The state of caesarean sections in South Africa: Challenges, unknowns and the way forward
DOI:
https://doi.org/10.7196/SAMJ.2026.v116i2.4227Keywords:
Caesarean section, maternal health, health equity, private sectorAbstract
The scarcity of safe and timely caesarean sections in much of Africa contrasts with SA’s paradox of having one of the world’s highest rates of caesarean section in the private sector – approaching 80% – yet persistently high maternal and perinatal mortality in rural public hospitals. This article addresses three challenges: (i) inequitable access to safe caesarean sections; (ii) high and rising caesarean section rates without evidence of better outcomes, raising concerns about overservicing, costs and respectful care; and (iii) research and data gaps. Closing these gaps requires action from all stakeholders to ensure equitable, high-quality and life-saving care for all.
References
1. Biccard B. Safer Surgery for Africa: Challenges and Solutions. Cape Town: Biccard Press, 2024.
2. National Department of Health, South Africa. Saving Mothers: National Committee for Confidential
Enquiry into Maternal Deaths: Annual Report for 2023. https://www.health.gov.za/wp-content/
uploads/2024/10/Saving-Mothers-Report-2023.pdf (accessed 18 February 2026).
3. Solanki GC, Cornell JE, Daviaud E, Fawcus S. Caesarean section rates in South Africa: A case study of
the health systems challenges for the proposed National Health Insurance. S Afr Med J 2020;110(8):747.
https://doi.org/10.7196/samj.2020.v110i8.14699
4. Council for Medical Schemes. Epidemiology and trends of caesarean section births in the
medical schemes’ population, 2015 - 2018: Policy, Research and Monitoring. CMS, 2020. https://
www.medicalschemes.com/files/Research%20Briefs/Caesarean%20section%20births%20-%20
Research%20Brief%201%20of%202020.pdf (accessed 11 February 2026).
5. Wu ML, Nichols PM, Cormick G, Betran AP, Gibbons L, Belizan JM. Global inequities in cesarean
section deliveries and required resources persist. Eur J Obstet Gynecol Reprod Biol 2023;285:31-40.
https://doi.org/10.1016/j.ejogrb.2023.03.036
6. National Department of Health, South Africa. Saving Mothers Triennial Technical Report 2017 - 2019.
https://www.health.gov.za/wp-content/uploads/2023/11/Saving-Mothers-2017-2019-Technical-
Report-FINAL-2-1.pdf (accessed 8 August 2025).
7. Choonara S, Eyles J. Out of control: Profit-seeking behaviour, unnecessary medical procedures and
rising costs of private medical care in South Africa. BMJ Glob Health 2016;1(1):e000013.
8. Naudé N, Horak TA, Fawcus S, Stewart CJ, Lindow SW. Preference for mode of delivery in a low-risk
population in Cape Town, South Africa. Eur J Obstet Gynecol Reprod Biol 2020;254:259-265. https://
doi.org/10.1016/j.ejogrb.2020.09.028
9. National Department of Health, South Africa. Saving Mothers 2008 - 2010. Pretoria: NDoH, 2010.
https://www.hst.org.za/publications/NonHST%20Publications/savingmothersshort.pdf (accessed 8
August 2025).
10. National Department of Health, South Africa. Saving Mothers 2011 - 2013: Sixth report on the
confidential enquiries into maternal deaths in South Africa: Short report. Pretoria: NDoH, 2013.
https://www2.kznhealth.gov.za/mcwh/Maternal/Saving-Mothers-2011-2013-short-report.pdf
(accessed 8 August 2025).
11. National Department of Health, South Africa. Saving Mothers 2014 - 2016: Seventh triennial report on
confidential enquiries into maternal deaths in South Africa: Short report. Pretoria: NDoH, 2016. https://
anaesthetics.ukzn.ac.za/Libraries/Obstets3_2019/Saving_Mothers.pdf (accessed 8 August 2025).
12. National Department of Health, South Africa. Saving Mothers Annual Report for 2021. Pretoria:
NDoH, 2021. https://www.health.gov.za/wp-content/uploads/2023/09/Saving-Mothers-Report-2021.
pdf (accessed 8 August 2025).
13. Council for Medical Schemes. Annual Report 2017/2018. CMS, 2018. https://www.medicalschemes.
com/files/Annual%20Reports/CMS_AnnualReport2017-2018.pdf (accessed 8 August 2025).
14. Dell A, Kahn D, Klopper J. Surgical resources in South Africa: An analysis of the inequalities between
the public and private sector. S Afr J Surg 2018;56(2):16-20.
