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

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Ahmed Banderker is the CEO of the AfroCentric Group, owner of Medscheme, with more than 3.8 million lives under management. Its clients include the country’s major open medical schemes Bonitas, Hosmed and Fedhealth. Entities within the AfroCentric Group include Pharmacy Direct and Activo AfroCentric Technologies, AfroCentric Distribution Services, AfroCentric, Wellness, AfroCentric Primary Care and PharmacyDirect.

The World Health Organization is worried about trends that show that 29% of global births will be by C-section by 2030. But our statistics show that C-sections account for 70% of all births on our medical schemes. This makes the C-section rate among South African medical scheme members the highest rate in the world.

Since time immemorial, childbirth has been one of the most frightening yet beautiful moments in a woman’s life. At its core, childbirth is an incredible event that is, in every sense, what makes us human. Children born naturally, and without unnecessary medical intervention, are delivered into this world in the same way as so many billions who came before them. And for 99.99% of human history, natural birth was the only option.

But, for the longest of times it was also one of the most dangerous things a woman could do – history has lost count of all the women lost over the past centuries to childbirth-related ailments. Today, many think of C-sections as reducing this danger, but go back a century or two and you will find that C-sections were treated as an absolute last resort.

Historically, and even dating back to ancient Roman times, this procedure was performed to save the baby rather than the mother. In fact, it was only in 1580 that the first case of a mother surviving the surgery was actually recorded.

Yet, the dawn of the 21st century saw modern medicine advance beyond humanity’s wildest dreams. The C-section quickly became considered a low-risk procedure, afforded to almost any expectant mother, regardless of complications or lack thereof. A procedure that was designed to be used as a last resort, only when natural birth placed mother or baby at risk, might now be considered the preferred method of delivery, if I look at the statistics to which my company has access.

The question has become: Why go through the trauma of natural birth?

The World Health Organization (WHO) has found that C-sections now account for more than one in five (or 21%) of all childbirths across the globe. The WHO believes this number will continue to rise in the next decade to encompass 29% of all births by 2030. Right now, though, South Africa is worryingly ahead of this trend, to a point that is alarming.

Data from Medscheme shows that C-section deliveries more than doubled that of normal births between 2016 and 2020. With 3.9 million members, this provides an adequate sample of medically insured child-bearing South African women. While the WHO may be worried about 29% of global births becoming C-sections by 2030, our statistics show that C-sections account for 70% of all births on our medical schemes.

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

Our numbers also do not show any sustained impact of Covid-19 on births or the choice between natural/C-section. There was a marginal decrease in the number of C-sections admission in early 2021 during SA’s level 5 lockdown, but this was not maintained. Rather the reduction in admissions follows a gradual downward trend year on year for both C-sections and normal deliveries.

But what is causing such high instances of C-sections in South Africa? And, more importantly, what if anything should we do about it?

Again, I look to our data. Maternity events recorded between 2011 and 2020 show that women are progressively giving birth at older ages. The average age of a mother delivering a baby gradually increased by 1.3 years over a nine-year period.

Why this is, I can only speculate: much has been reported on the fact that women are becoming more career-driven, and want to focus on their professional life by being more competitive in the workplace. This may lead to them extending the time at which they wish to start a family. Children are also expensive to raise and today’s youth are not reaching the same financial milestones at the same time as their parents did.

We also have to factor in affordability as another contributor as more women are medically insured making C-sections more accessible than ever.

Across the world, however, researchers continue to ponder why C-sections have gained such popularity. 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.

Of course, I would never downplay the importance of a C-section. It is a procedure that has saved millions of mothers’ and babies’ lives when natural birth put them in danger. At the end of the day, however, it is undoubtedly a woman’s right to choose how she gives birth. DM

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All Comments 23

  • I would be interested in a further breakdown of these data. What proportion of c-sections are elective, what emergency, and what in the space where long labours (and what constitutes ‘long’is now shorter than two decades ago) are deemed unproductive or dangerous to the baby? Many women are actively discouraged from VBAC deliveries, which also increases our c-section rate. Women who deliver by c-section have a harder time breastfeeding. There are many reasons to look closely at how to reduce c-srction rates in the interests of maternal wellbeing.

    • “There are many reasons to look closely at how to reduce c-section rates in the interest of maternal wellbeing” – I had an emergency C-section and had no problems breastfeeding, my baby is perfect and have grown up without any issues. I think it is more more to the benefit of mothers (physically and mentally) to be able to choose what they feel comfortable with than being pushed into natural birth by people feeling going through the process is part of being a woman. I can want a child without wanting to go through the excruciating process of birth with its possible complications – my choice.

      • The experience of childbirth is highly subjective. I found my c section to be dehumanizing and invasive and I found natural childbirth though painful also exhilarating and empowering. Objectively speaking we do have a problem when our rates are much past 20%. And our surgery rate for childbirth seems to me very difficult to legitimately defend. Women should be given access to up to date information and empowered in their birth choices, even when it’s not convenient. This is what we should be seeing in our systems.

  • I find this piece rather patronising – a male businessman looking like he’s trying to understand the issue by looking at dry numbers and conjecturing that they ‘want to focus on their professional life’ . If the number of C-Section births by women covered by health insurance is such an alarming thing, why not ask those 70% why they have made that choice, rather than speculating from your ivory tower.

    • Couldn’t agree with Jennifer more. Until the writer has pushed an orange out through his private parts, he has no personal insight.

    • Agreed. As far as I understand, the only ‘problem’ with C-sections is they cost more. Many obstetricians, however, consider them safer. An interesting article would consider the pros and cons of the C-section (today, not 300 years ago) taking into account the science, as well as the thoughts and feelings of those actually involved.

      • A c section is not a safer option! Please read the WHOs guidelines on positive outcomes in pregnancy and childbirth. C section is obviously critical in saving many mothers and babies but really anything more than 20% comes with problems.

    • My father was orphaned at birth in 1926, due to C Section not then being an option.
      Loss of his mother, which also resulted in him then being abandoned by his father, very negatively influenced his life (and the lives of so many others, myself included) for decades afterwards.
      Last word? It’s HER choice anyway!

  • 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.

    • I too have had a c-section followed by two natural births. C section was honestly traumatizing and I was unable to set foot in a hospital after it. Vbacs were an entirely different experience. Just had hubby and midwife at both. Just addressing c section is not good enough nor should it be the ultimate goal. Are obstricians well versed in supporting women in labor and do their understand how physiological Labour works? For example many obs like women to be lying down when delivering but this often complicates delivery considerably. Women need to be trusted to birth and trusted to make decisions about their bodies

  • 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.

    • I had both my children with natural childbirth, in both cases luckily after about 2 hours of labour.
      It is truly a wonderful experience to feel the baby leaving your body and entering this world.

  • 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!

    • Derek makes a good point. I think the medical industry (and it is largely an industry), plays a large part here. In terms of the hospitals and doctors, C-sections are easy to plan for, easy to schedule and more expensive procedures, generally. It makes business sense. (I am not talking about C-sections that are medically necessary). Of course it is a woman’s right to choose if and when she can. But she needs to understand the risks of C-sections too if electing to go that way. But I wonder how many women actually get to exercise that freedom of choice when there are no clear medical reasons for a C-section.

  • 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%.