Introduction
There is concern that C-section rates are increasing in the public health sector in South Africa
and wide variation has been reported between districts, provinces and hospitals. This study is
a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01-
2008/09 by facility, district and province. It aims to inform decision makers in maternal
health services of the trends and patterns occurring in C-section rates in South African public
sector hospitals. Variation in C-section rates is described to highlight the differences in care
that pregnant women receive in different parts of the country and to illustrate where inequity
of resource allocation is occurring, as well as highlighting possible data quality problems.
Methodology
This is a descriptive study using quantitative methods of analysis on secondary data obtained
from the National Department of Health’s routinely collected data specific to Caesarean
sections in the DHIS. C-section averages are weighted by taking the number of deliveries per
facility and level into consideration.
Results
1. Wide variation is noted between individual facilities, between and within provinces
and districts and within the different levels of hospitals in 2008/09.
The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in
Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest
district average C-section rates is seen for District Hospitals. Within provinces, average
District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict
variation in Regional Hospitals shows a 3.3 fold difference between the lowest
and highest average district rates. Among the eight National Central Hospitals there is a
2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section
rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine
hospitals of varying levels had rates of over 50%
2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing.
Nationally the average C-section rate in South Africa increased by 6.3 percentage points
from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth
rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear
relationship between time (year) and C-section rate (p<0.001). All levels of hospitals
showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial
Hospitals having increased by the highest amount (1.40%) year on year and District
Hospitals, the least (0.48%). Trends within certain districts and individual hospitals
however, show a decline.
3. A strong relationship between level of deprivation and C-section rate exists when
adjusting data for provincial variation
Bivariate linear regression analysis revealed no association between the level of
deprivation of the population at district level and the mean C-sections rate per district
(p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a
significant association (p=0.044). A negative association between the DI (p=0.006) and Csection
rate is seen in eight out of nine provinces.
4. Data quality of C-sections and deliveries in the DHIS needs improving
Data quality in the DHIS leaves uncertainty in some instances whether C-section rate
trends are a true reflection or not. The C-section rate indicator on its own is unable to
inform on the full spectrum of emergency obstetric care. The definition of C-section rate
for primary health care currently only considers deliveries in District Hospitals. The
national C-section rate for primary health care in the country however, reduces from
17.2% to 13.2% when including the deliveries which take place in CHCs.
Conclusions
The quality of data relating to C-sections (number of births, C-sections and hospital
categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and
should include deliveries and C-sections which take place in Community Health Centres to
allow for a more accurate reflection of C-section rate in primary health care.
The C-section rate indicator on its own is insufficient to adequately inform on the full
spectrum and quality of the provision of emergency obstetric care in South Africa. Including
additional indicators to the DHIS, such as the UN process indicators, could improve on the
current knowledge and monitoring of the provision of emergency obstetric care in South
Africa.
The wide variation in C-section rates seen among District Hospitals and the C-section rates
between and within districts and provinces, suggest inequity in resource allocation and
irregular service delivery patterns. Reasons and solutions for these wide differences need to
be found, which are likely to be unique to each district and province.
Further studies are needed to investigate the access of poorer women, especially those in
remote rural areas to emergency obstetric care services.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/12631 |
| Date | 05 April 2013 |
| Creators | Monticelli, Fiorenza |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf, application/pdf, application/pdf |
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