives of thousands of families. They focused on the most recent births that occurred in health facilities over the two years prior to the survey, narrowing their view to 6,645 women. Their goal was to isolate the specific effect of delivering in a private facility on the likelihood of a Caesarean section, while carefully accounting for the fact that women who choose private care are often wealthier, more educated, and live in cities. The researchers employed a sophisticated statistical approach called overlap weighting. Imagine trying to compare two groups of people who are very different; standard methods often struggle when one group has members who are so unique that no one in the other group resembles them. Overlap weighting solves this by focusing the comparison only on the women who sit in the middle—those whose backgrounds make it plausible that they could have delivered in either a private or a public facility. By giving the most attention to these women at the "margin" of choice, the researchers could estimate the causal effect of the facility type without relying on guesses about women who have no realistic alternative.
The results revealed a stark reality. Among women who genuinely had a choice between sectors, delivering in a private facility increased the probability of a Caesarean section by 47 percentage points. In concrete terms, if a woman with a typical profile delivered in a public or non-governmental facility, the chance of a surgical birth was about 37 percent. That same woman, delivering in a private facility, faced an 83 percent chance of a Caesarean section. This translates to a risk ratio of 2.27, meaning the likelihood of surgery was more than double in the private sector. The study found that this effect was even stronger for women in rural areas and for those from poorer households, suggesting that the pressure to perform surgery is most intense where the public system is the default and the private option is a significant departure. The effect did not vary based on whether the woman was having her first baby or a subsequent one, which is notable because previous Caesarean sections are a major clinical reason for repeat surgeries.
The researchers were careful to consider whether this massive difference was simply because women with high-risk pregnancies were flocking to private clinics. They acknowledged that they could not directly measure every medical complication because the survey did not ask detailed questions about pregnancy risks for most participants. However, they calculated how strong an unmeasured medical factor would need to be to explain away their findings. They determined that for a hidden medical risk to account for the results, it would have to make a woman nearly four times more likely to choose a private facility and four times more likely to need a Caesarean section simultaneously. Given the structure of the Bangladeshi health system, where the most serious emergencies are typically referred to public tertiary hospitals that do not charge for surgery, such a strong pattern of high-risk women self-selecting into private clinics is highly implausible. This suggests that the difference is not just about who is getting sick, but about how the two sectors operate.
The study concludes that for women who are at the point of decision between a public and a private facility, the private sector substantially increases the use of Caesarean sections beyond what clinical need alone would predict. The findings point toward financial incentives and supply-side pressures within the private, for-profit sector as likely drivers of this overuse. Because the analysis focused specifically on women for whom both options are realistic, the results speak directly to the population that health regulators and policymakers can actually reach. The data suggests that the fee-for-service nature of private obstetric care in Bangladesh may be encouraging surgeries that are not strictly necessary, raising urgent questions about how to align medical practice with clinical need rather than financial gain.
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