BREAKING NEWS! Rising maternal deaths due to C-sections

In South Africa, maternal deaths due to C-sections have increased by 63% between 2008 and 2014. We look at why these numbers are on the rise, and discuss the pros and cons of C-sections and vaginal births. By Licia Selepe and Xanet van Vuuren


The number of women bleeding to death as a result of a C-section is a national emergency, according to the latest issue of the South African Medical Journal. Published figures show a 63% increase in such deaths in South Africa between 2008 and 2014 – and in 71% of the instances, the deaths could have been avoided.

One of the authors of the report, Professor Sue Fawcus, of the University of Cape Town, says she is very concerned about the rise in the number of maternal deaths due to C-sections in our country. “A C-section is an operation designed to improve the outcome of mothers and their babies. There are many interventions that can ensure that it is a safe operation. So we are very alarmed when we note the increasing number of women who are bleeding out after a C-section. We see it as an area of great concern that needs to be tackled.”

Why have fatalities due to C-sections increased?

 “More C-sections are being done, and some of these are more complicated. Once you do a woman’s second C-section or third, it’s associated with more bleeding. Also, when you do a C-section late in labour, it’s associated with more bleeding,” says Prof Fawcus. “Our biggest concern is that most C-sections [in South Africa] are performed at district hospitals by the least experienced doctors who are both performing the surgery and giving the anaesthetic. Unfortunately, the skills needed for a safe outcome isn’t always available at district hospitals.”

What can we do to decrease these figures?

“We’re working very hard on strategies. There have been some things already done in South Africa, which have made a difference,” says Prof Fawcus. “Firstly, we need to ensure that unnecessary C-sections aren’t performed, and to improve the skills of both midwives and doctors to assist with normal births should complications arise. Secondly, a massive improvement of skills is necessary. Some districts in South Africa have launched a training programme called Esmo, which is really focused training for skills which will reduce deaths from bleeding by about 20%. If we can roll that out in every district, it would make a difference. Thirdly, we need to ensure that every facility offering C-sections meets the minimum standards. For example, there should be two doctors in the theatre. There shouldn’t be just one doctor doing the anaesthetic and the C-section. There must be enough blood in the fridge and enough drugs to help the uterus contract.”

The Western Cape has the lowest number of deaths associated with bleeding out due to a C-section, which has been attributed to a good support system in the province, where the regional hospitals work with the district hospitals to provide support. “This will help if it’s rolled out everywhere,” says Prof Fawcus.

C-Section vs. vaginal delivery

A Caesarean section (C-section) is customarily performed when a vaginal birth is considered too risky and the mother’s or baby’s health is thought to be at risk. However, Jude Polack, director of the Genesis Clinic, says that most private hospitals in South Africa perform far more C-sections than vaginal births, and a C-section has become an elective procedure rather than a necessity. According to one medical aid scheme’s report, over 70% of deliveries in private hospitals in South Africa are done via C-Section.

Safety vs. convenience

Why would a woman choose major surgery over vaginal delivery? Dr Zeelha Abdool, a consultant obstetrician and gynaecologist at the Steve Biko Academic Hospital and the Netcare Femina Hospital, says that opting to have an elective C-section means that you and the family are able to conveniently plan the arrival of your baby. “To some moms, having the delivery scheduled has considerable appeal, for many reasons. This eliminates the anxiety, stress and uncertainty of the onset and duration of labour, as well as the repeated vaginal examinations needed with a vaginal delivery. Most C-sections are performed under spinal anaesthetic, and the procedure is thus pain-free,” she adds.

Polack says that mothers may be under the impression that a C-section is an easy way out of labour and delivery, or they may feel that a scheduled delivery is far more convenient than trying to work around an unplanned birth, while in fact natural delivery is the safest way. “Generally, the health risks to both mother and baby are lower with vaginal delivery than with an elective caesarean delivery,” adds Polack.

