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The changing paradigm of birth in the public sector in South Africa

“An invasion of armies can be resisted, but not an idea whose time has come.”

Victor Hugo

Projects, research, reports, policies, training programs and social media support groups invested in supporting an “idea whose time has come” are burgeoning in the public maternity sector in South Africa. The idea is timely and in response to a crisis of maternal abuse in labor by medical staff that has reached epidemic proportions and is widely researched (Jewkes, Abrahams and Mvo 1998). Horrifying articles have emerged, such as the 2011 Human Rights Watch report, “Stop Making Excuses” (2011), which writes about mothers’ experiences in labor in clinics in the Eastern Cape, a very poor province in South Africa.

Abeba M. states in the Human Rights Watch article,

A lady and her baby died in our ward. I did not think I would survive. Later, another woman suffering from high blood pressure also died. I thought I was next. I was so sick. I had blurred vision. When the second lady died, the nurse asked me, “Oh, you are still alive?” and the doctor said, “That lady is dead? Who is next?”

I was suffering the whole night and I was calling the nurses and they did not come. I remember it was on a Sunday. The nurse I was calling was playing a gospel song on her cell phone and dancing. I told her I was feeling very sick. She said, “I know, and what do you want me to do?” She was walking up and down whistling and dancing. (Human Rights Watch 2011, 22)

Of course there are wonderful midwives as well; most South African midwives are empathic and caring. However, the system doesn’t always support them to be so. In their 2012 World Report, Human Rights Watch stated, “The government’s failure to provide effective oversight for the implementation of existing reproductive and sexual health-related laws and policies contributes to South Africa’s high and increasing maternal death rate, as does a lack of accountability for recurrent problems in the health system, including abuses committed by health personnel” (2012, 168).

The reports on maternity staff abusing patients have created a culture of shame amongst midwives, who are understandably defensive in response. However, the hierarchy in the medical establishments remains mostly unchallenged. In the public South African hospitals, there is little place for questioning, negligible space to be listened to and not enough recognition of the need for airing of grievances. The life of a midwife is hard. Many nursing staff live far from their work place in the urban areas, and public transport is both expensive and unsafe. Too many nurses in South Africa head up households and are the breadwinners, often to unemployed extended families. The unemployment rates are extremely high. Young, strong, beautiful men, who have no chance of ever getting a job, take to crime and alcohol or drugs to relieve the feeling of being thwarted at every turn. This creates a lack of worth so disempowering that these men sometimes take their frustration out on the women, and both domestic violence and sexual abuse are endemic. These same women who experience such hardship at home come to work where the stressors in the maternity wards are intense. They work twelve-hour shifts. There are too many women in labor and too few staff on duty per shift. The laboring women are often alone, have had little or no antenatal education and are terrified of the midwives and the authoritarian attitude in the clinics. As a result of their high levels of fear, they are in extreme pain and behave “badly,” and in consequence are subject to slapping. They are often reprimanded with statements such as, “If you don’t stop that, you will kill your baby,” or they are told to clean up their own mess and are made to wait in punishment for “bad” behavior.

Right now in South Africa, there is a groundswell response to the critically high stress levels in our maternity wards. It is a movement, a collaboration, an emergence of hope and vitality and a belief that perhaps we can really change the system. Like raindrops spattering into a pool of water, groups of people are creating concentric circles of influence that are radiating outwards and intersecting with other groups to create a network of promise for a different way.

Ruth Ehrhardt, a midwife, is a team member of the Compassionate Birth Project. She says, “I feel like I am no longer swimming against the stream, but that there is enough support around me that I am flowing with the stream these days.” The Compassionate Birth Project comprises of a three day retreat and a follow up 12 week program of one and a half hours per week per clinic, where midwives are given the opportunity to experience deep listening and learn listening skills, to apply this to solution oriented debriefing, to receive massage and be taught basic massage techniques, to learn relaxation, to dance, sing, and appreciate and value themselves and one another and lastly to be given time for silence and time to simply enjoy themselves.

Professor Lynette Denny heads the Obstetric Department at the University of Cape Town Medical School. Even amongst the top echelons of the Ministry of Health, she is a highly respected voice, demanding better birth practices and a recognition of women’s rights. Alongside numerous other research projects and studies, Lynette set up tutorials on compassion for her fourth and fifth year medical students, envisioned the initial concept for the Compassionate Birth Project and was the catalyst for the Patient-Centered Maternity Care Code of Conduct which has been ratified by the Department of Health. This is seen as a step towards addressing South Africa’s inability to meet their maternal child health care targets as stipulated by the Millennium Development Goals for 2015. The Western Cape Department of Health has committed itself to patient-centered care as a fundamental principle for its draft 2020 strategy.

