Birthing in a state hospital: What’s it really like?
For many of us who don’t have medical aid, giving birth in a government hospital is the reality. Here’s what you can expect, writes Margot Bertelsmann
DESPITE NEWS OUTLET hysteria around the implementation of NHI (national health insurance), which will theoretically force the collapse of our private healthcare industry, most of us 57 million ordinary South Africans use the government healthcare system. After all, only about 10 million South Africans belong to the medical-aid schemes that make private hospitals accessible to ordinary citizens. And this is not necessarily a bad thing.
Even though the state healthcare system is ailing, and there have been significant failings (remember the Life Esidimeni tragedy?), there are also pockets of excellence. The doctors and nurses you’ll see in the private sector are the same ones who once practised or still practise in the state (because all doctors are state-trained, and many remain there, at least part-time). It’s also only in the state healthcare system where you’ll see a team of specialists make peerreviewed, academically based decisions, which is ideal for complex cases.
So, if you’ll be having your baby in a state facility by choice or by necessity, read on…
Obstetrician Dr Salome Mokgohloe Tshabalala, who worked in the state sector in Johannesburg until recently, explains how the process works in the state sector.
WHERE WILL I GIVE BIRTH?
Most importantly, you don’t choose the hospital or clinic at which you’ll deliver your baby. “The health system is structured in the following manner,” she explains. “You begin at an MOU, which stands for a midwife obstetric unit. These are clinics with the capacity to deliver low-risk patients.”
There are no doctors, theatre or neonatal ICU facilities at MOUs. Says Dr Tshabalala: “The midwives are trained to manage low-risk pregnancies, assess women for risk factors, and refer them to the appropriate level of care.” If necessary, you’ll be referred on for more complicated care. “A level one hospital is staffed by a midwife and a medical officer, with limited access to specialist doctors, and has a caesareansection theatre, but no neonatal ICU. Level two hospitals have a midwife, medical officer and a specialist on the staff, as well as a caesar theatre, blood bank, a limited neonatal and maternal ICU, and basic radiology services. Level three and four hospitals have midwives, medical officers, registrars (specialists in training), specialists, subspecialists, and, in terms of infrastructure, provide facilities for caesarean-section deliveries, a blood bank, maternal and neonatal ICU and high-tech radiology facilities.”
WHAT PAPERWORK DO I NEED?
The government’s department of health has standardised the care for pregnant women in SA, says Dr Tshabalala, by putting in place policies and guidelines for care. Staff are obliged to adhere to those national guidelines and protocols. For instance, every pregnant woman in SA has the right to access health services regardless of nationality or age, according to our Constitution. Bring your ID document or passport as well as proof of address – if you have them – to your first clinic visit. These documents will also help you register the birth of your newborn later. “The proof of address is to ensure that you’re in the correct drainage area,” explains Dr Tshabalala. “For instance, if you live in the Johannesburg CBD, you must access health services at the Hillbrow clinic, which will then refer to the Charlotte Maxeke Academic Hospital should the need arise.”
This does not mean refugees, foreign, homeless or undocumented women can be turned away for lack of paperwork, as the right to access to healthcare trumps the regulations determining which facilities to access.
Says Dr Tshabalala: “Undocumented women in the country requiring medical assistance cannot be turned away. But the importance of proper documentation must be emphasised. It facilitates good record-keeping, ease of birth registration of the newborn and accurate statistics in SA, among other things.” She adds that you should still go to the clinic in the area where you live, because this contributes, ultimately, to the responsible sharing of state resources. “For instance, a woman with a heart condition can be at a level three hospital where she can be cared for by specialists, instead of not being attended to because the available beds have been occupied by low-risk
The staff’s attitudes toward you are also likely to be more positive if you have a file and a record of your treatment at their facility, rather than arriving on your baby’s birth day as a stranger
patients who walked into a facility because they can,” she explains.
But we do read media reports of women being mistreated in horrible ways while in labour at hospitals, especially if they are undocumented foreigners. Without minimising these experiences, we would like to stress the importance of taking responsibility for your own healthcare from early on in your pregnancy. This means going to open a file at your nearest clinic early on, and getting to know the people and processes. This will vastly ease you in forming relationships with the people who will care for you in labour. The staff’s attitudes toward you are also likely to be more positive if you have a file and a record of your treatment at their facility, rather than arriving on your baby’s birth day as a stranger. Seen from the nurses’ perspective in this instance, they will have no record of your baby’s growth, your HIV status and other health markers such as blood type and blood pressure and won’t be able to assess if you are a complicated case or not. This makes their jobs much harder.
WILL THE HOSPITAL BE COMFORTABLE?
The next issue is a cosmetic one. There may be differences in the “nice-to-haves” between state and private facilities: the condition of the building, the plumbing, paintwork, the linen, the food, the levels of privacy or the noise levels. But these are things you can prepare for, so that you can have the most pleasant birth experience possible under the circumstances. Check out your facility before, and bring food, linen savers and pads, or whatever is missing, from home on your labour day.
WHAT ABOUT PAIN RELIEF?
