In South Africa

One in three mothers in South Africa who delivers in the public sector gives birth via Caesarean section. In the private sector, two in three mothers or more deliver their babies via Caesarean section.

It's a trend that has been steadily increasing over the past decade. In 1985, the World Health Organisation recommended a target rate of 15 per cent, which was calculated by experts but no data was issued to support this figure. There is no doubt that too many Caesareans are being performed. Both patients and doctors are responsible for this.

All prospective parents, midwives and doctors have a common aim: a healthy mom and healthy baby. However, our views and perspectives differ. I hope to give you a balanced view as to how obstetricians and gynaecologists think in general and attempt to explain why the Caesarean-section rate is increasing.

Possible reasons

The following factors appear to be pushing the Caesarean rate upwards:

The mother's choice:
Increasingly, patients are requesting an elective Caesarean. "Too Posh To Push" first appeared in the UK tabloids a number of years ago to explain the high Caesarean rate in private practice there.

Reasons for this request include fears of labour and delivery (tocophobia), convenience, control and for the preservation of pelvic-floor function. Tocophobia is the unreasonable fear of natural childbirth either for a first birth or following a previous birthing experience. With more women working, and more control/order being exerted in their daily lives, having a specific date and time for an elective Caesarean has numerous advantages. It allows the maximisation of maternity leave and facilitates easier help from partners/family and other help.

Fear of lawsuits:
It is suspected that the threat of malpractice is, in part, responsible for the increasing Caesarean rate. A suing culture like that prevalent in the US is on the increase in South Africa. Recently, there has been a well-publicised case of an R11-million award to the family of a brain-damaged baby. The current annual medical insurance fee for an obstetrician/gynaecologist is R97000.

Six vaginal deliveries each month (at medical-aid rates) are required to cover this expense. A recent article in a reputable journal showed that as medical-defence fees rise, the Caesarean rate follows. More defensive obstetrics is definitely being practiced to avoid suboptimal perinatal outcomes and possible medico-legal action.

Thus far, many doctors have been sued for not doing a Caesarean section but no doctor has been sued for doing a Caesarean section too early. It is not surprising, therefore, that obstetricians may feel that performing a Caesarean reduces the risk of being sued or losing a lawsuit, even if a vaginal birth may be the optimal care.

Pelvic-floor protection:
Although a vaginal delivery is extremely rewarding to most women and often seen as the ultimate fulfilment of female sexuality, childbirth can be traumatic. In white women, one third will need surgery in later life for urinary incontinence (the inability to hold your urine when you cough or exercise) or pelvic-organ prolapse. Although pregnancy per se increases your chances of subsequent urinary incontinence, this is more common following a vaginal delivery (21 to 32 per cent) compared to elective Caesarean (up to 10 per cent). The inability to hold flatus (wind) and/or faeces (anal incontinence) is also increased with a vaginal delivery (eight to 19 per cent), as compared to an elective Caesarean (zero per cent).

Risks of a Caesar

A Caesarean section is a major surgical procedure that increases the likelihood of many types of harm to mothers and babies in comparison with vaginal birth. Traditionally, maternal death was higher in this group. This is less so nowadays with the advent of regional anaesthesia (spinal/epidural blockage), prophylactic antibiotics and clot-prevention strategies.

Short-term harm for mothers includes the increased risk of infection, surgical injury, blood clots, emergency hysterectomy, intense and longer-lasting pain, having to return to the hospital and poor overall functioning. Perhaps due to the surgical side-effects of scar formation, Caesarean-section mothers are more likely to have ongoing pelvic pain, to experience bowel blockage, to be injured during future surgery and to have future infertility.

Babies born via Caesarean section are more likely to have surgical cuts, breathing problems within the first 24 hours and difficulty getting breastfeeding going.

Of special concern after a Caesarean section are various serious conditions for mothers and babies that are more likely to occur in future pregnancies, including ectopic pregnancy (pregnancy occurring outside the uterus), placenta praevia (low-lying placenta), other placental abnormalities like placenta accreta (placenta invades the uterus and is difficult to remove), placental abruption (premature placental separation) and uterine rupture.

Risks of vaginal birth

A vaginal birth carries the risks of pelvic-floor damage and vaginal, cervical or perineal tears. Tragically though, occasionally intrauterine/intrapartum (during labour) foetal deaths do occur, even with the best obstetric care. Therefore, some argue that an elective Caesarean performed at 38 to 39 weeks would prevent the unpredictable intrauterine death that might occur after 39 weeks or during labour.

