A changing birth: What's behind SA's skyrocketing C-section rates?

A mother delivers via C-section in Mozambique. In South Africa, there’s no single reason for the climbing number of such procedures in the public sector but it could be proving deadly for mothers. (Shaun Swingler)

For decades, Caesarean sections were a last resort for mothers and babies in distress. If you had access to this kind of procedure, you could count yourself among the world’s lucky.

At the dawn of the 21st century, rates of the procedure in almost all African regions save for the continent’s north dragged along at less than 5%, recently published research in The Lancetshows. Meanwhile, the continent was home to more than half of the 13 countries responsible for the majority of the world’s maternal deaths, World Health Organisation (WHO) data from the year 2000 shows.

At the same time, C-section rates in much of Asia and Eastern Europe hovered around 7%.

Almost 30-million babies will come into the world this year by Caesarean if 2015 figures are anything to go by — nearly double the number of infants delivered in this way almost two decades before, a recent article published in The Lancet shows. The journal recently dedicated an entire series of articles that examined why C-section rates around the world are skyrocketing.

SA hasn't escaped the surge

About 26% of babies born in South African public hospitals are born by Caesarean, the latest available figures from the 2015/2016 District Health Barometer report show.

The annual publication charts health data from each of the country’s 52 health districts. In our district hospitals alone the rate is 24%. In 2001, about 13% of deliveries in district hospitals resulted in C-sections, earlier versions of the publication reveal.

But what’s driving this increase? When researchers behind The Lancet study looked at the numbers globally, they told a story of richer and poorer — as well as of progress and peril.

Determining factors

Globally, who gets a C-section is now often determined by factors such as income and education rather than by sheer emergency. When scientists looked at data from 169 countries, Caesareans were almost five times more frequent among the wealthiest people in low- and middle-income countries. Educated women in countries such as Brazil and China also often elected to have the procedure even when their deliveries were low-risk, The Lancet study found.

In contrast, many women in low-income and even in some middle-income countries, especially in sub-Saharan Africa, still don’t have access to the procedure — putting them at a higher risk of maternal death.

Almost twice as many procedures were performed in the private sector as in public health facilities, The Lancet study found.
In South Africa, about six out of 10 mothers in the private sector delivered by C-section in 2017, the Council for Medical Schemes’ annual report reveals.
Linda van Wyk* knew she wanted a Caesarean section from the moment she realised she was pregnant.

“I didn’t get maternity leave so I had to maintain myself and plan carefully for the four months I was taking off work,” she says.

“I told my doctor that a C-section would allow me to meticulously schedule my daughter’s birth and work until the last moment, and she never told me that I couldn’t.”

In the public sector, there’s no single answer to why C-section rates are climbing, the national health department’s deputy director general for communicable and noncommunicable diseases, Yogan Pillay, says.

Instead, reasons lie in everything from better access to services to declining use of other methods for dealing with difficult births.

For instance, the percentage of women who delivered at health facilities and not at home rose by 26 percentage points between 2001 and 2009, a 2010 Statistics South Africa report shows.
Increased access to medical services hasn’t just raised the overall rate of C-sections in the public sector, it has also created “hot spots”.

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