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Dehumanisation of Birth in South African Maternity Systems, and Possible Solutions

Recently I attended a birth at a government facility in Cape Town. I am a midwife living in South Africa and working for The Compassionate Birth Project which focuses on reducing obstetric violence by empowering frustrated, overworked, underpaid midwives to value themselves and their peers. The rationale behind the project is that when maternity staff feel valued they are less likely to take their disempowered frustration out on laboring women. 

My client had been transferred to high care for an obstructed labour and was awaiting a Caesarean section. Seven long waiting hours as the theatres were exceptionally busy that day. During that time, whilst managing intense contractions as best she could, a doctor, perhaps she was a paediatric registrar but we were never introduced to her, brought a tiny, twenty two week gestation baby into our rather small labour room. It had been born in the room next door where presumably there was no resuscitation equipment, and it was not considered viable. The doctor hooked it up to a heart monitor. It had a heart rate of thirty beats per minute instead of the usual one hundred and forty. And then the doctor, having still not acknowledged our presence, wandered off in a desultory fashion and left it there to die.

The frightening thing about the fifty minutes that this gorgeous little being spent with us before finally being returned to her mother where she should of course have been all that time (I think she was a little girl), was that staff members came in and out, peered at her, looked at us, and left again, with no word to us, no recognition that my client or the baby were people, and no concept that there was anything happening that was unacceptable. The premature baby eventually died about ten minutes after being returned to her mother, and then was brought back into our room, dead, to have her head measured and for a physical exam.

When the midwives and Drs checked my client most of them did so without introducing themselves, without explaining procedures like breaking her membranes, before doing them, or without explaining their findings after checking cervical dilation. In fact they managed to do most of their work without even looking at her. It felt rather as if she was a bit of a nuisance in the way of them doing their work.

This can’t really be called obstetric violence, of which there is much recorded evidence in South African maternity centres. It is simply a lack of genuine care. According to a report compiled by The National Committee for Confidential Enquiry into Maternal Deaths in South Africa, ‘60.4% of all maternal deaths were thought to be possibly or probably avoidable. This indicates a poor quality of care, but also by improving the quality of care there is the possibility of reducing maternal deaths.’

It also indicates a level of compassion fatigue that is almost incomprehensible. One of three markers for burnout used by the Maslach Burnout Inventory is cynicism or ‘de-personalisation towards recipients of care’. When we are worn down we become cynical. I have heard obstetric consultants refer to medical students as being in their ‘pre-cynical’ and then their ‘cynical’ years of training, instead of their ‘pre-clinical’ and ‘clinical’ years. As part of the Compassionate Birth Project programme, we meet with fourth and fifth-year medical students in tutorials to address issues such as burnout and to give them space to speak about their initial discomfort at the level of depersonalization of both themselves and their patients in the wards. Many of them have never been asked how they are feeling, or how they are coping with the intense pressures of their schedule.

If burnout is the problem, what are the particular stressors in maternity that create extreme burnout and resultant depersonalization of patients?

Women often experience intense pain in labour. The pain is exacerbated when they are frightened, and our maternity system does little or nothing to decrease fear in patients. There is no recognition that fear is unhelpful, it is simply seen as an irritation most of the time. However, the woman in labour will finally have her baby, then she will go home and hopefully bond with it happily. The staff in the maternity wards simply move onto the next patient in pain, and the next, and the next. Occasionally up to thirteen babies born in a twelve-hour shift, with only one midwife on duty.

They also leave work to go home to busy after hour care of their own children who are growing up in a violent society where they are not always safe.

Then they carry enormous responsibility at work. If a patient or a baby dies, fingers are pointed, and staff in maternity wards need to cover their backs, follow protocols and make sure that those fingers aren’t pointing at them. No fingers get pointed for not loving a woman enough in labour, or for not acknowledging her feelings. Or for shouting at her, or sometimes slapping her to make her behave, to please, please, please give them a break, and just behave!

It’s not really a whole lot of fun!

And finally we need to look at the dynamic of bully behavior. Firstly, we may only feel okay about mistreating people if we can objectify and depersonalize them, otherwise it is too painful for us. Secondly, when we are frustrated, and have no acceptable outlet for it, we take may that frustration out on those who are more vulnerable than us. Disempowered people who feel unrecognized and under-appreciated may turn into bullies.

Historically South Africa disempowered the majority of its population. The legacy of apartheid still runs strongly in the domestic and sexual abuse meted out to women and children, where we have the highest rate of rape in the world.

Midwives are not exempt from this legacy, and many of them report domestic violence at home. If a midwife has been traumatized sexually herself, it could create discomfort for her to witness someone else experiencing pain and helplessness associated with her genital and uterine area, and has the potential to trigger intolerable feelings.

Compare this scenario to a good birth. As a sixteen-year-old, rather frightened pregnant girl Lindii Mandyo wasn’t treated well in the hospital when she went for antenatal check-ups. Teenagers often report that they are shamed by midwives for falling pregnant and are punished in the hope that they will learn a lesson. She said “Nurses, when they were checking the baby, they made no communication with me”.

