Midwife crisis: a cold war with obstetricians is born
Up to 75% of births in the private sector are via surgery, while no more than 15% are medically justified, but doctors say they cannot afford any risks
Overdue by just a week, Theresa Sparks had to be induced as her first pregnancy was considered to be entering a high-risk stage.
After 27 hours in labour, she was rushed into theatre for an emergency C-section after her baby boy became distressed.
“It was not what I expected, as I was so eager to have a vaginal birth. But obviously the health of my son, Theodore, took priority, and I had to stop thinking about what I wanted. He came out just fine at the end.”
Three years later, she was still adamant about having a natural birth with her second child.
After 37 hours in labour, her 4kg baby girl, Celia, was born in a Cape Town private hospital at just more than 40 weeks.
This time around, her wishes had come true and her baby was delivered by a midwife.
“It was the most beautiful experience of my life. I felt such a great sense of achievement. This time around I birthed my baby unmedicated. She wasn’t taken out of me.”
But the Pinelands mother worries that the “safest way to birth for low-risk pregnancies” may soon become unavailable in the private healthcare sector.
Some private midwives claim obstetricians are reluctant to support them during high-risk pregnancies.
To avoid midwifery-supported birth becoming extinct, a new movement called Right to Birth SA was launched in Cape Town on Friday.
The group claims that in Cape Town, for instance, many private hospitals are no longer using midwives because many obstetricians view their practice as a high risk for litigation.
Glynnis Garrod, founder of private midwifery clinic Birth Options, said several factors were at play in the cold war between obstetricians and midwives. “The potential lack of choice is now very real for many women. Women should have the right to choose,” she said.
But obstetricians have defended their stance, saying natural births had become “too risky”, and if anything were to go wrong the doctor, and not the midwife, would be held responsible.
Dr Peter de Jong, an obstetrician and gynaecologist at Christiaan Barnard Hospital in Cape Town, said on average obstetricians paid about R1.3m a year in risk-cover premiums. He said lawyers often targeted vaginal births when suing doctors, as they regarded those as “high risk”.
“Unfortunately obstetrics is fraught with medico-legal complications. In a case where delivery goes wrong, an obstetrician, who has an unlimited risk insurance cover, is more likely to be sued than a midwife. While obstetricians don’t necessarily have any issues with midwives, it’s just not worth the risk in the end,” he said.
He said some of the risks associated with natural births included infection, allergic reaction, episiotomy, instrumental trauma to the perineum, scarring, uterine rupture and sexual dysfunction.
Garrod said Constantiaberg Mediclinic was the latest private hospital in Cape Town to show reluctance towards backing midwives, as it insisted on having at least two obstetricians to back up midwives.
In November she was quoted by Times Select as saying midwives were “devastated and deeply saddened” after the withdrawal of obstetric backup by the obstetricians at Vincent Pallotti Hospital in Cape Town.
She said midwives were never involved in the discussions other than rising insurance costs and “needing the support of all the obstetricians in order to make an on-call rotation work”.
Medical schemes were also not making the situation any easier, with some major players such as Discovery Health accused of not covering midwifery fees in full.
Discovery Health has, however, denied this.
Dr Noluthando Nematswerani, head of the clinical policy unit for Discovery Health, said: “Depending on the member’s chosen plan we cover all in-hospital healthcare services up to 300%.
“Where members obtain services from healthcare providers who don’t have an agreement, which may include midwives or obstetricians, and the provider charges in excess of the members’ chosen cover rate, the member will be liable for the cost difference,” she said.
Dr Estelle Coustas, nursing executive at Mediclinic SA, said the hospital group had “engaged extensively” with midwives to accommodate them at Constantiaberg and had proposed a service-level agreement.
“It is unreasonable to expect a single obstetrician to be available 24/7 and, as a result, the private midwives were requested, as part of the agreement, to identify two obstetricians to support their services within the hospital, providing clinical cover for each other. To date, Mediclinic has not received the commitment from a second obstetrician,” she said.
“Mediclinic will continue to engage with all parties to seek a solution that ensures the safety of patients.”
The annual Council of Medical Schemes report released on Friday shows the C-section admissions had increased by 5.1% from 2017 to 2018, with 75% of births being done through surgery.
“Caesarean births in medical schemes are more than three times higher than in the public sector and out of sync with some highly developed countries,” the CMS said.
The World Health Organisation is of the view that only between 10% and 15% of Caesarian births are medically justified.
The average amount paid to hospitals (excluding doctors’ fees) for a C-section birth in 2018 was R40,100.
Dr Anchen Laubscher, medical director at Netcare, said the hospital group had partnered with a private midwifery unit, The Birthing Team.
This was to preserve midwifery services “to provide the communities we serve with the most accessible and effective care possible in maternity services”.
“This service expands the maternity care options available to expectant mothers, including those who do not have medical aid and those with contracted health insurance plans,” she said. – Times Select