In September this year, Dr Ahmed Banderker, the CEO of AfroCentric Group and owner of MedScheme, wrote a piece in Daily Maverick expressing concern that the rate of Caesarean section (CS) deliveries among medical scheme members in South Africa was the highest in the world.

The article pointed to a recent Council for Medical Schemes report which showed that the rate of CS deliveries in the private sector more than doubled that of vaginal deliveries between 2016 and 2020 (what are called “normal vaginal deliveries” or NVDs in medical terms) — in fact, by 2018 the rate of c-sections in private hospitals was 76.8% compared to around 26.2% in public hospitals. 

In order to respond to the article by Dr Banderker, there are two questions that must be answered. One, is there anything abnormal or concerning about South Africa’s rising CS rates? Two, is there something happening in the private sector that is encouraging women (either subtly or directly) to undertake possibly medically unnecessary CS?

These questions will be answered in two pieces. This is Part One. Find Part Two, here.

Is there something abnormal or concerning about South Africa’s increasingly high CS rates?

Dr Banderker is not the first to hint that there is something worrying about South Africa’s high CS rates. In 2014, The Guardian reported on the rising rates in SA and how common elective c-sections were becoming. Bhekisisa also reported on SA’s skyrocketing rates in 2019.

CS rates vary all over the world with the lowest rates in sub-Saharan Africa (5%) and the highest rates in Latin America and the Caribbean (42.8%). South Africa’s public sector rate (26.2%) fits somewhere in the middle of these two ranges. Every province in the country had a public sector CS rate over 18% according to South Africa’s last Saving Mothers report (2017) with KwaZulu-Natal having the highest rate (30.5%) and Western Cape (29.2%), Eastern Cape (27.6%) and Gauteng (27.1%) all having rates above the national average at that time (25.7%). Yet, the rates in the private sector have always surpassed these, often by many percentage points. In fact, South Africa’s private sector rate is higher than the country with the highest overall rates (Dominican Republic with 58.1%).

In addition, in South Africa the rates of CS vary by mother’s education and wealth, with four in ten women (40%) with more than a secondary education delivering by CS compared to fewer than two in ten (15.2%) women with no education. Women in the highest wealth quintile were more than twice as likely as women in the poorest wealth quintile to deliver by CS (39.1% vs 17.2%).

But, it is not only South Africa’s rates that have generated concern. Globally the rates of CS are increasing in all regions and have been for the past two decades. Projections suggest that by 2030, 28.5% of women worldwide will give birth via CS. 

Research in The Lancet, in 2015 explains that rising rates are partly linked to the increasing delivery of babies in medical facilities (i.e. more mums who need a CS to deliver safely may now have access to this procedure) and partly linked to the increasing use of CS within facilities themselves. 

Other causes suggested in research are health systems and healthcare providers that promote CS, trends in the media, and societal trends. In Daily Maverick, Dr Banderker speculates that in the private sector in SA these rates could be linked to the increasing age of mothers, the affordability of C-sections when you’re covered by medical aid, fears of natural childbirth, and the desire of expectant mothers to control their delivery date.

Thus, South Africa’s rise in rates of CS is not anomalous, but are high rates of CS something to be worried about in themselves? 

International organisations say yes. According to the International Federation of  Gynaecology and Obstetrics (Figo) “the large variation in CS rates indicates that these rates have virtually nothing to do with evidence-based medicine.” The World Health Organization (WHO) and Figo have both suggested that the rising rates point to increasing numbers of medically unnecessary CS being conducted. The American College of Obstetrics and Gynaecologists suggest that the rapid increase in Caesarean birth rates “without clear evidence of similar decreases in maternal or neonatal morbidity or mortality raises significant concern that Caesarean delivery is overused”.

But how is overuse determined? A statistic that is often repeated in articles about CS is from the 1985 statement by the WHO that “there is no justification for any region to have CS rates higher than 10-15%.” That figure was based on estimates that tried to assess whether having increasing access to CS led to decreasing maternal and infant mortality and morbidity but it was largely based on European countries and has come under criticism many times since then. It is also true that some rate of CS will always be necessary because some births require a CS to avoid loss of life or to prevent injury.