So she decided to give birth with an independent midwife. Lindii says “I called my midwife. Yo, it was sore. I started to cry.” And sometime later “I saw blood. I was scared – no-one mentioned blood. (But) My midwife was so chilled….. A lot of hours later at 5.00 in the morning I gave birth to baby Mikhaya. It was like, everything was so perfect. It was nice. Ya.”

How then do we address this systemic problem of dehumanization in our maternity wards?

Just as love comes from being loved, so a caring attitude grows from being cared for.

The Compassionate Birth Project is a systems based programme which offers staff working in public maternity units, from midwives and doctors to clerks and security, a process to discover the human compassion within themselves, empowering them to provide more holistic, patient-centred care – where every mother and every infant matter.

Mothers and infants need to feel respected, safe and loved during labour and birth. Studies have found if we offer this kind of care women have:

  • Decreased length of labour
  • Decreased pitocin use
  • Decreased use of epidurals
  • Decrease use of forceps and vacuum extraction
  • Less intrapartum analgesia
  • Decreased cesarean section rates
  • More satisfaction with their birth experiences
  • Improved self-esteem 

And their babies have:

  • Better 5-minute Apgar scores
  • Better bonding with their mothers, with resultant improvement in breastfeeding rates and decreased stress biomarkers.

Maternity caregivers need to show compassion during labour and birth, because doing so offers the following benefits:

  • Improved working atmosphere for staff members with decreased stress levels
  • Increased sense of well-being and self-respect amongst midwives
  • Improved staff-patient interactions and decreased abuse of labouring women
  • Improved birth outcomes
  • Improvement in the Sustainable Development Goals of:

– Reducing under-five mortality

– Reducing maternal mortality

  • Cost benefits in terms of reduced numbers of obstetrics interventions and/or necessity of referral to hospitals
  • Decrease in expensive litigation. At a medico-legal summit in Pretoria in March 2015, South African Minister of Health, Dr Aaron Motsolaedi, stated that “Unprecedented levels of litigation for alleged malpractice by doctors have crippled South Africa’s health system” Obstetrics is under the most pressure for escalating litigation. Patients who are satisfied with their births are less likely to sue the medical system.

The Compassionate Birth Project has been designed to help improve compassionate care by offering midwives and maternity staff a place to feel loved, supported and cared for themselves. The Compassionate Care Course runs for 30 weeks – One and a half hours per week on site at some of the Midwife Obstetric Units in the Western Cape.

The course has 10 modules. Each of the 30 sessions begins with a safe listening space for a check-in and a review of the previous week’s session. This safe listening space is a core component of all the modules. Every class begins with an exercise in building present moment awareness, deep breathing, a short guided relaxation and a check-in. ‘Time to Think’, mindful awareness and Non-Violent Communication are taught as ways for the maternity staff to be present to their own feelings. Gratitude journals, massage techniques, singing and dancing are all introduced as methods to de-stress and to deal with burnout. Tutorials on up-skilling midwives in more compassionate care with recommendations on delaying umbilical cord clamping, and on skin to skin contact between mother and baby are given. Included in this part of the programme are discussions on sexual abuse and how it might affect women in labour.

Underlying the principle of improved care for women and their babies at birth lies the fundamental principal of Ubuntu, as expressed by our beloved Archbishop Emeritus Desmond Tutu when he says, “My humanity is bound up in yours, for we can only be human together.” It is a concept that is integral to community life in South Africa, and one that has the potential to change the face of birth in our maternity wards in South Africa.

References:

Joan Klagsbrun, Ph.D. Listening and Focusing: Holistic Health Care Tools for Nurses.

Jessica Wooliscroft. Freedom and oppression in therapeutic space: How do trauma therapists protect the therapeutic milieu? A heuristic study.’ University of Chester. 2010

Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial. Shauna L. Shapiro Santa Clara University. John A. Astin California Pacific Medical Center. Scott R. Bishop

Jane Branscomb (2011), Summation Evaluation of a Workshop in Collaborative Communication, M.A. Thesis, Rollins School of Public Health of Emory University.

Gates, Bob; Gear, Jane; Wray, Jane (2000). Behavioural Distress: Concepts & Strategies. Bailliere Tindall.

Inbal Kashtan, Miki Kashtan, Key Assumptions and Intentions of NVC, BayNVC.org

Harry Mills PhD, Natalie Reiss PhD, Mark Dombeck PhD. Kinetic (movement) strategies for Stress Relief.

Lindgren L, Rundgren S, Winsö O, Lehtipalo S, Wiklund U, Karlsson M, Stenlund H, Jacobsson C, Brulin C. Physiological responses to touch massage in healthy volunteers. Autonomic Neuroscience: Basic and Clinical. 2010; 158: 105-110.

Odent M. Birth Reborn. Pantheon (NY). 1984

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