Sensitive Midwifery - Issue 44 - October 2019

Birth naturally, fearing litigation. Not only, then, are doctors desperately trying to cover the enormous costs of indemnity cover (which have increased exponentially in the last decade), but the increased litigation risk has resulted in doctors practising defensive medicine. For those who’ve seen the research and know how much more risky a C-section really is compared to a natural birth, the reality of this ‘claims culture’ is a hard pill to swallow. Ultimately, the implications of the various types of claims nowadays count against natural birth being regarded as ‘financially and legally safe’, even if the statistics show it is safer, healthwise, for both mother and baby. According to Professor Leon Snyman from the Department Obstetrics & Gynaecology at the University of Pretoria, comprehensive indemnity cover for obstetricians is currently around R1.1 million a year, and this means that ‘a doctor needs to do about 25 deliveries a month just to cover the insurance cost’. Money and medical aids While there is no direct financial incentive for a private OBGYN to do a C-section over a normal birth, there is enormous pressure to be able to cover the insurance premium cost (never mind other overheads). This contributes to the trend of letting go the obstetric side of their practice. Sister Lilian, founder of Sensitive Midwifery, has one fear for the midwives eager to step into the breach: that they too will face impossible insurance premiums, because medical funders seem only to pay lip service to the evidence of midwifery-led birth being safer. Financial constraints, sadly, do limit women’s choices of care provider and thus, the types of births they may go on to have. Though some private patients may wish to opt for a private midwife, they find their medical aid will only cover a hospital birth with an obstetrician, or that only part of the midwife’s fee is covered. Many medical aids will contribute towards a midwife’s fee but in the event of an emergency, the medical aid will then not cover the fees of both the midwife and the doctor, leaving clients with additional medical bills. Some medical aids appear to regulate parents’ choice of midwife, and constraints on ‘recommended’ midwives can be quite daunting. Doulas are also generally seen as a luxury – support only for those who can a ff ord them. While some medical aids are now o ff ering to cover doula fees, there tend to be absurd restrictions. One medical aid, for instance, will only pay for a doula if the gynae doing the delivery is associated with them – meaning they will not cover a doula for a midwife- led birth. Others will tell clients that they cover a doula, but that this fee must come out of the client’s day-to-day medical savings account. Many practitioners have also been noticing how more and more people are dropping their medical aid plans because they can’t a ff ord it, and then relying on government hospitals. Though natural birth is statistically more likely here, maintaining quality care, during labour, birth and postpartum, is often just not possible given the lack of resources. Thinking out of the box ‘Everyone seems to be missing the point that normal pregnancy and birth are primarily life experiences, not medical conditions, and trying to fit them into the disease and funder structure, will inevitably lead to a type of dystocia!’ says Sister Lilian, adding that she thinks one possible solution is for couples wishing to access ‘private sector care’, to save up for a midwife-accompanied pregnancy and birth which they’d pay out of their own pocket. After all, that would cost only a fraction of what many a wedding or even a matric farewell does! Genuine complications would be far fewer and could then be covered as any more major health crisis would be by funders. ‘Let’s not be naïve,’ she says, ‘medical funds reached their tipping point on birth and neonatal claims solely because the model of "many paying premiums, fewer making claims", was becoming untenable with the expense of rising non-physiological vaginal birth and C-section rates, which quite obviously a ff ects their bottom line.’ What women want Despite all the challenges natural birth is facing at the moment, the culture of birthing in South Africa is slowly changing. Nowadays, more women are encouraged and empowered by information available to them online – from beautiful birth stories to evidence-based research – and specifically seek out birth practitioners who support and trust their innate ability to birth. Social Continued on page 22 21 eSensitive Midwifery Magazine Issue 44