Yet ranges in the rate do matter. WHO research estimated that the minimum threshold for a population would be a CS rate between 5% and 10% in order to ensure that those who need CS get it. As for the maximum rates, the research showed that there were no reductions in mortality or morbidity in mothers or newborns when the CS rate was more than 15%. Thus, the WHO concluded that “until further research gives new evidence, rates of more than 15% may result in more harm than good.” In 2015, the WHO released a statement saying that “every effort should be made to provide Caesarean sections to women in need, rather than striving to achieve a specific rate.”

CS can save lives, but it is not without risks

So, countries and areas with rates below 10% are seen as still needing more access to CS to prevent loss of life and injury, and those with a rate above 15% could be overusing CS as a medical practice. With those ranges in mind, South Africa would fall into the overuse category. But, Dr Manala Makua, Chief Director of Women’s, Maternal, and Reproductive Health in the National Department of Health (NDoH), argues that “CS rates should always be interpreted with morbidity and mortality rates. CS is classified as a life-saving intervention; thus, the rates can fluctuate depending on the risk profile of the people that fall pregnant. The higher the risk factors, the higher the CS rate.”

The evidence does show that a CS can be a life-saving intervention when medically indicated and the ideal scenario would be one where all women who need to deliver by CS can do so. As Dr Makua points out, risk factors in pregnancy are common in South Africa where many women present late for their first antenatal visit and where 14.4% of women are using prescribed medicine for chronic hypertension. Hypertension (high blood pressure) is commonly linked to maternal mortality in South Africa and was in fact the leading underlying cause of maternal death in 2015 and 2016.

Globally, the rates of Caesarean sections are increasing in all regions and have been for the past two decades. Projections suggest that by 2030, 28.5% of women worldwide will give birth via CS. (Photo: bhekisisa.org / Wikipedia)

For Dr Haynes van der Merwe, President of the South African Society of Obstetricians and Gynaecologists (Sasog), “it is important to be reminded that the perfect outcome of any pregnancy is the uncomplicated delivery of a healthy infant to a healthy mother. But unfortunately, we do not live in a perfect world. There are often foetal and/or maternal indications for CS in which case it would not be safe to allow for a vaginal delivery.”

Common situations where CS is deemed the safest option for delivery include when babies are lying in positions that may make labour dangerous (breech or transversal presentations), where there is foetal distress during labour, when there are problems with the placenta (such as a low-lying placenta or a placenta that has come away from the uterine wall), and in patients with previously scarred uteruses from a prior CS or who have very high blood pressure. The Department of Health Guidelines for Maternity Care (2016) indicate that CS may be necessary in cases of poor progress in the active phase or a prolonged second stage of labour.

“Not even all low-risk, uncomplicated pregnancies will end in an uneventful vaginal delivery. Unforeseen intrapartum events might necessitate an emergency CS. Unfortunately, it is impossible to predict these events. It is therefore important to have a thorough discussion with all women around the likelihood that she might not have an uneventful vaginal delivery. Sasog encourages our members to discuss this with their patients and to consent them for vaginal delivery in the same way women are consented for CS” explains Dr Van der Merwe. “Unfortunately, the decision about the appropriateness of CS during labour is often very difficult and not necessarily black or white. Interpretation of all the information at play in a specific situation cannot be captured in a simple and finite list of indications.”

But this interpretation of when a CS is and isn’t medically necessary is not set in stone and according to the National Department of Health Monograph on Safe CS, variations in the rates of CS across facilities and provinces are “likely due to differences in thresholds for interventions at institutional and practitioner level”. 

This means that different hospitals and obstetricians would look at the same pregnancy or woman in labour and may have different recommendations on whether a CS is necessary or not. Not a comforting thought for the expectant mother who is being told she needs a CS prior to or during labour.