Regarding pain relief, Dr Tshabalala says, “No woman should be denied pain relief. There are options such as Entonox, pethidine and Atarax. It has also been found that having a doula or birth partner present is helpful in alleviating pain. Epidural services are limited to level three and four hospitals.”
CAN MY BABY’S FATHER BE IN THE LABOUR WARD OR DELIVERY ROOM WITH ME?
Whether your birth partner will be allowed to be with you is another question, and can be facility-dependent.
“Where possible, staff will allow a birth partner inside,” Dr Tshabalala says. “But it might be a problem if the birth partner is a man. Most of the infrastructure in state hospitals were not built to accommodate this. These hospitals were built a long time ago, when it was thought that a labour ward is a place for women only. The thinking has changed, but the buildings themselves haven’t.”
CAN I CHOOSE A C-SECTION?
You do not have the option to get a c-section on demand in state hospitals, says Dr Tshabalala. “A c-section is performed for obstetric reasons or a maternal medical condition that makes a vaginal delivery unsuitable.”
Your hospital stay for an uncomplicated delivery will be short: between six and 24 hours. After a c-section, you’ll stay two to three days, and longer if there are complications.
WHAT ARE MY OTHER OPTIONS?
Knowing that many women find themselves with no medical aid and unexpectedly pregnant, the team of doctors and healthcare providers at The Birthing Team, to which Dr Tshabalala also belongs, came together to provide an affordable, fixed-fee pregnancy and birth-period care package, so you can get quality prenatal and obstetric care for a flat fee. Visit thebirthingteam.co.za.
THERE ARE MANY situations in which you may need to express breast milk and store it safely to use on demand when you need it.
Some short-term reasons may be occasional separations or to increase milk supply. Some long-term reasons may be a premature hospitalised infant or regular separations such as returning to work.
PLANNING AHEAD
Invest in a good breast pump. It needs to match the reason for use, be affordable, portable, fit well, have an adjustable vacuum, and cycling speeds of between 40 to 65 cycles per minute, to effectively express breast milk.
There are many different choices of manual, small electric pumps or professional-grade pumps available. Some offer alternative power options such as battery power and car adapters. Manual pumps don’t cycle automatically and may be tiring to your arms and hands.
Check with your medical insurance. They may pay for the rental or purchase of a pump if a healthcare provider writes a prescription for it. It is important to remember that no breast pump is as efficient as your baby at removing milk and maintaining a good milk supply.
GETTING STARTED
Wash your hands before expressing. Sterilise your equipment by washing it in warm soapy water, rinse well and sterilise as per the manufacturer’s instructions. The key to any kind of milk expression is to get the milk to let down. Electric pumps stimulate the let-down reflex automatically by mimicking the baby’s sucking action. However, when you’re hand expressing or using a manual pump, you may need to stimulate the let-down reflex yourself. Your milk might let down easily, but you also may have to work at it. Anything that helps you relax will help your milk let down. Try listening to music or breathing deeply.
HOW TO USE A BREAST PUMP
With a single-sided pump, pump five minutes a side and repeat. If you’re going to be pumping frequently or returning to work, you really need to be double pumping (pumping from both breasts at the same time). It cuts pumping time in half (from 20 to 30 minutes single pumping to 10 to 15 minutes or fewer). Your prolactin levels are also higher, so you actually produce more milk in less time. Each breast functions independently, so you may get more milk from one than the other. Pump after a breastfeed in the morning for three to five minutes a side, or from the breast that baby has not suckled on. Your supply is settled according to baby’s demand, so you may not get a lot of milk at first. Repeat after one of the evening feeds. Your volume is
lower in the early evening, so you may not pump a lot of milk at this feed.
HOW MUCH?
After regular pumping, your milk volume will increase, and you will be able to collect a full feed for baby – an average of 80 to 120ml. Date it, and use it in order of expressing.
Breast milk can be safely stored in glass or hard plastic (BPA-free) bottles with tight-fitting lids or bags especially designed to protect the nutrients and anti-infective qualities of breast milk.
INTRODUCING YOUR BABY TO BOTTLE FEEDING
Around six weeks of age, once a good breast milk supply has been established, a bottle can be introduced to your baby, allowing you to prepare baby to learn an alternative way of feeding.
After eight weeks, it may be more difficult to get baby to accept a bottle. Offer regularly at least once a day, by another caregiver or Dad to create familiarity and routine. Baby will not
easily accept this form of feeding from Mom. Baby is very clever to work out who it’s coming from.
Make sure you choose a bottle that requires a good vacuum to remove milk and takes the same effort as breastfeeding does. When returning to work, you need to pump around the relevant feed times, providing the milk feeds for the following day.
You need to express in place of missed feeds, to maintain your milk supply.
Most babies will readily drink milk at room temperature or colder. Never microwave breast milk or heat it directly on the stove. The cream will rise to the top of the milk during storage. Gently swirl milk to mix – do not shake, as this denatures the proteins.
Sometimes thawed milk may smell or taste soapy, due to the breakdown of milk fats. The milk is safe, and most babies will drink it. If the milk has a rancid smell, caused by the lipase enzyme, it can be deactivated by heating to scalding (bubbles around the edges) after expression, then cooled and frozen.