Birth in the Western Cape – my perspective
(adapted from a talk given at The Midwifery and Birth Conference 2013)
Listen to the above audio to hear the prayer sung by the nurses as they started each day.
The Western Cape – home to about 10% of South Africa’s population. Between 1999 and 2007 the amount of live births increased from 70 000 to 99 000. About 5% of maternal deaths in South Africa are from the Western Cape. Most deaths are caused by non-pregnancy related illness like HIV and next hypertensive disorders in pregnancy. But I am not going to dwell on statistics of mortality. Although it is sobering to always remember that pregnancy carries risks and moms can die!
I want to give you a flavour of my experience in the PUBLIC sector of Birth in the Western Cape – full of diversity and discrepancy – first some practical insight of the structure of birth in the Western Cape.
Public – you sit in a waiting room half a day to be one of about 60 mothers seen by 2 doctors. (Numbers vary and increase at different hospitals.) You have an ultrasound – if you are lucky – only when it is indicated.
Private – you make your appointment, pay at least R500 - R1000, have an ultrasound at EVERY appointment indicated or not and you wait a little. But you actually have about the same amount of time with your gynae.
Private midwives – you have your appointment, pay less, and have far more time with your midwife where you discuss deep subjects – your own birth perhaps, your home situation, stressors and how you are really feeling and coping.
Describing the delivery is also a similar exercise.
Which make talking about birth in the Western Cape open to several different angles.
I would like to give a very raw flavour of what birth in the western cape has been for me in my last few years in medicine.
A young girl – it was her 18th birthday. It was also Valentines day. She was wheeled in on an ambulance stretcher with her baby almost crowning. She was small and wearing a mini skirt and had been out with her boyfriend at the waterfront. Her baby girl was born quickly and she breastfed. Then we found out she did not want to keep the baby. Her boyfriend told us that 9 months ago she was raped. She believed her pregnant belly was a cyst, as she said she was told by her doctor. Therefore she had NO antenatal care. Her baby went up to the nursery, to prepare for adoption, and she went to the gynae ward.
When I was working in the trauma unit I saw a young girl 16 years old with her mother. Her drunk stepfather had gotten into a fight with her and stabbed her right through her right hand. The knife was still there. She needed surgery to remove it and lost some movement and feeling in her finger. She will never regain it. 6 months later I was now doing my obstetric rotation – I saw her again – 6 months pregnant. The stepfather was the perpetrator again, from that same incident. He had given her a slightly handicapped right hand and a baby. He was out of jail on bail.
A 28 year old lady, fairly large built and overweight, comes into the emergency ward with abdominal pains. She does not know she is pregnant but she is 8cm dilated and delivers a baby girl. She is unemployed, has no family support, is staying with a friend and the father is in the navy, working away. After a few days of counselling and promised support from her friend she decides to keep her baby.
A 37 year old lady is separated from her husband. She sees him while visiting the Eastern Cape about 8 months ago. Now she is 8 months pregnant with hypertension in pregnancy – so is on medication and close clinical attendance. She is admitted to postnatal ward – smelling of alcohol. It is the first time she drank in her pregnancy but she was so stressed she needed something to help her cope. She also had a horrible fresh black eye. She had had a fight with her current new boyfriend who had beaten her up. She had gone to the toilet and delivered a fresh stillborn at home. She needed to be home to grieve and heal but now her blood pressure was remaining high and she could not be discharged yet.
In the very busy trauma unit – a young lady 9 months pregnant is wheeled in unconscious. She was at the clinic that week and was scheduled for an induction in 2 days. She had taken large amounts of three different medications as a Para suicide. One of them was her Iron tablets she was given during her pregnancy – very dangerous in overdose.
We are phoning the school of the young mother, 16 years old, to organise that she can write her school exams at the hospital as she needs to be there for her young baby that was born premature. He has all ready been there 2 months and is slowly becoming stronger. He needs her breastmilk now.
