An observstion of the caesarean section rate at a teaching hospital in Johannesburg

Abstract

Background In 1985, the WHO stated: “There is no justification for any region to have caesarean section rates higher than 10-15%”. Almost three decades later, the optimal caesarean delivery rate remains a topic of controversy in the developed and developing worlds. Caesarean births are on the rise globally. Although caesarean sections have a crucial lifesaving role in modern day obstetrics and are safer than ever before, they still remain a major surgical intervention that is not without risk. This is particularly prudent to South Africa where obstetric haemorrhage, most importantly bleeding at or after caesarean section, is the commonest direct cause of maternal death. Therefore, in the South African setting, minimising caesarean delivery is an essential strategy to reduce maternal mortality. Caesarean section audits are an important tool to understand and make recommendations for a possible reduction in caesarean delivery rates. The Robson’s Ten Group Classification System is such a tool and allows auditing, analysis and comparisons of caesarean delivery rates in a standardised manner. Methods A prospective observational study was conducted over a two month period at Chris Hani Baragwanath Academic Hospital in 2013. Chris Hani Baragwanath Hospital is a tertiary hospital located south of Johannesburg. The hospital services 2 million people, mainly of low-income, and the maternity unit delivers in excess of 23 000 babies each year. Most patients are high-risk and are referred by midwife managed obstetric units (MOU) Demographic, obstetric and delivery outcome data of women who delivered by caesarean section during this period were collected and captured onto a data sheet. Each delivery was also categorised according to the Robson’s Ten Group Classification System. The data was entered onto an excel spread sheet and analysed using the STATA statistical program. Results There were 3898 deliveries during the two month period, of which 1534 were caesarean sections resulting in a caesarean delivery rate of 39.4%. The majority of patients underwent emergency caesarean sections after the onset of spontaneous labour (60.9%). Fetal distress, previous caesarean section and dystocia were the commonest indications for caesarean section in order of frequency. In terms of the Robson’s Ten Group Classification System, the high caesarean section rate in our institution is attributed to the women with previous caesarean deliveries at term (group 5) and nulliparous patients in spontaneous labour at ≥ 37 weeks (group 1). Groups 3 and 10 are also responsible for a significant amount of caesarean sections performed in this population. The near-miss ratio was 24.7 cases per 1000 deliveries. The rate of comorbid disease amongst patients that experienced near-miss was 84.6% and most (61.5%) patients required a preterm delivery due to comorbid disease. Hypertension was the most commonly occurring comorbidity (69.2%). Only 23.1% of near-miss was due to caesarean section. In most cases, morbidity was due to the indication for caesarean delivery rather than to the operation itself. The results demonstrate that pre-eclampsia and postpartum haemorrhage are the most important initiating factors of near-miss occurring in 76.9% of patients. Conclusion Defining an optimal caesarean delivery rate in our setting may not be realistic, as CHBAH is a tertiary, referral centre, with a wide range in the health status of patients. The World Health Organisations recommendations of 15% for caesarean delivery rates globally may need to be adapted to take into account the patient profile and morbidity in South Africa. Ensuring equal access to good quality, medically appropriate obstetric care should be our primary concern.