Babies born by planned C-section are more likely to end up in the neo-natal intensive care unit (NICU) with breathing problems than babies who are born naturally. “Giving birth naturally is painful and tiring, however once it is over, the pain of the contractions and the hard work of the labour and the delivery, are quickly forgotten,” she adds. When a baby is born naturally, a mother will go into labour – a sign that the baby is ready to be born. Since a caesarean is scheduled before labour takes place, an early delivery is a high and real risk.

With a natural birth, the infant engages into the birth canal, and the process allows the infant to prepare itself for the outside world. Natural birth takes place in stages, and each stage is preparation for the mother and the baby. With a caesarean, there’s no time for preparation.

Polack says that natural birth is more empowering. “While in labour, women are able to walk around freely and change birthing positions, but with a C-Section, they’re in theatre and play no role in the delivery of their child,” she adds.

The pros and cons of both

It’ll be up to you and your doctor to weigh up the risks and benefits of having a caesarean or vaginal delivery, and what’s best for you and your baby. The best thing for women to do is arm themselves with information about the pros and cons of both methods of delivery, as outlined below:

Click here for 10 tips to preven a C-section.

Vaginal birth

What’s good about it?

  • There’s no surgical recovery time, so you’ll have shorter hospital stay and immediate mobility after the birth.
  • According to Polack, babies born naturally are six times less likely to suffer from respiratory distress syndrome or fluid in the lungs.
  • Latching and feeding happen more quickly and successfully.
  • The baby is potentially less likely to develop allergies, asthma, or lactose-intolerance.
  • The mother is much less likely to need a C-section for future births.
  • There is less of a risk of haemorrhaging, blood clots, or infection for the mother.

The down side
There’s a risk of:

  • Oxygen deprivation for the baby if there is cord compression or problems during delivery
  • The mother’s perineum tearing
  • Additional trauma to the baby when passing through birth canal, or from forceps or vacuum extraction
  • Pelvic organ prolapse for the mother after delivery. This is when the uterus, bladder, or bowel protrudes into the vaginal canal, causing discomfort and possible incontinence.

Elective caesarean

What’s good about it?

  • Caesareans can be more convenient for a woman and therefore may reduce her stress and anticipation of labour
  • There’s a reduced risk of oxygen deprivation to the baby during delivery
  • There’s a lower risk of birth trauma to the baby that’s sometimes sustained from his passing through the birth canal, or from forceps or vacuum extraction being used.

The down side

  • A pre-term delivery is possible if the due date calculation is inaccurate
  • There can be infant injury when the doctor makes the uterine incision
  • There’s a risk of damage to the mother’s bowel and/or bladder
  • There may be increased maternal blood loss and a risk of needing a transfusion
  • Complications from anaesthesia, like pneumonia, allergic reactions and low blood pressure, could occur
  • There’s a higher risk of infection and blood clots for the mother
  • The hospital stay is longer (three to five days), and so is the recovery period
  • Possible complications with breastfeeding can arise.

Questions to ask your medical practitioner

You have a right to choose and to question the doctor’s decision. Here are some of the questions you can ask your medical practitioner to help you decide which is the best delivery method for you.

For vaginal delivery:

  • How long does vaginal delivery normally take?
  • How long does it take to recover from vaginal delivery?
  • What are the common side effects associated with vaginal delivery?
  • What are the pain-control options?
  • Why would I want to avoid a caesarean?

For C-section delivery:

  • Do you often perform caesarean? What are the main reasons that you perform them?
  • How long does an average caesarean take?
  • How long does it take to recover from the operation?
  • What type of pain relief is offered before and after a caesarean?
  • Can I still breastfeed if I had a caesarean?
  • Will it affect future pregnancies?

If your doctor recommends a caesarean, ask these questions first:

  • Is my baby okay?
  • Is there any danger at this point?
  • What problems could occur if I continue with my plan for a vaginal birth?
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