15. Tudor Hart J. The inverse care law. Lancet 1971;297(7696):405-412. https://doi.org/10.1016/S0140-
6736(71)92410-X
16. National Department of Health, South Africa. South African maternal, perinatal, and neonatal health
policy. Pretoria: NDoH, 2021. https://knowledgehub.health.gov.za/system/files/2024-02/SA%20
MPNH%20Policy%202021.pdf (accessed 8 August 2025).
17. Kredo T, Cooper S, Abrams AL, et al. ‘Building on shaky ground’ – challenges to and solutions for
primary care guideline implementation in four provinces in South Africa: A qualitative study. BMJ
Open 2020;10(5):e031468. https://doi.org/10.1136/bmjopen-2019-031468
18. Matahela SR, Adekola AP, Mavhandu-Mudzusi AH. Exploring quality standards implementation at
a South African municipality’s health facilities. Curationis 2023;46(1):e1-e9. https://doi.org/10.4102/
curationis.v46i1.2416
19. Odendaal W, Chetty T, Goga A, et al. From purists to pragmatists: A qualitative evaluation of
how implementation processes and contexts shaped the uptake and methodological adaptations
of a maternal and neonatal quality improvement programme in South Africa prior to, and during
COVID-19. BMC Health Serv Res 2023;23(1):819. https://doi.org/10.1186/s12913-023-09826-5
20. Solanki GC, Doherty T, Brijlal V, Daviaud E, Fawcus S. Towards developing new private sector
obstetric care and contracting models in South Africa: Insights from public hospitals using private
general practitioners to provide caesarean deliveries. S Afr Med J 2024;114(4):e1531. https://doi.
org/10.7196/SAMJ.2024.v114i4.1531
21. Nkonki L, Bhengu N, Ramokgopa M, Fonn S. The Health Market Inquiry and its potential contribution
to improving health systems functioning in South Africa. S Afr Health Rev 2019:81-88. https://www.
hst.org.za/publications/South%20African%20Health%20Reviews/07%20SAHR_2019_The%20
Health%20Market%20Inquiry.pdf (accessed 8 August 2025).
22. Taylor B, Van Waart J, Ranchod S, Taylor A. Medicolegal storm threatening maternal and child
healthcare services. S Afr Med J 2018;108(3):149. https://doi.org/10.7196/samj.2018.v108i3.13139
23. Snyman LC. The incessant escalation of medico-legal challenges of South African healthcare
professionals. Afr J Obstet Gynaecol 2024;2(3). https://hdl.handle.net/10520/ejc-afjog_v2_n3_a1
(accessed 8 August 2025).
24. Standing Committee on Appropriations. Status of the medico-legal claims and service delivery
implications (with Minister and Deputy Minister). Pretoria: Parliamentary Monitoring Group, 2024.
https://pmg.org.za/committee-meeting/39467/ (accessed 8 August 2025).
25. Health Systems Trust. District Health Barometer 2023/2024. Report No. 17. Durban: HST, 2025.
26. Solanki G, Daviaud E, Fawcus S, Brijlal V, Doherty T. Models using private general practitioners to
provide caesarean deliveries at five South African district public hospitals: Insights for public-private
contracting for obstetric care in rural areas. Glob Health Action 2023;16(1):2241811. https://doi.org/
10.1080/16549716.2023.2241811
27. Maswime S, Jayaraman S, Alaba O, Robalo M. Universal access to surgical care – a global public health
priority. PLoS Glob Public Health 2025;5(4):e0004326. https://doi.org/10.1371/journal.pgph.0004326
28. National Committee on Confidential Enquiries into Maternal Deaths. Setting minimum standards
for safe caesarean section in South Africa. Obstetr Gynaecol For 2015;25(3):41-44. https://hdl.handle.
net/10520/EJC174707 (accessed 11 February 2026).
29. Doherty T, Solanki G, Daviaud E, Bartmann Y, Hawkridge A, Fawcus S. Utilisation of private
general practitioners to provide caesarean deliveries in five rural district public hospitals in
South Africa: A mixed-methods study. BMJ Open 2023;13(3):e067663. https://doi.org/10.1136/
bmjopen-2022-067663
30. Doherty T, Fawcus S, Brijlal V, Solanki G. Towards developing new private sector maternity care
models in South Africa: Results from a deliberative stakeholder dialogue. Glob Health 2025;21(1):50.
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Copyright (c) 2026 M Bhathena, S Maswime, S Fawcus, M Isiagi, M V Kinney
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