Alarming rise in C-section births
More women than ever are opting to give birth via Caesarean section, but it’s an unequal world where the poor often suffer
IT USED to be the last resort, an operation doctors would perform only when natural birth posed a threat to mother or baby. Then the rich and famous started opting for it – women dubbed the too-posh-to-push brigade who preferred a relatively quick operation over hours of labour. But these days more and more Caesarean sections are being performed the world over – a rise laid bare in a series of three reports published in the respected medical journal The Lancet and revealed at the recent world congress of the International Federation of Gynaecology and Obstetrics (Figo) in Brazil.
The authors reported 21% of babies worldwide are delivered via C-section, a figure that’s tripled since 1990, and 60% of countries overuse the procedure.
In Brazil, 80-90% of births in private clinics are C-section deliveries, and figures for South Africa are thought to be not far behind.
“The Caesarean section rate for the private sector is estimated to be between 60 and 70%,” says Dr Liesl de Waard, specialist and senior lecturer at the department of obstetrics and gynaecology at Stellenbosch University.
And it’s on the rise in the public sector too: the global C-section rate was about 26% in 2016, compared with 23,1% between 2011 and 2013.
So why is this form of delivery growing ever more popular – and what are the implications for mom and baby?
We asked the experts.
Why moms want them
For many women a C-section often boils down to a lifestyle choice.
“Many mothers work and have important jobs. It wasn’t always like that in the old days,” says Professor Priya Soma-Pillay, honorary secretary of the South African Society of Obstetricians and Gynaecologists and head of the University of Pretoria’s maternal and fetal unit.
More mothers prefer the birth of their baby to be planned so they can manage their lives better, she adds.
In the private sector, mothers can request a C-section, an option not available in public health facilities.
Other common reasons women request C-sections include past negative experiences of vaginal birth, fear of labour pain or of the effects of labour such as pelvic floor damage, urinary incontinence and reduced quality of sexual functioning.
They suit doctors too
Safety and security are contributing factors to the rise of C-sections in some South African cities, Soma-Pillay says.
Doctors put themselves at risk of crime if they have to travel in the dead of night to get to a delivery. “I’ve been a victim of a smash and grab and I’m aware of several female gynaecologists who have also been victims of crime,” Soma-Pillay says.
Safety of another kind is a factor. As society grows more litigious, doctors are going to great lengths to protect themselves from being sued, which leads to a more defensive approach to medicine.
“There’s a general feeling that doctors get sued for acts of omission rather than commission,” says Dr Chris Archer, CEO of the SA Private Practitioners Forum.
For obstetricians who specialise in childbirth, defensive medicine means sometimes performing C-sections even when they aren’t necessary, he adds. Gynaecologists in private practice can pay up to R1 million a year for malpractice insurance.
When a C-section is unavoidable
In certain situations Caesareans can be life-saving, De Waard says.
“C-sections are performed on patients
C-sections are overused in some parts of the world – yet unavailable to many women at risk
who have already had two or more Csections, in instances of placenta previa [where the placenta covers the opening in the cervix], when the baby is lying breech, and more often than not in the case of twins or other multiple pregnancies.”
Soma-Pillay says an elective C-section might also be advisable if the mother has a complicated pregnancy for a example because of cardiac disease.
There are several reasons for emergency C-sections, De Waard says. These include when the baby is in distress and when the umbilical cord prolapses. SomaPillay says the increase in diseases such as hypertension and diabetes can also necessitate C-sections as pregnancy is known to complicate these conditions.
The downside
Soma-Pillay believes strongly that patients need to be informed of the dangers of C-sections. They have an increased rate of morbidity and mortality for the mother and also place future pregnancies at increased risk
De Waard agrees, saying there’s evidence that the chance of death after a C-section is two to three times higher than with a natural birth.
“The main risks are for the mother and include bleeding, infection and sepsis, and injuries to the bladder, bowel or other organs,” she explains.
The risk of complications in future pregnancies is also higher after a Caesarean, De Waard adds, as the uterus could be weakened from the C-section cut.
For the baby, a vaginal delivery is undoubtedly preferable. Immediate bonding is more likely as the mother won’t be in pain from the C-section cut and breastfeeding is likely to be more successful for the same reason.
Then there’s the health immunity issue. “Babies born by elective Caesarean have increased long-term risks of developing certain conditions such as asthma,” Soma-Pillay explains.
Babies born naturally pass through the vaginal canal, which exposes them to microbes that boost immunity. As C-section babies miss out on this vital stage on the way to life on the outside, their immune system could be compromised.
Not passing through the birth canal can also affect children’s metabolism, making them more than 50% more likely to be obese.
Earlier this year researchers at the University of Edinburgh released the findings of the biggest analysis ever done on the effects of C-sections.
Reviewing data from 80 studies and trials that looked at 29 million births, they concluded the risk of obesity for children under five jumped by 59% if they’d been delivered by Caesarean.
“Scientists said there was growing evidence that C-sections influence the development of the immune system and gut bacteria,” The Telegraph reported.
The cost factor
Caesareans are more expensive than natural births because more medical experts – including an anaesthetist – are needed and the level of medical skill required is greater. Time in the operating theatre also costs money.
“The stay in hospital is generally longer too, plus you need to take more medication,” Soma-Pillay adds.
“In some countries doctors get paid more for doing a C-section than a vaginal delivery because it involves more hours and time, but in SA the remuneration for doctors is roughly the same.”
If you have a C-section you’ll pay around R26 000 in a private hospital compared with R20 000 for a natural delivery. This doesn’t include extra specialist fees, such as for the anaesthetist, which can add R10 000 to your bill.
Women should check with their medical aid what it will cover if they choose an elective C-section, the experts say.
Meanwhile, the poor continue to suffer
C-sections may be overused in many parts of the world but there are hundreds of thousands of women who have no choice at all – it’s vaginal delivery or nothing. And the consequences can be disastrous, Soma-Pillay says.
Catastrophic conditions such as fistulas – where a hole develops in the vagina between the bladder or rectum and urinary or faecal matter might leak through – can develop in complicated births with no access to C-sections.
“In South Africa not all women labour in facilities with a Caesarean service so they have to be transferred to other hospitals and this can sometimes take several hours,” Soma-Pillay says.
According to the World Health Organisation, 830 women die each day of conditions related to pregnancy and childbirth – and 99% of maternal deaths occur in developing countries.