How about that time when we are on a ward round with our senior consultant, Head of department – and we come to a Somalian lady who has just delivered her second baby – the previous day. They had had a loud, angry fight during her labour because she refused to go for a caeserian section for slow progress. She had delivered her baby vaginally 4 hours later but the baby was now in the neonatal ward for observation for head cooling due to low apgars. The consultant reminds her loudly in front of the 5 other patients in the ward, and all the doctors on the round– “IT IS YOUR FAULT YOUR BABY IS BRAIN DAMAGED” – he repeats several times. The baby was discharged to her the next day and didn’t need head cooling.
Yet – birth in the western cape – for me is one weekend on call – a labouring lady gets off her bed and squats down along with the help of 3 other nurses who are singing and dancing to encourage her.
Another word comes to mind – DISCREPANCY.
What we are taught and what we read is not how we practice.
Some more of my personal experiences that have built my professional experience of birth in the Western Cape.
We are taught baby friendly initiative – yet we see episiotomies done without medical indication and without local anaesthetic.
We read about the benefits of free movement in labour yet we see women restricted to fetal monitoring hours on end in bed in labour without indication.
We learn about the benefits of birth assistants or doulas and we read the hospital protocols and look at their posters yet we sometimes see women denied the presence of their doula or even their partner.
We are presented with evidence based research on the benefits of delayed cord clamping yet there is practically a panicked rush to cut the cord immediately after delivery.
We know the importance of the first hour and no separation but the newborn may be swiftly transferred to lie in the incubator in the same room in that time while the placenta is delivered and the mother “cleaned up”.
We are taught how to take a good history including a thorough social history and when we present that in a labour ward round we are ridiculed in front of everyone.
We know the meaning of informed consent but we do not reveal all of the major risks of caeserian section and anaesthetic when taking consent. How can we?
We understand that spinal anaesthesia is the better anaesthetic generally for a caeserian section but then we work in a hospital where they categorically do general anaesthesia for all caeserians.
Birth in the western cape for me is that…these experiences have formed – what for me is Birth in the Western Cape.
Why the discrepancy?
Because our population is different? – Public living conditions are so sub-optimal it INFLUENCES moms disease and risk profile in pregnancy!! Social stressors and situations are so consuming and extreme mothers are full of stress hormones, their affects and the tangible consequence of destructive social situations.
We hear comments from gynaes about homebirths when they have never been to one. We hear comments from public about doctor’s decisions when they have no idea what has built that doctor’s experience.
Birth in the Western Cape – a women comes into labour ward. She is 35 weeks and started bleeding this morning. Very mild pains. She is bleeding a lot now. You put the ultrasound scanner on her belly – praying you find a heartbeat. The other nurses are putting up her iv lines and catheter. Damn! No heartbeat. Can I be sure? Maybe I am missing it? Should I get a second opinion? Damn! Her abdomen is hard. You have to act quickly to transfer this lady to a higher care hospital. IV lines, order bloods, arrange ambulance, discuss with doctor on that side and tell her the news very gently – that she has lost her baby. And while she sobs – you write your notes.
You are worried about her until she leaves – she is HIGH RISK. But you don’t stop – next door is a lady with an intra-uterine death at 24 weeks. It is busy being expelled but is breech and is stuck – they call you to help. You extract the small limp fetus and spare a thought for this precious life and this natural divine ending.
But you know you can’t spend long – the wards are full today and you still have many to see. And you are on call – which means you are at work for 27 hours.
Birth in the western cape where doctors are overworked, emotionally drained and burnt-out. Where the poverty, crime and social situations of women are affecting their risk profiles and birth outcomes. Where numbers are drowning out resources and influence service quality. Where we are mopping up the effects of all this – when the damage is all ready done. While there is a HUGE gap crying out for preventative interventions – social support, antenatal education, nutrition and continuity of care.
I would like to end with two important ideas – as food for thought.
There is a burning need for increased primary preventative care in maternity services. In 2007 I wrote my elective on the Place of Homebirths in the Primary Care setting in the Western Cape. There is outstanding support for the place of comprehensive private continuous out of hospital based maternity care.
Secondly – a whole seminar in itself but I could not exclude it. Birth makes a difference. Impressions of birth carry itself into parenting and the child and mothers future. Succinct to say – we need to put in the effort to make changes to people’s birth experience…not only for the sake of mortality but to make a real change in society.