Expert profile

Meet Dr Howard Manyonga, the man who’s putting the ‘team’ back into birthing. Read on, especially if you don’t have medical insurance.

WHAT IS THE BIRTHING TEAM, IN A NUTSHELL?

The Birthing Team is a network of maternity-care teams that offer pregnant women a complete antenatal-care package at an affordable, fixed rate, where all the costs of your normal pregnancy, labour and delivery as well as post-delivery care are included, whether you end up with an uncomplicated delivery or whether you need an emergency c-section. Each team is multidisciplinary and is made up of doctors, nurses and midwives.

IS IT AIMED AT WOMEN WHO DO NOT BELONG TO MEDICAL AID SCHEMES AND SOCIETIES?

Yes, we launched The Birthing Team in 2017 in the uninsured market. A unique feature is that we agree to a guaranteed fee upfront, and you know that you will not get unexpected additional bills. In the current system, costs are rising faster than this group of patients can afford – the whole sector is headed for disaster. The number of people who can afford medical aid is shrinking. Doctors who work on a fee-for-service model are tempted to see their small pool of paying customers too frequently – above international averages. A good work-life balance is not sustainable for them: babies come at unpredictable times, and one person can’t be available 24/7. Partly for that reason, private practitioners working alone also do not tend to promote vaginal deliveries, resulting in a 76 percent caesarean-section rate in the private sector. The average obstetrician in private practice delivers only about 13 babies per month. That’s not good use of their time when doctors working in hospital teams can oversee the delivery of up to 80 babies per month. Our private healthcare system is designed to maintain this dysfunctionality, when in fact, internationally, most babies are delivered by midwives, with referral systems in place to obstetricians in complicated cases.

THE BIRTHING TEAM AIMS TO CHANGE ALL THAT.

Do you remember during the 2004 floods in Mozambique, a woman gave birth while sheltering in a tree? That’s when the penny really dropped for me. Pregnancy is not a disease; it is a physiological state that sometimes develops complications with a variety of causes, including psychosocial determinants. Once you wrap your head around that, you understand that a multidisciplinary birthing team has the best outcomes for the patient. An obstetrician is required at, generously, 20 percent of all deliveries. Most of us obstetricians learn the art from midwives. In my case, a memorable one is a certain Sister Duminy, whom I worked with in Bellville, when

I was a young obstetrician. Once she delivered a patient for me when I couldn’t get there in time and told me to stand down, as the patient was now fast asleep and I could see her the following morning. Even though I was stressed, the patient was so happy, so grateful!

Midwives can and should do the bulk of deliveries, also to prevent them from becoming deskilled through lack of practice. In the current system, they have been relegated to mere doctors’ assistants. This is a sad state of affairs in a country where there is a shortage of midwives.

So, at The Birthing Team, we work with healthcare practitioners and support them to self-organise into a team that can offer integrated maternity care. We have developed the tools and have gained experience in managing the development and management of such teams. Practitioners buy shares to join the team as shareholders and share the care of patients. We already operate in four locations and are hoping to add another 11 sites in the coming years. The system is designed to benefit everyone: patients and professionals.

YOU KNOW THIS BUSINESS, BECAUSE YOU ARE AN OBSTETRICIAN YOURSELF.

Yes, I was born in Zimbabwe and qualified as a doctor at the University of Zimbabwe. I worked in Limpopo as a medical officer, and specialised in obstetrics and gynaecology in the UK, where I lived and worked from 1996 to 2002. I then moved to Cape

Town, where I worked as a research fellow at Groote Schuur Hospital, and then spent almost 10 years in private practice.

DID WHAT YOU’VE LEARNT IN OTHER CAREER PATHS HELP LEAD YOU TO YOUR CURRENT JOB?

Absolutely. In the UK public health service, as it is here, midwives routinely deliver babies, realising the convention that midwives can and should work independently when they are fully supported in a team. I particularly enjoyed working in a team where each discipline contributed maximally to the care of the patient, and where you feel supported by your peers. In private practice, I missed the interaction, the peer review, between professionals.

My exposure to programmatic work at the Wits Reproductive Health and HIV Institute, where I headed up Women’s Health, and at Marie Stopes heightened my desire to work in a broader scope, at a system level. My MBA at UCT had a focus on systems thinking and managing in complexity, both of which have become very handy in my current role.

AT WITS RHI

YOU PIONEERED PRECONCEPTION CARE FOR HIVDISCORDANT COUPLES…

It was part of my drive to improving healthcare-systems outcomes. Dr Natasha Davies and I set up a pew-conception clinic where we trialled pre-exposure prophylaxis (Prep) for couples who wanted to conceive naturally when one of them was HIV positive. It’s now become mainstream treatment.

THEN YOU JOINED THE MARIE STOPES CLINICS FOR TWO YEARS.

That’s right, I joined in 2014 as a medical director. By the time I left, I was the COO. While there, I had been strongly advocating for the organisation to increase and diversify its offerings. Here, I learnt what patient centricity means in practice, where professionals provide integrated, values-based care.

WHEN IT WAS TIME TO MOVE ON, YOU APPROACHED DR BRIAN RUFF, WHO HAD LAUNCHED PPO SERVE.

I knocked on their door at the end of 2015 – and the rest is history. PPO Serve has grown to a large team leading the transition to value-based care in South Africa. PPO Serve has the GP Care Cell, a team working in the HIV space, The Birthing Team and The Value Care Team, for aged-population medicine. PPO Serve manages the teams that provide these products and takes a fee to do so. It provides an IT platform, admin and business support, clinical governance, it can identify skills gaps, all to help an integrated team of healthcare providers. This is quite a huge leap for me personally after a few harebrained ideas in medicine – for instance, at one time I held a hospital licence, and I thought seriously about entering the medical tourism business…

But I knew I wanted to help make quality improvements in healthcare, and because I had been thinking it through for a long time, I feel like I have been working toward this for years. I had deferred my dream long enough. I joined the team and now head The Birthing Team.

WE BELIEVE YOU’RE NOT THE FIRST CHILDBIRTH ACTIVIST IN YOUR FAMILY, THOUGH…

My grandmother was a traditional midwife, and so was her mother before her. Her home was filled with the goats and chickens she received as payment from grateful villagers. So in a way, yes, I have taken my grandmother’s job. She passed in 2008, but in her lifetime she used to call me over to talk, “doctor to doctor”. Now I advocate for midwives again. We’ve come full circle.

Most of us obstetricians learn the art from midwives… Midwives should do the bulk of deliveries.