Caesarean section rates in South Africa: Evidence of bias among different ‘population groups’

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Abstract
Objective. The aim of this study was to assess the effect of ‘population group’ classification, as a specific instance of ‘racial’ categorization, on caesarean section rates in South Africa. Design. Information on ‘population group’ classification ('Black’, ‘Coloured’, ‘Indian’ or ‘White’, as defined under apartheid legislation) and place of delivery, together with basic obstetric, sociodemographic and perinatal data, were extracted from the birth notification forms of 5456 children who made up the birth cohort of the Birth to Ten longitudinal study. This cohort included all births that occurred to mothers resident in Soweto‐Johannesburg during a 7‐week period in 1990. Results. After accounting for differences in maternal age, gravidity, birth weight and gestational age at delivery, the rate of caesarean sections at private facilities was more than twice that at public facilities. Although there were significant differences in the utilisation of private facilities by women from different ‘population groups’, there was an independent effect of ‘population group’ classification on caesarean section rates: caesarean section rates among women classified as ‘White’ and ‘Coloured’ were significantly higher (95% confidence intervals for odds ratios: 1.40–2.42 and 1.05–1.81, respectively) than among women classified as ‘Black’. Conclusion. ’Population group’ differences in caesarean section rates among South African women are not explained by differences in demographic risk factors for assisted delivery, nor by differences in access to private health care. Instead, the differences in section rates may reflect the effect of bias in clinical decision‐making, and/or differences among women from different ‘population groups’ in their attitude towards assisted delivery, and their capacity to negotiate with clinicians.

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