The Choice that gives you more Choice

Midwife-Led-Care in South African Private Sector

By Anchen Verster – Nursing sister and midwife, SA certified perinatal educator

In South African in the private sector you have basically two options for birthing practitioners – obstetric led care or midwife led care. Obstetric Led Care is most common in the Private Sector. You choose your Obstetrician but when you go into labour the midwife on duty in the labour ward will care for you until you are ready to give birth and then the Obstetrician will be called. This midwife might change shift or be busy helping other labouring mothers. Dedicated Midwife Led Care means you have enlisted the services of a private midwife to care for you during your pregnancy, birth and postnatal period. She may or may not have an assistant midwife to help her. This form of care is growing in popularity in our country, as more women would like birth choices and a better chance of a vaginal birth. Your midwife remains dedicated to you throughout this period and is the primary caregiver during your birth. You will need to visit a “back up” Obstetrician twice prior to the birth and this Obstetrician will be called if your labour becomes complicated or does not progress according to standard guidelines. Worldwide Midwife led care is recommended for low risk pregnancies.

Midwife led care is based on the premise that pregnancy and birth is a normal life event and should be treated as such unless complications arise. If we think of birth in this way it challenges us to think differently about circumstances and interventions surrounding the birth.

Birth is a Medical Event 

(In the absence of complications)

Birth is a Normal Life Event

(In absence of complications)

Requires specialist doctor (obstetrician) Skilled trained midwife provides care
Only partner may be present Other birth support (doula) or family members (mother/ sister) welcome
Medical Pain Management (Epidural, Pethidine) Other pain management options (breathing, water immersion, reflexology, massage)
Hospital bed for mother only Birthing and postnatal room may include stay over facilities for partner
Clinical Environment Homely environment (but may still be in a birthing unit or hospital)
Hospital Policy and Doctor’s practices are primary Parents wishes significant part of birth plan
Water birth not option in many hospitals Water birth option for birth or pain management
Confined to bed (e.g. monitoring such as continuous foetal monitoring) Intermittent monitoring is encouraged so that the labouring mother can keep moving around and stay as upright as possible
Birthing position determined by care-giver Birthing position guided by mother
39 or 40 weeks gestation requires induction 41 or 42 weeks requires induction
Skin-to-skin with baby not always routine practice Skin-to-skin routine practice
Baby often taken to nursery or separated from mother for observation Baby stays with mother after birth
Formula often given for low blood sugar in baby Mothers colostrum given to baby with low blood sugar
Stay in hospital maximum stay covered by medical aid Shorter hospital stay

The Private hospital practices vary considerably across the country depending on their ‘Baby Friendly Hospital Designation’. If a hospital has the ‘Baby Friendly Designation’ the staff will encourage skin-to-skin as a routine practice and mom and baby will not be separated unless absolutely necessary. 

South African Midwife Led Care varies in availability around the country and is usually a more accessible model of care in the larger cities although some smaller towns have private midwives who travel between towns. South African women who have used a Private Midwife Led Care Model give emphatic thumbs up when asked to describe their experience. As a childbirth educator in Gauteng I am exposed to the pregnancy and birth journey of a variety of women using different service models. Parents who used the Midwife Led Service often give me incredibly positive feedback about their birth. Mothers feel the birth empowered them and they are awed at what their bodies are capable of doing. Dads in particular value their level of involvement and the skin-to-skin that they usually get to do with their newborn after mom has had her turn. Many mothers have tried different models with the birth of their 3 or 4 children and often express disappointment at the very medical model they followed with their first birth.

A large Cochrane review (an assessment of many good quality studies world-wide) showed that women who had midwife led care for their pregnancies, birth and beyond were more likely to have vaginal births, felt more in control of their births (yes many women want to feel in control of their births!) and were more likely to initiate Breastfeeding and continue breastfeeding. The statistics also show shorter hospital stay, less need for (regional) anaesthesia and a lower incidence of prematurity. This of course translates into significant lower cost to medical aid.

A 2015 Masters Thesis looked at the “Outcomes of Births Attended by Private Midwives in Gauteng” between 2012 and 2013 (Jordaan; 2015). It’s exciting to read these outcomes because it gives us more specific perspective on the South African Private Practice context albeit Gauteng as a starting point. The study compared Gauteng Midwife Led Births with a Cochrane review that compared Midwife Led Care with other models of care. The Gauteng midwives came out tops when it came to a lower percentage of interventions, more women with intact perineum’s and a significantly lower neonatal ICU admission rates. They had a higher postpartum haemorrhage rate but fewer women admitted to High Care because of this, which may indicate a discrepancy between definition or measurement criteria. The Gauteng midwife led outcomes scored higher on the Caesarean section rate (19.3%) by comparison to the international statistics (12.5%) but this percentage of 19.3 is still significantly lower than the Caesarean rate of most private hospitals in South Africa. The midwives statistics were comparable with positive outcomes in the rest of the world.

Its important to keep in mind that this model of care is most suitable for low risk pregnancies.

Seven Reasons why South African moms choose midwife led care:

  • Your midwife/ midwives stay the same throughout perinatal period (continuity of care)
  • Parents birth wishes are high priority
  • More flexibility with birth place and position during birth
  • Emphasis placed on relationship between care-giver and expectant parents
  • Practices are mother and baby friendly
  • Parents are more confident that if intervention is used it was really necessary
  • Home based postnatal care part of package

Jeannine from Pretoria says…

My midwife-assisted-birth enabled me to have a wonderful birth that was focused on welcoming our son into this world naturally rather than a birth focused on pain, medication and procedures”

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