Researchers from Trinity College Dublin, Ireland and Sahlgrenska Academy at the University of Gothenburg in Sweden have carried out the first ever review of why caesarean sections (CSs) are carried out.* They were concerned that around a quarter of women in the United Kingdom and a third of those in Ireland give birth by CS, saying: “Caesarean section (CS) rates have risen substantially over the past few decades, often without clear rationale and limited additional maternal or neonatal benefits,” and “without medically justifiable reasons”.
Sydney Grové, General Manager of Origin Family-Centred Maternity Hospital in Panorama, Cape Town (who is also a male midwife and has assisted at the births of over 24 000 babies) says this study did not come a moment too soon. “In South Africa the CS rate is lower in the government hospitals than in the private sector. A recent official review put the rate at 65%, but this has gone up to 85-90% in some private hospitals, and even 100% in some individual hospitals at particular times of the year. The whole drive is to decrease the CS rate, and the World Health Organization puts the rate to aim for at 15-20%.
“I think the goal in South Africa should be not more than 25-30%. For example, according to our statistics at Origin Family-Centred Maternity Hospital, over the 12-month period from 1 March 2017 until the end of February 2018 our CS rate was 35.8%. This includes planned and unplanned or emergency CSs and those stemming from clients aiming for a VBAC (vaginal birth after caesarean) where it ended up as a CS. The gynaecologists whom we partner with deal with more high-risk cases, which also raises this percentage. Since March our rate has been around 25%.”
The review of doctors’ perceptions of factors that influence their decision to perform a CS was published in PLoS One and assessed responses from 7785 obstetricians and 1197 midwives from 20 countries. It found that nearly 70% of doctors who deliver babies by CS may do so because they are afraid of being sued. As well as fear of litigation, doctors also said they choose CS to avoid damage to the woman's body or because there are not enough staff to allow a vaginal birth. They may also prefer a CS because it is more 'convenient' and 'organised', and senior medics are more likely to be in favour of the procedure. This is despite evidence that natural vaginal births are safer and less likely to have complications.
Adds Sydney: “There is evidence that if a woman is looked after in labour and prepared by a trained and registered midwife then you are looking at a lower CS rate. This is not because we are better than doctors but because of the different approach and peacefulness around it. In terms of the increasing CS rate, what is especially worrying is that although CS is a common procedure carried out all over the world, I don’t think people are given all of the information and options so that they can make an informed decision.
“Also, we can’t see the CS rate in isolation. The biggest issue that we have, in South Africa in particular, is that the two professions have become a threat to each other instead of working together. We need to sit around a table and hold hands and work in synergy, respecting one another and our different expertise and skills in the best interests of each client.
“Owing to a watering down of nursing training in the last few decades, doctors may find it difficult to trust the midwives in the labour wards to call them in time if there is an emergency. Coupled with the fact that incidences of litigation have increased (which may or may not be opportunistic), many of the doctors – and I have sympathy for them – practice what we call defensive medicine, where they would rather prematurely take the decision to cut. They will do this rather than allow the women to have a trial of labour, or don’t let them labour for long enough while it is still safe
“Decision-making becomes very challenging for doctors if they suddenly need to make a decision on a patient in the middle of the night, perhaps working with a particular staff member or limited staff that they do not trust. So quicker procedures and invasive procedures become the order of the day – and that is why we are where we are. We need more nursing staff and in particular midwives to be cultivated who work at institutions where they have developed ownership for what they do.
“We are hoping that nursing training in South Africa will revert to what it used to be, as from next year (pending a final decision by the SA Nursing Council). Midwives will then require a 4-year university degree or diploma in general nursing science in order to qualify as a nurse, and then a further 2-year postgraduate course to become a midwife. Nurses and midwives will soon (by September 2019) also need to complete Continuing Professional Development points – all of which will push up standards of midwives, leading to this being a profession that is fully recognised, accepted and respected by other professionals in the medical environment.”
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*See the full study at Panda S, Begley C, Daly D (2018) Clinicians’ views of factors influencing decisionmaking for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. PLoS ONE 13(7): e0200941. https://doi.org/10.1371/journal. pone.0200941