Think | In the news

published in Mail and Guardian Jul 26 2009 06:00

by QUDSIYA KARRIM | JOHANNESBURG, SOUTH AFRICA -

for full online version of article including blog comments click here.

Deaths of pregnant women have soared by 20%, but more than a third of them could have been prevented.

Among healthcare providers, poor assessment of health problems and failure to follow standard health protocols are the most frequent causes of these deaths.

These are major findings in a report by the government-appointed National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The department of health silently posted the report on its website this month without any public notification.

The report is based on maternal deaths in all health institutions from 2005 to 2007 that were reported to the NCCEMD. “Maternal deaths” are defined as “deaths of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes”.

In this period 4 077 maternal deaths were reported, up 20% from the 3 406 deaths reported during 2002 to 2004. The majority of these occurred in public health institutions but the report does not specify how many.

The report states that the 4 077 deaths may be an underestimate as most maternal deaths occurring outside of health institutions are not reported to the committee.

In rural areas maternal deaths occurring in health institutions vary between 20% and 66%, the report estimates. Of the 4 077 maternal deaths reported, 38,4% of them were “clearly avoidable”, the report says. Four out of five of these deaths were because of complications of hypertension, pregnancy-related sepsis and non-pregnancy-related infections.

The top five causes of maternal deaths were non pregnancy-related infections, complications of hypertension, obstetric haemorrhage, pregnancy-related sepsis and pre-existing maternal disease. HIV infections were the biggest killer, accounting for 43,7% of maternal deaths. “The ways to prevent these deaths are known,” the report says. “Specific protocols have been developed … Despite this, the most important avoidable factor is still substandard care.”

The lack of appropriately trained staff contributed to 9% of assessable maternal deaths and was a factor in 22,4% of anaesthetic-related deaths and 17,5% of obstetric haemorrhage cases. Incorrect diagnoses, delays in referring patients and infrequent monitoring of patients by health workers were common problems.

These occurred most frequently in community health centres and district hospitals and least in provincial tertiary and national central hospitals. The report contains no data on staff-related problems in private health institutions.

Other major problems include the lack of patient transport and of ICU facilities — factors in more than 8% of maternal deaths. A lack of blood for transfusion was reported in 19% of cases. Patient-related avoidable factors such as delays in seeking help and lack of attendance at antenatal clinics were recorded in 46% of cases.

The report also underlines the mounting impact of HIV/Aids on maternal deaths. Seventy-nine percent of maternal deaths tested between 2005 and 2007 were HIV positive and Aids-related illnesses accounted for 43,7% of maternal deaths reported during this period.

Marion Stevens of the Health Systems Trust, a health research and activist NGO, says the intersection between HIV/Aids and maternal deaths is a major cause for concern. “While we have seen improvements in the prevention of mother to child transmissions, treatment is poorly conceptualised. At present pregnancy is an incentive to get HIV/Aids treatment. We need to better integrate HIV/Aids, sexual and reproductive health services.”

She added that it was unlikely that South Africa would meet the Millennium Development Goal to reduce maternal deaths by 75% by 2015.

The NCCEDM calls for the continuous scaling of ARV therapy and HIV testing and counselling.

It stresses the urgent need for emergency transport facilities to be made available for all pregnant women. Delays in seeking medical help were recorded in nearly a third of cases of maternal deaths, with the most common reason being the lack of transport between the woman’s home and a healthcare institution.

The report further recommends training for all health professionals in maternity units and the provision of comprehensive care to pregnant women, including screening for HIV, malaria, anaemia and cardiac disease.

Jagidesa Moodley, chairperson of the NCCEMD, declined to comment on the report. The department of health had not responded to questions at the time of going to press.

The world for the pregnant woman is one filled with excitement, anticipation, anxiety and, in many instances, a very real fear or trepidation, particularly for first timers. HypnoBirthing® is designed to alleviate the factors which cause fear, allowing you to birth your baby using your body’s natural, perfectly designed, and ultra-efficient muscles and pain relief to manage the process calmly and with minimal discomfort.

Understanding how pain occurs

At the onset of labour, all the senses mentioned above become heightened, and all too often, the fear responses take hold, and begin to govern the progress of the labour. In physiological terms, the body’s response to fear is to release adrenaline, causing muscles to tighten (the flight, fight or freeze response), and blood to divert to the major survival organs (of which the uterus is not one). Thus, the very muscles designed perfectly to birth your baby begin to work against each other and cause pain. The pain causes the body to release more adrenaline, and a cycle of pain-adrenaline-pain is triggered. Added to this, the lack of oxygen in the uterine muscles creates lactic acid, increasing the level of pain even further.

•               The way your body is supposed to work

In contrast, when a woman is excited and relaxed about meeting her baby, and she understands and trusts that her body is perfectly designed for the task, she releases endorphins, the body’s natural relaxant, at the onset of labour, which supplement the hormones specifically released to allow her to birth her baby easily. This powerful natural combination of endorphins (which help the muscles relax and are also 200 times more potent than morphine!) and hormones makes the birth an exhilarating and exciting process, rather than one filled with escalating pain and discomfort.

