Could midwives be the solution to curbing South Africa’s dismal maternal mortality rate, currently among the highest in the world? The rheumatologist and health economist Dr. Brian Ruff seems to think so. He is the CEO of South African private healthcare management company PPO Serve. In order to make births safer and cheaper for women in the lower middle class who lack health insurance and are often unable to afford high quality private-sector deliveries, his company created in June 2017 The Birthing Team, an initiative based on midwifery.
In South Africa, about 134 mothers die in childbirth for every 100,000 children who are born. Although this death rate has dropped by almost a third in public hospitals in recent years, according to research published by the peer-reviewed South African Medical Journal , specialists note that urgent interventions are needed to achieve the country’s goal of halving these losses by 2030.
“In the United Kingdom, all low-risk pregnancy patients are managed by midwives,” said gynaecologist Dr. Howard Manyonga, who leads The Birthing Team. He noted that in South Africa, midwives employed by private hospitals are “underused and become de-skilled,” adding that the best ones often leave the country.
Today, the Birthing Team’s initiative is underway at three private hospitals in Durban, Johannesburg and Pretoria. Obstetrician Dr. Selina Ramatsoso, one of the team’s members in Pretoria, said the initiative empowered these specialist caregivers. “We are giving midwifery back to the midwives,” she noted. With a staff of specialised nurses and a few doctors who support them, each hospital’s team manages everything related to birth, and at a reduced cost.
The Birthing Team’s care package covers mothers and babies starting at 20 weeks of pregnancy and until six weeks after birth, and comprises everything from tests to examinations, medication, three ultrasounds and delivery — including a C-section if necessary. It costs around 21,000 South African rands (USD 1,500).
In contrast, women who have health insurance pay 38,000 rands on average for delivery and accommodation in a private hospital, according to Discovery Health Medical Scheme, the largest private health insurer in the country. At overcrowded public hospitals, uninsured women can spend up to 36 hours in labour waiting for an emergency caesarean. Such long waits can lead to babies being born with brain damage.
Ruff’s holistic approach can bridge these gaps. In the private sector, which serves about 16 percent of the population, obstetric specialists usually tend to all pregnant women, whereas a midwife supported by a team of doctors could manage uncomplicated pregnancies, saving time and money.
That is why the Birthing Team’s model costs less; obstetricians treat patients only twice during their pregnancy (at their first appointment and at 36 weeks, unless they present complications) and a midwife manages most appointments and deliveries. The team’s scope does not include highly complex cases or patients who are likely to deliver prematurely — although so far they have only rejected five percent of all the cases.
The patient’s medical files are discussed weekly among midwives and doctors, who remain fully available for telephone consultations. Dr. Ramatsoso, who now only attends patients who suffer complications, believes the system helps doctors to use their skills more efficiently.
As a result, the initiative assisted 250 births in the past year, none of which resulted in maternal or child deaths. “One baby was born without enough oxygen but after a few days in intensive care, the baby recovered completely and had no lasting brain damage,” Dr. Manyonga said.
And while about 62 percent of middle-class women with medical aid plans have C-sections, according to the latest Council for Medical Schemes report, the Birthing Team system has managed to drop C-section rates among its patients to only 40 percent. “We monitor women’s experiences. They enjoy being managed by a midwife who can afford to spend up to an hour with them at each appointment,” said Dr. Manyonga.
A Johannesburg mother, Natascha Loubser, used the Birthing Team for her pregnancy and 14-hour labour. “Throughout my pregnancy and checkups they were wonderful,” she said, adding that she’s grateful to everyone who assisted in bringing her “princess” into the world - particularly to her midwife.
This year, the Birthing Team bid for a South African government tender that would enable the approach to enter the country’s planned National Health Insurance system and assist with high-risk pregnancies. If granted, the teams would “assist in 11 districts across the country with antenatal care and high-risk deliveries,” noted Dr. Manyonga, adding that discussions with low-cost insurance providers were also underway. Over time, the team aims to roll out the programme nationwide.