Cerebral palsy (CP) occurs in two to three out of every 1000 births. Only 10 per cent of CP occurs during labour. Therefore, elective Caesareans would prevent CP in 0.2 per 1000 births. Pooled data from Sweden, Australia, Canada, UK, Norway, the US and Ireland showed that with increased Caesarean rates CP rates remained stable. Thus, a Caesarean section does not prevent brain damage in babies.

Birth injuries, including intracranial haemorrhage, facial nerve injury, brachial plexus injury and seizures, but with the exception of surgical cuts, are no different in vaginal and elective Caesarean births. Emergency Caesarean sections and vaginal deliveries using forceps or vacuum can lead to increased complications.

Previous C-sections

When one looks at the success of a vaginal birth after Caesarean section (VBAC), research universally shows that a "trial of labour", or attempt to give birth naturally, is appropriate. The success rate for VBACs is 60 to 70 per cent.

In the UK and in the public sector in South Africa, a VBAC is commonly offered to patients who have had a Caesarean. Ironically, in the private sector in South Africa this is the most commonly cited reason for a repeat elective Caesarean. To offer a VBAC, it is recommended that 24-hour access to a theatre, an anaesthetist, an obstetrician and a paediatrician is needed. Unfortunately, this is not the case in private practice when your obstetrician is at home.

While a failed trial of labour is uncommon and the rupture of a scarred uterus even less so (1 in 200), the maternal and feotal consequences of such failure can be disastrous. A delay in an emergency Caesarean (while your obstetrician and other staff are travelling to hospital) may be critical. It is unsurprising that a number of obstetricians do not recommend having a VBAC.

Convenience

Time is money
Obstetricians are paid a flat "global fee" for normal deliveries. This means there is no extra fee for the specialist who patiently supports a longer vaginal birth.
A planned Caesarean (although paid out to the obstetrician at virtually the same fee as a normal delivery) is an efficient way to organise hospital work, office work and, let's face it, a personal life. In other words, time can be managed more efficiently.

Birth experience
Women undergoing spontaneous vaginal deliveries and elective Caesareans view their birth experiences more favourably than women delivering by emergency Caesarean or operative vaginal delivery. Studies show that a planned Caesarean is not associated with higher postpartum depression or with painful sex at three months post-delivery.

Professional preferences
Several studies have asked hypothetical questions to medical staff about the favoured mode of delivery. A London study showed that 31 per cent of the female and 17 per cent of the male obstetricians favoured elective Caesareans for an uncomplicated singleton pregnancy. In contrast, midwives, who see mostly normal deliveries, replied differently: 96 per cent of a group of 135 practicing midwives said they would choose to encourage a normal delivery.

On the day...

Your first delivery is the most important one, as a normal delivery in the first pregnancy more or less paves the way for subsequent vaginal deliveries. As explained earlier, a previous Caesarean section increases the likelihood of another one. Therefore, if you would like to maximise the chance of having a vaginal delivery then consider the following...

From the outset, you must find an obstetrician who is most likely to support your decision and give you this chance. Different obstetricians practicing in the same areas (even hospitals) have widely differing Caesarean rates. ("Rate" is the total number of Caesareans over the total number of births.) Finding out your obstetrician's rate will give you an indication of your chance of having a Caesarean section: the higher the rate, the greater your chance of having a Caesarean section.

If you feel that you are being pushed into having a Caesarean section, especially with debatable indications like "your pelvis is too small and your baby too big", "there is meconium that can be seen on the scan" or "the cord is around the neck", then I encourage you to seek a second opinion.

In cases of a breech presentation (bottom or feet first), you should be offered an external cephalic version (ECV). This involves using hands-to-belly movements to turn a breech to a head-first position. This is attempted at 37 weeks, involves slight maternal discomfort and is usually performed in your obstetrician's rooms. It is offered in all units in the UK and there is no recent evidence to suggest that an ECV is detrimental to you or your baby in the absence of other risk factors, for example, existing hypertension, diabetes or a previous Caesarean section.

If you have an early induction of labour, your chance of having a Caesarean section is increased. In an uncomplicated pregnancy, the usual time for an induction is 41 to 42 weeks.

It is your right as a pregnant woman to receive accurate and unbiased information about childbirth to enable you to make an informed decision about the planned mode of delivery of your baby. The rising Caesarean-section rate is a complex issue and numerous factors contribute to this. Having read this article, some women will choose to have an elective Caesarean and just as many will choose to have a normal delivery. In the end, you have to consider all the evidence, trust your instincts and find an obstetrician who will support your decision