Childbirth in South Africa

Like many other aspects of the country, when it comes to childbirth there is also a wide gap between the choices and facilities available to have's and have not's. As doula's we have a unique perspective on childbirth in that we are not limited to where we practice and spend time in both government and private facilities. We therefore get to experience first-hand the wide gap between the two and the pro's and con's of each.

In government hospitals natural birth with minimum intervention is the norm, and epidurals are very hard to come by. At this point in time hospitals have put in place protocols which require them to perform a certain number of epidurals otherwise they just wouldn't do them and trainee doctors would never get this experience. The reason why they are so limited is because they just generally don't have the equipment or personnel available to give closer monitoring of labour progress.

At the other end of the spectrum are the private hospitals where a variety of choices can be ordered up "on demand" whether they are medically needed or not. Equipment is high-tech, the meals are good and the staff are generally pleasant to deal with.

As doula's, many of us find it very interesting to note the differences in approaches between the two extremes. Doctors in government hospitals generally have a hands-off approach and it is mainly the midwives who oversee the deliveries unless there is a major complication. There is no such thing as an elective c-section and sometimes even women who need them will have to wait many hours as the more urgent cases receive priority.

In private hospitals the majority of doctors take a very conservative approach to birth and women are often coaxed into having a cesarean birth, or even actively dissuaded from having a vaginal birth (to the point where some women have been made to sign documents outlining the dangers of vaginal birth). Some doctors who at first seem open to a vaginal birth will often wait until a few weeks before the due date before starting to make comments about the size of the baby and the need to "explore other options". Without the proper information many women feel they have no other choice but to accept surgical intervention for a "big baby" and are then surprised to discover that the baby is up to a kilogram lighter than the scan had predicted.

The other more recent trend is to recommend induction at 38 weeks while citing a number of reasons for doing this such as the "big baby" concern. An induction at 38 weeks is very unlikely to work but gives the mother the impression that she has been allowed to "try for a natural birth" but with the high likelihood of an "emergency" c-section being the final result. It's important to note that while it is called an emergency c-section, it could be more accurately referred to as an unscheduled c-section. This incurs a higher fee than an elective/scheduled c-section, and so the question must once again be raised as to the financial benefit certain medical providers may be seeing from this kind of intervention.

Another mitigating factor for the excessively high c-section rate in private hospitals is the fact that up until now, many medical aids would pay for this costly surgery without there being an medical need for it. This has made it a very convenient option for doctors running busy practices in that they can schedule births of their clients.

Why should you care?

For those fortunate enough to have medical aid, the fees you pay to be part of your medical aid are affected by those having surgery "on demand" without medical necessity. This has been covered in a special edition of Carte Blanche Medical which can be viewed below.

Another reason why we should be concerned is due to the high numbers of c-sections taking place and the consequences of this when they are done without reason. The World Health Organisation has stated that no hospital should have a c-section rate higher than 15%. South Africa's rate is around 80% in private hospitals and around 20% in government hospitals. It must be noted however that the government rate is not of concern due to the fact that we have so many women who are HIV+ and therefore a c-section is a safer option for them.

C-section is not without risk and very few women are ever given any information about this, let alone made aware that a c-section is 4 times more likely to result in maternal death than a vaginal birth. 

The South African model of birth is very similar to that of the United States and in a recent report it was found that, despite the plethora of medical intervention used, the maternal death rate is amongst one of the worst in the world. Other countries where there is midwifery led care it has been found that those countries also have the lowest c-section rates and maternal death rates are the lowest. In the Netheralands homebirth is the norm with only complicated pregnancies being sent for doctor-led care and birth in a hospital. The Netherlands is also credited with being one of the safest places in the world to have a baby.

What needs to change?

  • Better facilities for birth in government hospitals
  • Easier access to surgery for women in rural areas
  • Better monitoring of c-section rates both in private and public sectors
  • Easier access to information for all women in South Africa
  • The establishment of either a government led or independent source for non-biased information about options in childbirth
  • More pressure on doctors to give women access to research-based information
  • More support of vaginal birth
  • More support for, and information about, Vaginal Birth After Caesarean (VBAC)
  • Medical Aid Schemes to fund all types of birth equally
  • Midwives to be the primary care-giver for pregnant women

So how can YOU make an informed choice?

We suggest the following resources to help you take charge of your birth, and make the best decisions for you and your family. Click the headings below to be taken to the websites.

"What every woman should know about Cesarean Section" 

This is a downloadable document available from Childbirth Connection which offers research-based information on the pro's and con's of cesarean birth and compares this to those of vaginal birth. (Click the text above to visit their website)

MIDIRS - Informed Choice

This British-based charity, Midwives Information and Resource Service, is a wonderful place to find information on just about any aspect of pregnancy and childbirth. It is a wonderful resource for mothers, midwives, doulas and any other healthcare professionals who work in the areas of pregnancy and childbirth.

BirthWorks is a local website with loads of fabulous resources, both for information and even an online midwife to answer all your questions!

And learn more about these terms:

VBAC (pronounced VEE-back): Vaginal Birth After Cesarean. Contrary to popular belief the rule is not "once a c/s, always a c/s". Research has shown that a vaginal birth is still an option after 1, 2 or even 3 cesarean sections as having repeat c-sections also carry their own risks. You can learn more on this website - VBAC SA  

Doula : A non-medical, professional birth partner who helps both the mother and other birth partners (such as the father) through pregnancy and childbirth. A doula offers the mother and her family emotional and physical support during pregnancy and birth, and sometimes in the first weeks after the birth as well. Don't give birth without a doula! - South African Doula Database

And finally, take a look through our Informed Choice blog for tons of information related to just about every topic you can think of!

South African rates for c-section as provided by various organisations:

  • Government Department of Health in the Western Cape: 19.6%
  • Board of Health Care Funders in South Africa: 65%
  • Largest Medical Aid Scheme in South Africa: 70%
  • Council of Medical Aid Scheme’s in South Africa: 82%
  • For one Private Hospital in Cape Town, South Africa in one month: 90% (total births were 120)

Why is the C/S rate in SA rising?
  • Defensive medicine
  • Medical aids pay for C/S without requiring medical necessity
  • Art of normal delivery is being lost
  • Casual attitudes about surgery
  • Fear of natural birth: “Baby is too big”
  • Growing belief that C/S is "safe"
  • Side effects of other common procedures
  • Failure to support normal physiologic labor 
  • C/S chosen before less interventive methods
  • Women are having c-sections for HIV+ status; National HIV rates = 30% KZN = 39.1% WC = 15.5%.
  • Convenience
  • Increased use of epidural anaesthesia
  • No VBAC policy