Along with the evidence of the need for CS in certain cases, there is also evidence that while a CS is potentially lifesaving, it is not without its own risks and both short- and long-term health consequences for mother and baby. In South Africa, CS has been associated with a higher rate of maternal deaths than vaginal delivery. Between 2011 and 2013, the risk of a woman dying as a result of CS was almost three times that of vaginal delivery. This trend remained the case between 2014 and 2016. Thus, Dr Van der Merwe explains that “in certain cases, CS is definitely safer than vaginal delivery, but it would not be generally considered as safer than vaginal delivery.”

According to 2018 research “almost every woman who has a CS increases her risk of certain morbidities in subsequent pregnancies.” For mothers, the prevalence of maternal mortality and morbidity is higher after a CS than a vaginal birth, and CS is associated with increased risks of uterine rupture, abnormal placentation, increased risks of hysterectomy, a higher frequency of bleeding and the need for blood transfusions, and adverse outcomes for women in subsequent pregnancies (ectopic pregnancy, stillbirth, and preterm birth) among others. It also makes attempts at a vaginal delivery in the next birth more dangerous. 

Emerging evidence suggests that babies born by CS can have altered immune development, increased likelihood of allergies and asthma, and reduced intestinal gut microbiome diversity, and increased risks of late childhood obesity — challenges that can persist into later life.

Given these risks, healthcare providers choosing to propose a CS to their patients should be doing so based on an evaluation of the current and future medical risks. They should also be advising their patients of these risks so that they can make evidence-based medically informed decisions. 

To avoid doubt and unnecessary CS, the WHO recommends the implementation of evidence-based clinical practice guidelines, CS audits, and timely feedback to healthcare professionals. The organisation also recommends that there be a requirement for a second medical opinion for a CS decision in settings where this is possible. For many mothers in South Africa, this would be impractical and unaffordable.

Elective vs emergency — an important distinction

This leads us to another important point — the nature of the CS itself — that is, whether it was performed for medically necessary reasons (either planned before the onset of labour due to pregnancy complications that would make it the safest mode of delivery for mother or baby, or intrapartum as an emergency procedure when an attempt at a vaginal delivery has not been successful) or whether it is performed as a non-medically indicated procedure at the mother or obstetrician’s request.

South Africa’s NDOH 2013 Monograph on Safe CS indicates that “healthcare professionals have the responsibility to inform patients that available evidence suggests that normal vaginal delivery for uncomplicated pregnancies is safer in the short and long term for both mother and baby and that surgery on the uterus has implications for later pregnancies and deliveries. As hard evidence for a net benefit does not exist at present, performing elective CS in uncomplicated pregnancies for non-medical reasons is ethically not justified.”

Similarly, the 2020 Sasog guidelines on mode of delivery based on patient preference suggest that obstetricians and gynaecologists should “never offer elective Caesarean section during discussions related to birthing plans for patients where no medical indication for a Caesarean section exists.” 

In order to assess which CSs were medically necessary and which were not, we would need data on all pregnancies and births in the country, classified by whether the CS occurred as a medical necessity or at elective request. Unfortunately, that level of data is not available at a national level.

South Africa’s last Demographic and Health Survey reveals that 15.9% of all CS deliveries were planned before the onset of labour pains, though it doesn’t allow us to see whether these were medically necessary planned procedures or scheduled CS at mothers’ or doctors’ request. However, given the high rates of hypertension, diabetes, and HIV in the general population, recent research suggests that the public sector CS rate “may be appropriate even though higher than the 10-15% [WHO range] if morbidity is considered.”

Yet, that same research shows that in the private sector, 73.6% of births in 2015 were by CS (with a breakdown of 29.1% elective CS, 29.2% emergency CS, and a further 20.7% unknown/unspecified) despite the fact 95.8% of mothers were classified as healthy — i.e. did not have hypertension, diabetes, or HIV. So, there is room to speculate that at least some of the CSs that are being administered to women in the private sector are occurring without medical justification.

So, it is to the private sector we turn in Part Two of this piece. DM/MC