Caesarean section: The fatal option

The number of women bleeding to death as a result of a Caesarean section is a national emergency.

Published figures show a 63% increase in such deaths between 2008 and 2014 - and in 71% of instances the deaths could have been avoided, experts say.

The information was published in this month's edition of the South African Medical Journal. Among the authors of the journal article are members of the National Committee on Confidential Enquiries into Maternal Deaths, which was convened by the Department of Health.

The lack of skills among doctors and a shortage of resources, especially in rural hospitals, have been blamed.

Surgical skills were said to be "insufficient" and there is said to be a lack of skills among anaesthetists. Doctors' theatre notes on Caesarean deliveries were ''frequently of such poor quality" that it was not possible to determine the volume of blood lost or the reasons for the loss.

The authors of the article said there were "delays in calling for help if there was ongoing bleeding", patients were inappropriately discharged from post-theatre recovery, and they were "poorly monitored" in the post-natal ward.

Sue Fawcus, of the University of Cape Town, one of the authors and deputy chairman of the National Committee on Confidential Enquiries into Maternal Deaths, said: "We are concerned that the problem has not got better but worse, and we wanted to highlight this to the obstetrics community, doctors, midwives ... each hospital needs to be seen to be accountable so that it can work out its solutions.

"We don't think the increase in the number of deaths is because we are doing more Caesarean sections - there is something else going on in terms of the quality of care."

But the number of Caesarean sections has increased. In 2014 there were 236149, an increase of 30% from the 181405 in 2008.

"Caesarean-section deliveries should only be done for good medical reasons," Fawcus said. "Unnecessary Caesareans must be avoided. It is a major operation and should not be performed lightly."

Stefan Gebhardt, head of general specialist services at Tygerberg Hospital, Cape Town, explained that for every 10000 Caesarean sections at a public hospital, three women would die during or after the operation.

"Junior doctors are not always skilled enough to do complicated Caesarean sections but there are often no more senior or experienced doctors around to help," said Gebhardt.

"Bleeding only starts after the abdomen is closed and the patient is in the recovery room. Pregnant women do not show signs of blood loss until it is very late. This bleeding is often missed because it is into the abdomen and the blood pressure and pulse rate remain normal until very late."

Peter de Jong, a consulting gynaecologist at Groote Schuur Hospital and the University of Cape Town, said: "There is great concern about women who have emergency sections in rural areas, where there is poor training, poor supervision and poor facilities. The best facilities are in cities and C-sections are done electively."

He said there was a need for ambulances reserved for women and women's health should take priority.

"It's a scandal; it's a disgrace. You need to have people explain what those preventable factors are in the rural areas and what is being done about it. There has to be accountability."

Health Department spokesman Joe Maile said he could comment only after consulting departmental experts.