South Africa is plagued by four intersecting health epidemics – HIV and TB, non-communicable diseases, violence and maternal and infant mortality. These are not about high-tech medical solutions. They are about changing lifestyles and providing basic public services like clean water and air, sanitation, housing and primary health care.

It is well known that South Africa is the most unequal country in the world. Now, we have added another dubious honour – a recent study has found that we have the highest caesarean section rates in the world.

A 2019 study by Geetesh Solanki, Susan Fawcus and Emanuelle Daviaud of the SAMRC and UCT on caesarean sections in the private sector shows that we have the highest caesarean section rate in the world. At 73.6% this is considerably higher than the safe rates recommended by the World Health Organisation (WHO).

This is also three times higher than the South African caesarean section rate in the public sector. The South African private caesarean section rate is also higher than those of well-functioning public national health systems such as Britain and the Netherlands, which have better or similar outcomes than the SA private sector in terms of maternal and perinatal mortality.

Caesareans are important medical interventions to save the lives of mothers and their new born babies when required by specific medical and obstetric indications. These interventions are supposed to involve the professional medical team weighing up the immediate threats to the mother and baby’s health against the fact that caesareans can increase risks to mothers and their babies both during delivery and for subsequent pregnancy.

The SAMRC-UCT study says most healthy women “prefer to give birth via a normal vaginal delivery provided safety for them and their baby can be ensured.” The WHO, in a 2015 statement, based on country data, says that caesarean section rates above 10-15% confer no further benefit in reducing maternal and perinatal deaths.

So what is the significance of this study?

South Africa is a signatory to the Sustainable Development Goals of the United Nations – one of which is a commitment to reducing maternal and neonatal deaths. These are women dying while giving birth and/or babies dying within 28 days of being born.

The target for maternal mortality for this year is fewer than 100 maternal deaths per 100 000 live births. And for neonatal mortality the goal is six maternal deaths per 1 000 live births. But the South African Medical Research Centre records (SAMRC) that between 2011 and 2016 we have as many as 154 maternal deaths per 100 000 and 12 per 1000 for babies dying within 28 days, so we are not nearly reaching the goals to which the government is committed.

South Africa, in fact, has nearly 1% of global maternal and neonatal deaths and two to three times the average for comparable countries – according to the Centre for Rural Health and the SAMRC’s Health System’s Unit. Yet, after decades of apartheid discrimination against black women, some 97% of South African women giving birth now do so accompanied by a health professional.

These figures point to the urgency of fixing the healthcare system as a national crisis and also ensuring that all people have access to health care without cost, amongst other things, being impediments. They also speak to the misconception that we can ring-fence one section of health care – private health care and its systems of medical aids – and be content with this kind of medical apartheid.

Government has undertaken to move towards universal health care access, in which everyone is able to source health care when required, without being turned away because they cannot afford it. Currently we have two systems of health care. Some 20% of South Africans use the private health care system, the majority by paying fees to one or other private medical Aid. While 80%of the population use the public health system, in which hospitals are often overcrowded and understaffed, where patients face cruel waiting times and sudden shortages of drugs and staff is the norm. Those in rural areas often have little to no access to medical care.

The vehicle that Government envisages for realising this goal of universal healthcare is the National Health Insurance (NHI), in which people may access health care in the public sector or the private sector (which has been accredited), by drawing on the NHI. The NHI has been through waves of negotiations and delays as various private interest groups have lobbied against it and economic and political commentators have questioned whether South Africa can “afford” the NHI. Others have called on the government to fix the public healthcare system first and to regulate the private system, including medical aid schemes.

But as it stands, the 2018 NHI Bill, which has been approved by the Cabinet, and is ready for presentation to Parliament is all about setting up the NHI as a fund, and discussing the management of that fund.

Which brings us back to the study done by the SAMRC’s Health Systems Research Unit.

Today we can add one more figure to South Africa’s top-of-the-table notoriety. But with the NHI envisaged as a fund that will pay for care in the public or the private system… then costs in the private system will have a direct bearing on the sustainability and functionality of the NHI.

So what are the drivers for this exceptionally high CS statistic and what are the possible outcomes for our healthcare system, if it is not addressed?

While the authors of the study are at pains to say that it would take further studies to examine – with the appropriate degree of rigour – what the principal drivers are: Is it the women themselves? Is it the outcome of obstetrician pressure? Is it the fear of litigation? – they have conducted presentations of the study with groups of medical practitioners from which some anecdotal evidence has emerged.

The average overall cost of caesarean deliveries is significantly higher than the average cost for vaginal delivery – R38 000 against R25 000 – with hospital costs and gynaecologist costs the largest contributors. So there is an important financial incentive in the private sector to do caesareans instead of vaginal delivery. The authors also noted the role of the high cost of medical indemnity fees pushes private obstetricians towards caesars as the default option.

While in the private sector most obstetrics practitioners operate solo, in the public sector medical professionals work in teams of specialists, junior doctors and midwives. So decisions about caesarean section versus vaginal delivery in the private sector can often be taken alone or may be booked in advance by the specialist concerned. In the public sector, by way of contrast, midwife-led obstetrics is associated with less intervention and lower caesarean section rates.

Then there are the women themselves. Many associate caesareans with less pain and no protracted labour nightmares. Many in the private sector are wealthier women already paying high medical aid fees so cost is not a dis-incentive. Others are concerned with postnatal incontinence and the like.

But the role of the medical specialists in presenting the case for vaginal delivery where there is no medical threat to the mother or the baby cannot be gainsaid. Which is why the team model adopted in the public sector may well have to be part of future NHI regulation.

This brings us to the financial implications for the healthcare system as a whole of the current high levels of caesars and their likely impact on the future of universal access and the NHI.

As currently envisaged the NHI is a sum of money which people requiring healthcare can draw on to access that healthcare in either the public or the private sector – with the proviso that not every desired medical intervention will be part of that access. Maternal and neonatal healthcare – given that maternal and neonatal healthcare deaths is one of our four intersecting health epidemics – will almost certainly be included.

With our world-leading statistic of 73.6% caesarean rates in the private sector, and the associated costs of caesareans in that sector, we need to find ways to do two things together – reduce caesarean section rates closer to what the WHO recommends; and reduce caesarean section costs – both hospitalisation and obstetrics, as the biggest drivers. And to be ready to present evidence-based arguments when private interest groups compete for public opinion.

This SAMRC-UCT study is giving us an important area for intervention and focus if we are to make the NHI and universal access realisable and sustainable.