The recent Council of Medical Schemes (CMS) report on the trends of caesarean sections (C-sections) in South Africa cites the World Health Organisation (WHO), which estimates almost 15% of all pregnant women develop complications serious enough to require rapid and skilled intervention if they are to survive without lifelong disabilities.
This means that women need access not only to trained midwives, but also to obstetricians when complications arise.
The majority of private sector obstetric services are centered around the obstetrician and the patient. This is viewed as an enabler of medicalisation of childbirth because obstetricians take sole responsibility for routine antenatal care and delivery services, instead of only getting involved in complicated cases.
This is compounded by the current reimbursement model, which incentivises this practice and undermines the value of a team-based approach that is funded accordingly.
The C-section rate of 76.9% in the private sector is quite high for this population group, hence the recommendation by the CMS to intervene on patient/healthcare provider/practice factors, including the need for malpractice and reimbursement reform.
The same report cites a paper confirming a C-section rate of 26.2% in the South African public sector for the 2015/2016 financial year.
In a study conducted in Brazil, 237 of 502 caesarean deliveries were decided on before admission in 23% of women in the public sector and 64% of women in the private sector.
It can be inferred that most of these C-sections were related to elective cases and a small percentage linked to emergencies.
The significant difference in the rates of C-sections in women in the public and private sectors was owing to more unwanted C-sections among private hospital patients rather than to a difference in preferences for delivery.
The conclusion was that high or rising rates of C-sections were not a reflection of patients’ demand for surgical delivery.
There is a need to understand various factors influencing decision-making for C-sections, which vary between physician-specific factors, patient factors and system factors.
Understanding the perspective of obstetricians is critical when addressing the problem of high C-section rates.
Obstetricians are decision-makers and therefore increased access to obstetricians is a significant determinant of C-section.
Decisions are influenced by various factors, including belief systems about C-section, dynamics within the care team and availability of resources.
According to a study conducted in South Africa, obstetricians working in private hospitals regard C-section to be a safe option, compared with public hospital-based obstetricians. This is despite them having access to good facilities to monitor difficult deliveries and being aware that C-section should only be considered when clinically necessary.
Obstetricians working in the private sector in Turkey reported having a more positive attitude towards C-section on maternal request, and, as a result, acknowledged that their C-section request rates were significantly higher compared with obstetricians working in public hospitals.
This laissez-faire approach raises ethical questions relating to socioeconomic status allowing patients access to clinically inappropriate C-sections and the unjustified higher costs of care. It is not surprising that Turkey is among the top five countries with high C-section rates.
Countries with a C-section rate above 50% are the Dominican Republic, Brazil, Egypt, Turkey and Venezuela, in that order.
The increase in the C-section rate in Egypt is associated with the increased utilisation of private hospitals and further enquiry on the actual indications for C-section needs to be conducted.
In the Dominican Republic, four out of every 10 births in public hospitals and nine out of every 10 births in private facilities are via C-section, while one out of 10 cases in the intensive care unit are a result of infections associated with C-section.
Women using private healthcare services have more access to foetal monitoring technologies, although more access does not equate to better access. These technologies are made available to pregnant women irrespective of the risk profile, and some scholars believe increased access sometimes raise alarms leading to unnecessary C-sections.
This is also debatable in an environment experiencing a litigation crisis, with obstetrics being the most at-risk specialty for medical litigation and the cost of malpractice insurance being exorbitant.
This reminds me of a statement made by former health minister Aaron Motsoaledi during the 2015 Medico-Legal Summit: “Doctors are now practicing law and not medicine because they see patients as potential enemies.”
This is a worrying observation because it creates fertile ground for defensive medical practice.
A relationship between a doctor and a patient should be based on trust. Most doctors care about their patients and professional reputations. Litigation may cause a shift from compassionate to defensive care when patients are seen as a medical liability. Fear of litigation has a negative impact on healthcare expenditure and may lead to inappropriate and excessive investigations and interventions. Unnecessary C-section also exposes patients to risk associated with surgery and anaesthesia. Besides, vaginal deliveries are less risky.
There are a number of studies citing that, in the private sector, women with high decision-making power and multiple births have a higher probability of getting a C-section.
Interestingly, a recent study looking at disparities in C-section prevalence among sub-Saharan countries found the C-section rate in the private sector to range from 0% in São Tomé and Príncipe to 64.2% in Rwanda.
Other researchers cite fear of pain during childbirth, cultural beliefs around luck and fate of birth dates, as well as the perceived impact of vaginal delivery on cosmetic appearance, the pelvic floor and sexual functioning as some of the main factors that influence childbirth preferences.
Societal perceptions around prestige may drive maternal requests for C-section. Exploration of this problem needs to go beyond the analysis of claims data because country level dynamics have to be considered when tackling overuse of C-section.
It is also important to understand that facilitators of access may go beyond obstetric reasons. We currently do not know if personal safety concerns in a country with high crime rate influence practitioners’ decisions around controlling the date and time of delivery.
There is no doubt that the high rate of C-section in the private sector is a multifaceted and complex problem. Therefore, it needs to be explored from economic, medical and social perspectives to facilitate better understanding of the contributing factors. Socioeconomic issues seem to play a role in accessing C-sections, as echoed by a study conducted by the WHO, which found that the “urban rich” had more access to C-section compared with the “rural poor” in a specific region. This inequitable access may unfairly enhance access to C-sections, which are not clinically indicated.
Importantly, higher C-section section rates do not necessarily translate to better clinical outcomes for pregnant women and neonates. C-section services ought to be available and accessible to those who need them, and care decisions must be clinically and ethically justifiable.
- Dr Kubheka is a risk management and ethics consultant at Health IQ Consulting
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