Caesarean delivery rates exceed 70% in the private sector, among the highest globally, but regulatory oversight and reevaluation of current models could correct this skewed statistic.
The development and implementation of new, hospital-based birthing centres with team-based maternity care models offer a promising solution
Professor Tanya Doherty and Geetesh Solanki
Maternal and child health remains a critical public health issue in South Africa. Despite significant strides in reducing maternal mortality — from 173 per 100 000 live births in 2000 to 127 per 100 000 in 2020, according to the World Health Organization — the country continues to face severe disparities in maternal care between the public and private sectors. These disparities not only affect the distribution of care providers but also influence the quality of care and outcomes for mothers and their babies.
One of the most pressing concerns lies in the high rates of caesarean deliveries. In the public sector, caesarean delivery rates stand at 28.1%, consistent with other low- and middle-income countries. However, the case-fatality rate for caesarean deliveries is three times higher than that of vaginal deliveries, with 27% of these fatalities associated with haemorrhage. These alarming statistics can be attributed to delays in performing caesarean deliveries due to overburdened services and a shortage of adequately trained professionals to manage these procedures safely.
The situation is even more concerning in the private sector, where caesarean delivery rates exceed 70% — among the highest globally. Such high rates suggest that a significant proportion of these procedures may be medically unnecessary, driven by a combination of individual-specialist driven care models, fee-for-service remuneration structures, and a fragmented medico-legal framework. These issues underscore the urgent need for regulatory oversight and a reevaluation of current models or care.
The Council for Medical Schemes has recognised this problem, calling for “urgent steps to reduce what is likely to be high levels of medically unnecessary caesarean delivery rates in the medical schemes population.” However, the challenge extends beyond merely reducing these rates. South African policymakers must find ways to harness private-sector resources to benefit the broader population, particularly those reliant on the public sector, without perpetuating the problematic practices currently observed in the private sector.
The development and implementation of new, hospital-based birthing centres with team-based maternity care models offer a promising solution. These models could serve as essential building blocks for the proposed National Health Insurance (NHI), which aims to integrate healthcare services across both the public and private sectors. However, creating such partnerships will not be easy. The private sector’s high levels of inappropriate care and its fragmented nature complicate efforts to design and implement effective, collaborative models.
Drawing on our research on care and contracting models from five rural district hospitals in the Western Cape, we have identified six key features that are critical to delivering appropriate maternity care:
1. Risk-based service model: Midwives should handle normal vaginal deliveries, while medical officers, private general practitioners, or obstetric specialists manage complicated vaginal deliveries and caesarean deliveries.
2. Strict clinical governance: Adherence to clinical protocols and strong governance structures are essential for ensuring the safety and quality of care.
3. Team-based approach: Maternity care should be delivered by a coordinated team of healthcare providers rather than relying on individual practitioners.
4. Time-based remuneration models: Healthcare providers should be compensated based on the time they dedicate to care, rather than the number or type of deliveries they perform.
5. Group liability arrangements: Professional liability should be at a group (birthing centre) level to bring down costs and to encourage collaborative care and shared responsibility.
6. Continuous monitoring and evaluation: Regular monitoring of outcomes, evaluation of performance, and the application of remedial measures are crucial for ongoing improvement in maternity care.
South Africa’s maternal healthcare system is at a crossroads. The current patterns of obstetric care, particularly in the private sector, are unsustainable and inappropriate. Policymakers must take bold steps to reform these practices and create a more equitable, effective system that serves all South Africans. By embracing team-based, risk-appropriate care models, we can pave the way for a brighter future in maternal health, ensuring that every mother and child receives the care they deserve.
Professor Tanya Doherty and Geetesh Solanki work for the South African Medical Research Council