Facility type, Cesarean section delivery, and distress financing for delivery: Evidence from the demographic and health surveys in Bangladesh

Background Bangladesh has accomplished remarkable progress in maternal health and institutional delivery. However, Cesarean section (CS) deliveries have increased substantially, resulting in high out-of-pocket (OOP) costs. This raises concerns about ‘distress financing’, defined as borrowing to cover costs or selling assets to do so. This study examines the association between delivery facility type, cesarean delivery, and distress financing for childbirth in Bangladesh. Method The study used three rounds of the Bangladesh Demographic and Health Survey (2014, 2017/2018, and 2022), focusing on Bangladeshi women aged 15–49 delivering in healthcare facilities. Descriptive analysis assessed trends across the surveys, while logistic regression analyzed the association between facility choice, cesarean births, and distress financing. Result Between 2014 and 2022, the proportion of cesarean deliveries increased from 58.5% to 69.4%, while distress financing rose from 10.8% to 21.3%. In 2022, private hospitals accounted for 70.0% of facility deliveries and nearly 85% of all cesarean births. Cesarean delivery was strongly associated with distress financing (OR = 4.15; 95% CI: 2.68–6.42). Compared to public hospitals, deliveries in private hospitals had significantly higher odds of cesarean birth (OR = 6.07; 95% CI: 4.98–7.40). Distress financing was lowest among the wealthiest households (OR = 0.25; 95% CI: 0.19–0.33), indicating substantial socioeconomic inequality. Conclusion The rapid rise in cesarean deliveries, particularly in private facilities, poses a substantial financial burden during childbirth. Strengthening regulation and monitoring, reducing unnecessary cesarean deliveries, and expanding financial risk protection are critical to ensuring equitable maternal healthcare in Bangladesh.