Caesarean births - also known as C-sections - are growing at an alarming rate in South Africa, studies have found. And one of the biggest role players in healthcare - medical schemes - claim they are paying exorbitant amounts of money on Caesareans that are not medically required.
One of the country’s biggest schemes, Discovery Health, said at least 72 percent of deliveries claimed from the scheme were Caesareans.
The scheme said that of the 36 790 deliveries claimed by private hospitals, between October 2009 and September 2010, 26 292 were Caesarean births while 10 498 were normal (vaginal) deliveries. The number of Caesareans topped the scheme’s list of admissions during the same period, followed by digestive system diagnoses, and pneumonia and whooping cough.
Between May 2008 and April of 2009, the scheme paid for 23 734 Caesarean deliveries. Normal births - at 9 871 - were less than 50 percent of that number.
Bonitas medical scheme had a total number of 9 015 delivery claims last year, and at least 6 169 of these were Caesareans. The previous year the scheme paid for 9 096 deliveries, of which 6 166 were Caesarean.
While the World Health Organisation (WHO) advises a maximum of 15 percent Caesareans per country, in South Africa’s private sector the rate is around 70 percent. In the public sector it is about 18 percent.
Last year the South African Childbirth Educators’ Forum reported that, in the private maternity sector, 67 percent of women had Caesareans. In the US, the rate is said to be about 32 percent.
An average cost of normal birth in the private sector is about R25 000, while a Caesarean can be anything from R30 000.
The Board of Healthcare Funders (BHF), which represents most medical aids, said while it was concerned about the disproportionate number of Caesareans due to the risk of maternal mortality and the impact it had on contributions, it had very little power over the issue as a Caesarean was part of prescribed minimum benefits (PMB).
Spokeswoman Heidi Kruger said while many gynaecologists had portrayed Caesareans as a safer method of birth, the board’s view was that they were “not necessarily safer”.
“We are very concerned at the high rate of C-sections, especially as a reduction in maternal mortality is one of our Millennium Development Goals. However, having said that, South Africa has a high prevalence of HIV, which pushes the C-section rate up. There is also a litigation trend emerging which pushes the rate up a bit. We believe, though, that our C-section rate should not be more than 30 percent,” she said.
Kruger also regretted the Health Professions Council ruling that made delivery method a patient choice - irrespective of whether it was medically indicated or not.
Jonathan Broomberg, chief executive of Discovery Health, said while the scheme had no definite view on the high rate of Caesareans in the private sector, it seemed the convenience factor was one of the reasons that pushed up numbers. “There is no doubt that the high rates in SA are not explainable purely on clinical grounds, as they are far higher than most other countries, and far higher than public health care where you would expect to see only those which are clinically required being done,” he said.
Bonitas spokeswoman Christa van Dyk said while it supported the WHO’s guidelines on Caesareans, due to the risks, it had no power to micro-manage these cases.
“The cost is a major concern to all schemes as it has a direct impact on contributions. However, with Caesareans, doctors always send a motivation to justify the procedure.”
So has birthing been “medicalised” or are Caesareans pushed up because they’re safer? Or is it simply for convenience reasons?
According to Dr Peter De Jong, an obstetrician and gynaecologist at Christiaan Barnard Memorial Hospital, the rate of Caesareans could be attributed to the fact that more women were exercising their right to choose their birth options, HIV incidence and the fear of litigation by doctors. De Jong also added that the procedure had been “medicalised”.
He said some gynaecologists were advising women to opt for a Caesarean as it was considered to be less of a risk, and was convenient for all parties involved.
De Jong said both options were equally safe, but the chances of being sued were higher for a normal delivery.
“I’ve never heard of any doctors who were sued for doing a C-section, but many of the doctors I know have been sued for doing a normal delivery. Whenever something goes wrong with normal delivery, lawyers always ask why didn’t you do a Caesarean… didn’t you see the potential of things going wrong?” he said.
De Jong said women were also opting for Caesareans as they were a better option when looking at long-term effects. He said research suggested it was somewhat protective against urinary and faecal incontinence.
But according to Professor Rob Pattinson, director of the Medical Research Council maternal and infant health care strategies research unit, who also did research on Caesareans in the public sector, the risk of maternal death was higher for Caesareans than in normal birth.
“The major concern is the complications that are associated with them. Haemorrhaging is much more common for C-sections. Subsequent pregnancies also have a higher complication rate.”
Professor Lynette Denny, head of obstetrics and gynaecology at UCT and Groote Schuur, agreed.
She said while Caesareans in public hospitals were done for good evidence-based reasons to ensure the safest outcome for mother and child, in the private sector the motive was different and this included doctor convenience and financial incentives for private hospitals.
Denny rejected suggestions that Caesareans were safer, describing this as a “false perception”.
She said WHO research showed that a Caesarean without a medical requirement was more life-threatening - about 10 times more likely than it was for normal vaginal deliveries.
“Women are being duped into believing that a C-section is easier, quicker and that it will prevent injury to the bladder and rectum. That is not true. Unnecessary interventions in childbirth, such as C-sections without medical indication are, in my opinion, not only bad practice but an assault on women and their babies, and should be discouraged at all costs.
“The vast majority of women are more than capable of delivering vaginally and if all is well it is without doubt the safest option for mothers and their babies,” she said.
Professor Gerhard Theron, head of the department of gynaecology and obstetrics at Stellenbosch University, said as long as private sector deliveries were still doctor-managed and not nurse-managed, the rate of Caesarean births was likely to remain high.
Theron said the nature of doctors’ duties didn’t allow them to tend to women in labour all the times as they had other obligations to tend to.
He said good examples of countries that had managed to keep Caesareans at a low rate were Scandinavian nations such as Denmark, Norway and Sweden, including Holland, where C-sections remained low - between 18 and 20 percent. In such countries uncomplicated deliveries were mainly carried out by trained midwives.
“In these countries doctors only intervene in the birth process when there are deviations from normal. Midwives are completely competent in managing deliveries,” he said.
He said Caesareans could only drop if women empowered themselves with factual information on birth options did not rely solely on doctors’ advice.
“If women can start putting pressure on the system and demand to have a normal birth for uncomplicated pregnancies, the rate of C-sections can drop,” he said. - Cape Argus