Dr. Nils Bergman, a world authority on skin-to-skin contact, has a vision to create a birth facility designed on neuroscience, where women in the public sector have access to skilled and compassionate care. His project intersects with the Compassionate Birth Project, with the plan to up-skill midwives, doctors and student midwives by exposing them, one or two at a time, to best birth practices in this clinic. Nils says, “We need to re-create a standard for what is a normal birth: not one based on a disease orientation and adverse outcome avoidance. The key is to ensure the mother feels safe, supporting oxytocin and the reproductive neuroscience linked to this” (Bergman, personal communication).

Zinzile Seepie, who runs the Zulu Birth Project, is collaborating with the Compassionate Birth Project to devise doula-training programs that can be rolled out nationwide. She says, “If African women in all their glory, forms and kinds can be supported through birth in a dignified, conscious and empowering manner, many of the social ills witnessed in South Africa will become a distant memory. When women birth in terror, their parenting is affected, their relationships with their children are affected. However, the opposite is also true! Women who are compassionately supported and loved through pregnancy, labor, birth and postpartum are reminded that they are precious, honored and worthy of love. This is echoed in their relationship with their babies” (Seepie, personal communication).

The annual Midwifery and Birth Conference provides a melting pot for the exchange of exciting ideas for midwives. In the past, the majority of attendees have been independent midwives and doulas. Now midwives from the public sector are clamoring to attend, too. They are waking up to the idea that there is support out there and that birth work doesn’t need to be so arduous. They are finding out about this conference, and the upcoming Human Rights Conference, and about changing the way they work through social media support groups, such as Empowering Midwives of South Africa, Young Midwives of South Africa and African Midwives.

These social media platforms are also offering a crucial form of support for young midwives, who after six months of midwifery training are sometimes sent to rural clinics where they often find themselves as the only midwife on duty. On occasion they have to deal with complicated obstetric emergencies on their own. At least these days they can send out an online cry for advice from their more experienced peers when they find themselves in a situation that they don’t know how to deal with.

Cape Town Embrace is working with mothers and babies in the first 1000 days, monitoring, educating and supporting them. They have found that the pregnancy and birth experience of these mothers hugely affects their ability to bond with and parent their children. While there has been much emphasis on skin-to-skin contact and on the value of breastfeeding and mother-to-mother support, Cape Town Embrace is now looking at ways to better support mothers in pregnancy and during the birth. Plans are afoot to provide antenatal education during the pregnancy and doulas during the labor and birth.

South Africans generally have access to adequate medical facilities and medical interventions (although sometimes it can take the ambulance thirteen hours or more to arrive in the rural areas). Operation Smile, who has in the past been providing surgery for children with cleft palates, is responding to the call for improvement of maternity care Africa-wide by instituting, supporting and funding maternity programs. These include the Helping Babies Breathe program, the Saving Mothers program, and they have recently begun focusing some of their fly-in surgery teams elsewhere in Africa to operate on young girls who have developed obstetric fistulas as a result of poor nutrition, rape or lack of access to medical facilities.

The idea that changing consciousness around birth can be fun and exciting is gaining momentum. Two years ago it was impossible to speak about the “sacred nature” of birth within the medical establishment, since this kind of language was so foreign as to render it inaccessible. These days, the recognition that something needs to be done to change the existing paradigm is emerging. In retrospect, all of us are waking up to the fact that our primal instinct is to labor and birth in an environment of safety, privacy and quiet support, where we can bond, breastfeed and provide undisturbed skin-to-skin care to our babies. The element of regarding birth with the reverence that we assign to the process of dying is emerging quietly. South African maternity services are awakening to the concept that so many of the issues we are facing with regard to abuse in labor have at their roots a lack of love. It is an idea whose time has come.

References:

Bergman, Nils. December 24, 2014. Personal communication.

Chadwick, RJ, D Cooper and J Harries. 2014. “Narratives of Distress about Birth in South African Public Maternity Settings: A Qualitative Study.” Midwifery 30 (7): 862–68.

Human Rights Watch. 2011. “Stop Making Excuses: Accountability for Maternal Health Care in South Africa.” https://www.hrw.org/report/2011/08/08/stop-making-excuses/accountability-maternal-health-care-south-africa.

Human Rights Watch. 2012. “World Report 2012: South Africa.” https://www.hrw.org/world-report/2012/country-chapters/south-africa.

Jewkes, R, N Abrahams, and Z Mvo. 1998. “Why Do Nurses Abuse Patients? Reflections from South African Obstetric Services.” Soc Sci Med 47 (11): 1781–95.

Seepie, Zinzile. December 23, 2014. Personal communication. 

Robyn Sheldon is a South African midwife offering a variety of services ranging from Soul Integration sessions, which seek to enable pregnant parents to connect on a soul level to their unborn babies, to training medical students and midwives in compassionate care. Her birth preparation classes assist parents in creating sacred and meaningful births for themselves and their babies.

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