Are Rocketing Numbers of C-Sections in South Africa Contributing to Maternal Deaths?

South Africa has a worrying maternal death rate, with an average of 119 deaths per 100,000 live births.

While the death rate has declined in recent years, it has slowed at a rate way below targets set by the South African Medical Association.

Since 2000, there has been a surge in the numbers of C-sections in South Africa, across both the private and public sectors.

Are these rocketing numbers of C-sections contributing to maternal deaths in South Africa?

High number of Caesarean sections in South African hospitals

The World Health Organization suggests that a normal, or healthy, rate of C-sections is around 15% of births.

In South African public hospitals, about 26% of babies are born via Caesarean section. In some hospitals, the rate is even higher.

In certain private hospitals, the C-section rate is 90% or even higher. According to Discovery medical aid, 74% of babies delivered to its members are now born via C-section.

Compared to international figures in both developing and developed countries, these C-section figures are unnaturally high.

Consider a comparison. In Los Angeles, at the famed Cedars-Sinai hospital where celebrities like Kim Kardashian and Victoria Beckham gave birth, the rate of C-sections in 2018 was 24.3%.

Risks of C-sections in South Africa

For decades, C-sections were a last resort for mothers and babies in distress. Often, they were – and are – life-saving surgeries.

Now, women often elect to have a C-section or are given one without choice, despite inherent risks.

According to Professor Lut Geerts of the Department of Obstetrics and Gynaecology at Stellenbosch University, the potential risks associated with C-sections are underestimated.

Risks include:

• anaesthetic complications
• postpartum haemorrhage (including a higher risk for hysterectomy)
• infections
• venous thrombosis
• trauma to abdominal structures
• subfertility following birth
• in subsequent pregnancies, abnormally invasive placenta, scar pregnancy, uterine rupture, difficult repeat surgery, later complications of adhesions.

Risks for babies include accidental cuts, respiratory complications, a lower success rate for breastfeeding and being slow to acquire certain types of “good bacteria”.

Poor standards of care

These risks exist in both private and public hospitals.

However, they are greater in state hospitals. According to former Minister of Health Dr Aaron Motsoaledi, the local standard of training in obstetrics and gynaecology has dropped so dramatically that “an ordinary Caesarean section is now like brain surgery for most interns”.

Factors that contribute to the risks for women undergoing C-sections in public facilities include:

• insufficient staffing
• poor standards of care, before and after surgery
• the not uncommon practice of having a “single operator” – one doctor who both administers anaesthetic and performs the C-section.

Maternal deaths due to C-sections in South Africa

The hard truth is that the mortality rate of women having Caesarean sections is three times higher than those having normal deliveries.

It’s an inherently risky surgery that should be performed only when it’s medically indicated for mother and baby and when medical staff is skilled and equipped to perform one.

When this is not the case, mothers and babies can and do die.

A recent report on maternal deaths found a sharp increase in deaths from injuries incurred during C-sections between 2014 and 2016.

Results from an earlier Saving Mothers report found that of all the mothers who died during or following a C-section, 3.4% died during the procedure and 14.5% from haemorrhage afterwards.

There were 5.5 deaths from haemorrhage for every 10,000 C-sections performed.

Septic C-sections in SA hospitals

Pregnancy-related sepsis is the fifth leading cause of maternal death in South Africa.

Undergoing a C-section is the most important risk factor for sepsis.

Sepsis is up to 20 times more common following a C-section than after a vaginal birth.

Many deaths from septic C-sections are avoidable and caused by negligence or “botched” surgeries.

In 2018/19, Gauteng public hospitals alone reported 866 septic C-sections.

They also reported 1,148 cases of hypoxic-ischemic encephalopathy, which causes brain damage to babies deprived of oxygen.

Medical malpractice claims for maternal injuries and deaths

There’s no getting away from the fact that the conditions in state hospitals are deteriorating.

Incompetence and gross negligence is leading to unnecessary deaths and injuries as a result of the surge in C-sections.

There’s nothing that can compensate the loss of a mother or baby during or after childbirth, but when a death is caused by negligence, the family has a right to make a claim.

Between January 2017 and March 2018, the Gauteng health department alone paid out R521 million in medical negligence claims, the vast majority of the 138 claims related to neonatal deaths, hypoxic ischemic encephalopathy, obstetrics and gynaecology, and post Caesarean-section sepsis.

Common forms of negligence on the part of a medical practitioner and/or hospital staff include:

• failure to observe and monitor foetal and/or maternal distress
• failure to diagnose medical issues or failure to provide the correct diagnosis
• embarking on a C-section too late, especially after extended labour or periods of foetal distress
• failure to perform a C-section in a non-negligent manner
• improper wound closure resulting in infection or sepsis
• failure to treat maternal infections and other medical conditions.