C-section rate among South African medical scheme members the highest in the world

Why is a Man writing this? Camilla McDowell, Cape Town

I have been through a Natural Birth, an Emergency Caesearean and Elective Caesearen - I certainly would not say that natural childbirth was one of the ‘most beautiful moments’ in my life? How would this man know, having never been through it? And how patronising! On my 2nd attempt at natural childbirth I ended up having an Emergency Caesar. What a difference! No bladder damage to be fixed, no perineal tearing, no squashed baby head from forceps etc etc… the last time it was elective Caesar for me, all the way! No brainer… Camilla McDowell, Cape Town.

Ironically, the first recorded successful C section was performed in Wynberg in 1827? Dr Barry safely delivered Willimena Munnik's son. Arguably a more important development than the heart transplant? No wonder South African women prefer it.

"Some say it is the perceived rise in health problems associated with natural birth and even a fear of natural childbirth, while others say expectant mothers increasingly want more control over their delivery dates." In my experience, there are far more women bullied into having c-sections (I am one of them), than women freely choosing to have one because of fear of pain or wanting to choose dates. My experience is of course anecdotal but I have come across over a dozen women (friends, family and friends of friends - me included - all covered by medical aid) who ALL wanted to have natural delivery but were convinced by the gynaecologist (usually at the woman's most vulnerable time while she labouring) to have an elective c-section, or emergency one because baby is at some form of risk. Reasons included baby is too big, baby is not in the right position, fetal distress during labour, and so on. Many of these reasons do not necessarily support the choice of a c-section, as many issues (like baby position) solve naturally during labour. On the contrary, all - and I mean ALL - of the friends and family who give birth in Europe had natural births. Does no European baby ever go into fetal distress during labour? Don't get me wrong. I am in no way against c-sections, but I am criticising the systematic bullying of women by the medical system to undergo a serious operation that they do not need, and to birth their children in a theatre surrounded by machines and doctors' chit-chats.

There is actually so much to explore here. The woeful situation that women find themselves in when giving birth in South Africa is perverse. Women worldwide are giving birth at older ages and we see countries like the UK and Europe able to sustain reasonable rates of c-section despite this. Even our public sector which is immensely under resourced is able to achieve better rates (though they too are rising). There is a misconception that a c-section is a safer option and obstetricians don't do much to dispel this. Actually many obs are reluctant to perform any more than three c- sections on the same woman but very few will let you know that they are effectively limiting your potential pregnancies when they perform the first. The tragic reality is that this is all a non issue as it's a womens issue. The same goes for obstetric violence. Obstetricians across public and private will not offer most of the women they serve with evidence based care. In Cape Town obstetricians have effectively muscled out independent midwives by refusing to offer them medical backup. Midwife led birth is the gold standard of care worldwide and yet moms paying for medical aid in cape Town must take their chances with obstetricians who's c section rates are 70% and higher. I had a vbac with my second baby and my obstetrician refused a procudure for induction that is proven to be both safe and effective. She is one of the few who will support a mom looking for a vaginal birth after a c section. What I would like to know is who exactly are South African obstetricians accountable to? To me it seems there is some sort of case to be made for collision between medical schemes and obstetricians. Council for medical schemes should demand reasons for "emergency" c sections. Historically women are misled into surgery by being told they are overdue; they have low amniotic fluid and that their baby is too big (or hips too narrow). Research tells us very few of these cases should result in surgery.

Have you thought perhaps that the Medical Schemes are the problem? When our second child was born at home with a midwife, the medical aid was only willing to pay the midwife the amount that a visiting post-natal nurse would receive for post-birth care visit but they were willing to pay gynecologist specialist his (and it was his not her) full fee. So naturally one doesn't want to be out of pocket and if we had had a third child we would have used a medical specialist for the birth. They, of course are so busy that C-section is the only way to fit in all their work. This occurred in the 1980s and I hope Medical Schemes have improved over midwife services since then. That daughter now has had a child of her own and had a real hard time finding a gynecologist willing to allow natural birth. So maybe this comment is full of old news and generalizations!

I'm not sure if age really is really relevant. I had my 2 children in my late 30's in a state hospital as I had no medical aid and delivered by a midwife. I had short labour and quick natural delivery - no stitches required. I know younger women who had hours of labour and difficult deliveries.

A surgical delivery should not be something a woman has a right to choose. It is a procedure with attendant morbidity and mortality which must be weighed up relative to the likely morbidity and mortality of a normal delivery in the particular case. The doctor needs to weigh up the relative risks and give the mother advice as to the safest decision. A mother is not qualified to do this - her criteria are about fear of labour pain and of inconvenience, not of relative risk, of which she knows nothing.

I would say that Mr Banderker has made an honest attempt at highlighting the figures and raising the question/s of why these rates in SA are so high. SA's private healthcare system is incredibly complex, often with misaligned incentives between stakeholders and information asymmetry between users and providers of care. These were well outlined in the Competition Commission's 6-year long Health Market Inquiry into the private health sector. Global efforts at implementing what is commonly called value-based healthcare systems are showing promising signs of improving outcomes and aligning interests. These systems work on measuring and modelling outcomes and then publicising the relevant data to allow users/patients to make choices on who they want as their service providers. This dramatically improves user/patient choice and aligns providers towards meeting the needs, wants and choices of patients.

"At the end of the day, however, it is undoubtedly a woman’s right to choose how she gives birth." If only it really WAS a woman’s right to choose. Real choices for women are being eroded daily, and in Cape Town if you are on medical aid you can't elect to have midwife-led birth in a private hospital - despite midwife-led care being the gold standard in most European countries. If you want a midwife-led birth you have to have a homebirth (and that comes with all sorts of hoops regarding what the Med aid will/won't cover) or if you wish to give birth in a private hospital it has to be under the care of a Obs/gynie (and that comes with an increased likelihood of becoming part of the 70% - for a multitude of reasons). Which means there IS no real choice at all. Women wanting an elective C section are served well by the current set up, but women wanting a natural birth are far more likely to get it by opting for a homebirth, or throwing themselves on the mercy of the state. But that raises it's own moral issues if you can afford medical aid. This article was written by the OWNER of Medscheme and is a simplistic view of a deeply complex issue, as you can see from some of the comments below. You should be talking to private midwives, doula's, and gynaes themselves to see what's driving these statistics, and how our medical aids and insurance companies are complicit in creating a scenario in which birth is treating like an illness that requires surgical intervention in 70%.