Too many women having unnecessary C-sections: WHO
Despite new guidelines, obstetricians at private hospital terminate relationship with midwifery team
Throughout her first pregnancy 12 years ago, Nazli Desai was adamant she was going to deliver her baby naturally.
But the day she went into labour everything changed. The pain was so intense that she begged her gynaecologist to perform a caesarean section.
And when her second and third pregnancies came along, natural birth was the furthest thing from her mind.
“I couldn’t imagine myself pushing that baby out … in my mind, my body was just not capable of doing it and it became very scary for me,” she said.
According to the World Health Organisation (WHO), too many women like Desai are having C-sections unnecessarily, in the process putting their lives, and those of their babies, at risk.
Last month, for the first time, the WHO issued guidelines in an effort to reduce C-sections.
They suggest a greater role for midwives, but come too late for independent midwives at one of Cape Town’s private hospitals, Life Vincent Pallotti.
Obstetricians at the hospital have decided to terminate their relationship with a four-strong midwifery team, saying risky vaginal births have driven up litigation and insurance costs.
Dr Paul Soko, clinical directorate executive at Life Healthcare, said the hospital would honour existing bookings, but the midwives’ new clients would no longer be welcome at the hospital. He said litigation cases were often linked to vaginal births.
“Unfortunately, these are challenges that all healthcare service providers, including obstetricians, face across all private hospitals in South Africa,” he said.
The midwives are fuming at the decision to terminate their services. One of them, Glynnis Garrod, said: “As a team we are truly devastated and deeply saddened by the withdrawal of obstetric back-up by the obstetricians at Vincent Pallotti.
“We were not involved in the discussions leading to this decision and were not officially informed of the reasons, other than rising insurance costs and needing the support of all the obstetricians in order to make an on-call rotation work.”
Cape Town gynaecologist and obstetrician Peter de Jong said it was women, not doctors, who opted for C-sections. “The reality is that every woman who needs a C-section should get one,” he said.
He was critical of the WHO guidelines, arguing that the notion that vaginal births were morally superior to C-sections should be strongly discouraged. De Jong said doctors were also concerned about their own safety, and crime discouraged many from working during awkward hours.
“A large number of obstetricians are women, who justifiably feel vulnerable driving alone at night to do deliveries. My wife has, on two occasions this year, been followed to hospital at night by men in motor cars, which makes her reluctant to do deliveries between midnight and 5am,” he said.
The SA Society for Obstetricians and Gynaecologists (Sasog) said it was concerned about the high rate of C-sections.
“This is a global problem and not unique to SA, with rates in China and South America of above 50%,” said society secretary Priya Soma-Pillay, head of obstetrics at the University of Pretoria.
She said patient requests to have C-sections, increases in lifestyle disease, such as hypertension and diabetes, and the “medico-legal onslaught” on gynaecologists were major contributors to the rise in C-sections. Malpractice premiums for gynaecologists were about R1m a year.
Soma-Pillay said Sasog had introduced proposals to reduce C-sections, which included promotion of medico-legal reform, obstetrics protocols and the establishment of expert-opinion panels to reduce lawsuits.
The WHO said apart from being expensive, C-sections were associated with long-term health risks, including urinary incontinence and pelvic organ prolapse in mothers, and asthma and obesity in children.
“Worldwide, caesarean-section rates have been steadily increasing, without significant benefit to the health of women or their babies,” said the WHO.
“While many women in need of caesarean sections still do not have access to them, particularly in low-resource settings, many others undergo the procedure unnecessarily, for reasons which cannot be medically justified.”
According to the latest annual report of the Council for Medical Schemes, SA’s private healthcare sector has experienced an unprecedented upsurge in C-sections over the past decade, with rates way above the public healthcare sector and about six times the 10% to 15% WHO recommendation.
In the past year there were 590 C-sections for every 1,000 births. The report suggested patients’ ability to pay, rather than clinical reasons, was behind the high number.
But Desai said women should have the right to choose. “I think by prescribing to women or doctors that women should have more vaginal births, indirectly you are taking away their right to choose. Women should be given a choice and I should choose how I want my delivery,” she said.