Sensitive Midwifery - Issue 43 - July2019

See references on page 34 Birth Making an active change Marilyn remembers how, in the early 1980s, one doctor working at the then Johannesburg General Hospital (nicknamed Joburg Gen) and then Coronation Hospital ‘started to think out the box and look at what was happening in the rest of the world’. He opened the first active birth unit at the Joburg Gen: in a calm, low-light environment, women could move around and were even given the option of a water birth. At the Marymount, Mona, who by then had become Assistant Matron, set up one of the first private active birth units in the country in the early 1990s. She recalls: ‘Midwives in private practice made use of this unit with its birthing pool. In no time, women got to know and love it. This unit was next door to the labour ward, and we had a few doctors we could call on if intervention was necessary. There was little in the way of objection, though I recall one doctor storming into my office: “You are taking away my bread and butter,” he roared at me.’ Variable conditions continue In the 1990s, healthy women in private care were generally still ‘subjected to routine procedures, such as enemas, restricted oral intake, intravenous therapy and episiotomies, with no evidence of effectiveness’, according to one 1998 journal article. In private hospitals, many labouring women had epidural or spinal analgesia, and C-section rates were between 45–80%. However, those who chose to deliver with the support of a private midwife, mostly had active labour and births. Water baths, upright positioning and mobilisation were used for pain relief, although some midwives did offer pethidine or nitrous oxide and oxygen (‘Entonox’). In state hospitals throughout South Africa, midwives continued to provide primary care for all low-risk pregnancies, and many of these did sterling work. Epidural or spinal analgesia were not usually available. Though C-section rates were incredibly low (6.8% in some hospitals), overcrowding meant that women could have to wait as long as three hours for the emergency procedure. Unfortunately, diminishing midwifery education standards and resources, and increasing medicalisation of birth, gradually eroded the quality of birth care provided in state facilities. As the author of the 1998 journal article insightfully noted, ‘As varied as the Rainbow Nation of South Africa is, so variable are the conditions under which midwifery is practised.’ The more things change … Looking back at South Africa’s birth practices, the trajectory towards increased intervention and higher C-section rates is clear. Today, C-sections appear to have become the norm for most private patients, with one recent 2019 report revealing that 74% of babies born to members of Discovery medical scheme are delivered via C-section. This is almost three times the 26% national average for public hospitals, where elective C-sections are not offered, but where C-section rates are still high, particularly when compared to the World Health Organization’s recommended 10–15%. And yet, while these figures may cause natural birth advocates to feel despondent, there is also much to celebrate. Not only are there more active birth units around the country than ever before, but as more and more women (encouraged by birth stories and evidence available to them online) seek out birth practitioners who support and trust their innate ability to birth, the culture of birthing in South Africa is beginning to change. As Marilyn Sher reflects, ‘In the new millennium, support for midwives has increased many-fold and there are a lot more midwives working independently now.’ Part 2 of this topic, in the October 2019 edition of Sensitive Midwifery Magazine , will take stock of the various natural birth trends in South Africa, and factors that might influence the future of birth in the country. 14 eSensitive Midwifery Magazine Issue 43