South African women overwhelmingly opt for Caesarean sections over vaginal births. Why do they do this? We investigate to bring you all the facts. By Paula Marais
The choice between Caesarean sections and natural (vaginal) births is a fundamental one for mothers and obstetricians, with South Africa registering C-section rates that are considerably higher than that recommended by the World Health Organization (WHO). According to a 2019 study of 6542 births registered in South Africa, 4815 were Caesarean sections – making up 73.6% of the population. Of these, emergency C-sections made up 39.7% with elective C-sections making up 39.5%. These numbers are significant if one compares these rates, for example, to those found in a 2021 report done in the UK, in which C-sections were measured at 35% in the 2019/2020 period.
So why are South African women and gynaecologists choosing C-sections above natural births? It certainly isn’t related to cost effectiveness, since a natural birth including a two-to-three day recovery in hospital will cost a South African around R25,000, while a C-section requires an amount of R38,000 to R44,000, excluding any hospital stay of three to four days, which will of course incur additional costs. This can hugely affect medical aids and the financial balance of healthcare systems in general. It stands to reason, then, that most medical aids may prefer their clients to have a vaginal birth, yet in South Africa this does not always happen.
The first ever recorded C-section in SA
In a Facebook thread on the popular parents’ group, The Village, started by this author, discussing the choices women made regarding their deliveries, there were many reasons for C-sections over vaginal birth. These included: the large size (or head) of the baby; a baby in distress; unexpected early delivery; geriatric pregnancy; a placenta previa diagnosis; a baby with a cord around the neck; a breech baby; pre-eclampsia; a mother’s lupus diagnosis; the birth of multiples; intra-uterine death of baby; a baby presenting forehead first; insufficient amniotic fluid; prolapsed cord; severe maternal anxiety; and a calcified placenta, among many other reasons.
This confirms the findings of a 2019 study, in which C-section rates increase with higher maternal age but are also more prevalent for women with certain medical conditions. While C-sections are important interventions for at-risk pregnancies, these are still surgeries and can be linked to adverse complications in the short term and also possibly for future pregnancies.
However, obstetrician gynaecologist, Dr Frances Paterson, says, “From a medical perspective, there is no real benefit of the vaginal or the Caesarean section over the other. A vaginal birth that goes well is wonderful, but vaginal births are by nature unpredictable. Unfortunately, the consequences of a complicated vaginal birth are far reaching and can be extremely serious.”
Despite the surgical risk involved with C-sections, there are also women who elect for a C-section when vaginal birth is still an option. Sandra Pearl*says, “I didn’t care about the birthing experience or pain or recovery, only that my babies had the best chance of medical intervention should they need it.” 
The generally acknowledged risks and benefits of C-sections versus vaginal births are detailed in the table below.
Comparison of C-section and vaginal birth risks and benefits
| C-section | Vaginal birth |
| Can plan ahead (doctors and parents decide) | Cannot plan ahead (baby comes when ready) |
| Low risk of injury to the pelvic muscles, tissues and anal sphincters | Higher risk of injury to the pelvic muscles, tissues and anal sphincters |
| Lower risk of episiotomy (cut made in the tissue between the vaginal opening and the anus during childbirth) | Higher risk of episiotomy |
| Less/no pain felt during labour | High pain during labour |
| More predictable, controlled environment | Less predictable environment |
| Slower, more painful recovery | Faster, less painful recovery |
| More expensive | Less expensive |
| Slower return to pre-pregnancy figure | Faster return to pre-pregnancy figure |
| Greater possibility of infection, clotting, bleeding or scarring | Lower chance of infection, clotting, bleeding or scarring |
| Greater chance of injury to other organs | Temporary loss of anal or uterine function |
| Less chance of oxygen deprivation (baby) or other birth trauma | Greater chance of oxygen deprivation (baby) or other birth trauma |
| Lesser success breastfeeding (milk can take longer to come in; discomfort of holding baby newly healing incision) | Greater success breastfeeding |
| Greater chance of low-lying placenta, placenta accreta (placenta attached and embedded too deeply into the wall of the uterus) or damage to the womb in future pregnancies | Less chance of these issues |
| Mother may feel more disconnected from the birthing experience | Mother may feel more connected and more active with regards to the birthing experience |
| Does not prompt the body to release these brain proteins | Helps to increase the production of proteins in the baby’s brain that helps in brain development and brain function |
| Miss out on these hormonal changes | Hormonal changes during labour help in the proper development of lungs, stimulating the respiratory tract, allowing them to function optimally. |
| Babies more prone to develop asthma, allergies and infections and even diabetes later in life | Exposes the baby to beneficial bacteria present in the mother’s body that play a major role in developing the immune system of the baby |
According to the Village women, some of the reasons for elective C-sections included: fear of giving birth naturally; previous emergency C-sections; not wanting to give birth naturally; wanting a specific date (or doctor availability); and perceived lower risk (both for doctors and patients – medical insurance premiums are also vastly more inflated for doctors who assist in natural deliveries).
Another possible factor for the high number of C-sections in South Africa could be that this option is preferable to doctors as it does not inconvenience their schedule. Some women, like Jessica Scales*, reflected that she felt “fairly pressured by her gynae to have a Caesarean over a vaginal birth for her second child.” How many South African women may feel the same?
Read Overcoming a traumatic C-section
Interestingly, some women opted for vaginal birth due to a fear of needles or the faster recovery period alone. Some, however, may also choose a natural birth after the delivery of their previous baby by C-section, called VBAC (Vaginal birth after Caesarean section). Interestingly however, Dr Paterson, notes that in her practice currently, she finds that there has been a resurgence in the “natural approach”, as she has not found that women are choosing C-sections over vaginal birth. This could indicate a changing trend.
Currently, especially in private practice, it is up to the doctors and patients how they deliver. Says mother, Amanda Knight*, in the Village thread: “I don’t believe there is one way ‒ should be what’s best for mom, baby, age, health and circumstances.” It needs to be what’s right for the mother and the child. Dr Paterson agrees, “As long as my patient and the baby are well, and as long as there are no contra-indications to a vaginal delivery, I do not have any preference for my patients.”
Read more about C-sections
What I wish I had known before my C-section
* Names changed for privacy reasons.
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