SA’S skyrocketing C-section rates?
to deliver babies naturally for fear of litigation, Pillay explains.
In 2017, Health Minister Aaron Motsoaledi told Bhekisisa that claims against the health department since 2011 totalled more than R50-billion — or a third of the whole public healthcare budget at the time. Obstetricians and gynaecologists are particularly vulnerable to allegations of botched births, leading to a ninefold increase in premiums to insure their practices against litigation in the past decade, he said.
“Obstetricians and gynaecologists are the prime targets,” he said.
“Why is this so? They work in areas where adverse events or complications are more likely to happen.”
Just how many babies should be born via C-sections has been debated for decades. The WHO has historically said “there [was] no justification for any region to have caesarean section rates higher than 10-15%”, based on a 1985 WHO expert meeting. A 2014 review published in the journal Birth reviewed data from 19 countries, mostly in Europe and North America, and found that, although C-section rates had risen markedly in each over three decades, increases above 10% had no effect on maternal mortality when factors such as increases in quality of life and economy were factored in.
But there is no universally accepted benchmark for just how many C-sections should happen in countries, the Health Systems Trust says. This is why the research organisation no longer includes it in their District Health Barometer.
“While the caesarean section rate is important in various contexts as an indicator, with no absolute target value, it isn’t necessarily a good option for summarising district health system performance,” the organisation says.
Ultimately, it may be less about benchmarks and more about ensuring women can have a C-section when they need it.
“There is no ideal C-section rate,” Pillay says. “The idea is to ensure that all those women who require a C-section have access to one.”
But that doesn’t mean that the health department isn’t worried about the increase in procedures, which aren’t without expense or risk. C-sections can cost up to almost 60% more in the public sector than a natural birth, according to a presentation by Matan Abraham of Insight Actuaries and Consultants to the Actuarial Society of South Africa in October 2017.
The country’s latest report on maternal deaths also found a sharp increase in deaths from injuries incurred during C-sections between 2014 and 2016. Researchers argue this may indicate, in part, a growing trend as doctors contend with a greater number of difficult repeat caesarean sections. More than half of women who die of obstetric haemorrhage had caesarean deliveries, the report found.
“The mortality rate of women having caesarean sections was three times higher than those having nor- mal deliveries,” the report warns.
Other risk factors for mothers going under the knife included risks associated with poor staffing at hospitals, particularly for anaesthesia.
“It is absolutely unacceptable and unethical that spinal anaesthesia is being administered to mothers by doctors who are unable to deal with the complications … and who are also unable to … administer safe general anaesthesia,” authors argue.
“Equally untenable and unethical is the ‘single operator’ for a caesarean delivery, where one doctor administers the anaesthetic and performs the caesarean section.”
In contrast, mothers undergoing the procedure in the private sector are attended to by teams of healthcare workers, including nurses, obstetricians and anaesthetists.
In recent years, the national health department has introduced its safe caesarean delivery programme in a bid to make C-sections safer. The project is supposed to include the development of criteria that would accredit facilities to provide safe C-sections by, for instance, ensuring that they have enough doctors with the surgical and anaesthetic skills to perform the procedures. But the programme and these standards have yet to be implemented, the latest national maternal death audit revealed in January.
“The mortality rate of women having caesarean sections was three times higher than those having normal deliveries”
Researchers warned that some public facilities would be unable to meet criteria and this was likely to result in some services closing — which could mean that some women would have to travel farther to access caesareans.