•               How HypnoBirthing® works for you

By using a range of simple self-hypnosis, breathing and relaxation techniques, from around 28 weeks of pregnancy, HypnoBirthing® mums are, with regular practice, able to reach a deep state of relaxation, allowing them to switch off the part of the mind which is responsible for triggering the adrenaline release. You’re in full control - the techniques produce an effect no different to the mild state of hypnosis experienced when you become engrossed in a good book, watch TV, daydream, or drive (ever got somewhere and not remembered parts of the journey?). The relaxation makes pregnancy easier and more enjoyable, and HypnoBirthed babies are on average significantly calmer and more relaxed infants.

•               HypnoBirthing® statistics speak for themselves

95% of women are capable of having a ‘comfortable’ birth without medical intervention; 70% of women that have used HypnoBirthing® used no pain relief at all; a further 15% used only something mild such as Entonox (gas and air).

HypnoBirthing® was founded by Marie Mongan in the late 1980s in the US and is now taught in 34 countries worldwide. Only practitioners affiliated with the HypnoBirthing® Institute (still run by Marie Mongan) are qualified to teach the course, of which there are now many generic versions.

•               How HypnoBirthing® worked for me

Our daughter Kiera was born in 2005 in hospital, after a fairly “typical” first labour - 14 hours, lots of shouting, stalling and screaming, all of which was exhausting and painful. I discovered HypnoBirthing® shortly after falling pregnant for the second time in 2007, and this time I was determined to have a more positive experience, and take control of the process. After learning the HypnoBirthing® methods, our son James was born, at home, in under 2 hours following a pain-free, drug-free labour. It was one of the most incredible experiences of my life and inspired me to train as a practitioner so that I could pass on what I had learned and experienced. I trained and qualified as a practitioner in the UK in 2008, and have been lucky enough to teach many mums who have all had wonderful birthing experiences.

I returned to Cape Town permanently at the beginning of Dec 2009 and founded ‘Beautifully Born’. I hope to help women in South Africa have comfortable, natural and fulfilling birth experiences, and offer a viable alternative to the “standard” labours that have for so long been the only way to bring children into the world.

For more details on HypnoBirthing® in Cape Town or to contact Kim visit www.beautifullyborn.co.za

The current US Health Care System is failing babies and families before, during and after birth. At this critical moment when the US government is re-envisioning our health care system, we are seizing the opportunity to make a 10-12 minute video not only to point out the flaws in the way we care for babies and families, but also to identify the keys to improved care. Our infant mortality ranking is 42nd on the world stage which means 41 countries have better statistics. This places us right in the middle of the following countries: Guam, Cuba, Croatia and Belarus, with over double the infant deaths compared to the top 10 countries of the world. (CIA World Factbook).

Our astronomically high African American infant mortality rate at 16 deaths per 1,000 is similar to countries such as Malaysia and the West Bank. Not only are babies dying needlessly, but the ones who survive this failing system are also often adversely affected by unnecessary procedures and separation from mother and family. Our intent with this video is to encourage policy makers to consider a health care system that holds prevention of these calamities as a high priority. The midwifery model of care for healthy low-risk women is a simple solution which addresses many of these issues simultaneously.

We are advocating for a health care system in which it will be standard procedure for mothers and babies to thrive and not merely survive through birth and early life. The midwifery model of care will save our health care system millions of dollars each year.

Reducing Infant Mortality from Debby Takikawa on Vimeo.

As we approach Nelson Mandela’s 90th birthday, I am reminded of this famous remark he once made. With each birth that I attend I am struck by how important it is that children are born gently into this world. That babies and children should treated with respect and consideration, and that this should start in pregnancy and childbirth.

With each story I hear from a woman that was not treated well or felt traumatized and disempowered by her birth experience, I am again reminded of these words.

Unfortunately the majority of births are not beautiful moments. Women are terrified rather than reassured by staff, women are left to labour alone attached to monitors.
Malcolm X once said that “to educate a man is to educate an individual, but to educate a woman is to educate a nation.” So, too to care for a woman is to care for a nation.
In this country most women are not cared for. Whether they are lying labouring alone in a township clinic, or whether they are wheeled toward theatre out of fear of birth. These women are not being served well, and it is a shocking reflection on our society that we can not care for our women as they bring forth the next generation. To have healthy babies, you need healthy happy mums, this is greatly contributed to by how women give birth.

In both the private and the public sector we have a lot to do to improve how babies are born. Maybe remembering Nelson Mandela’s words can encourage women to seek caregivers that will honour and respect them and their babies during their pregnancies and birth. Perhaps caregivers too can be motivated by these words to provide the care for women during this time that would result in women feeling strong and empowered by their birth experiences and as they walk into motherhood

2 October 2007

The UK’s National Institute for Health and Clinical Excellence (NICE) released new childbirth guidelines last week that call for more normal births, and more control for women over how and where they give birth.

Andrea Sutcliffe, Deputy Chief Executive of NICE said: “We want to make sure every woman’s experience of birth is as good as it can be and have used the best available evidence to set a national standard on how midwives and doctors can make labour a positive experience for women.”

Reading through these suggestions for care, they might sound like common sense, and they should be. However, few of them are followed in reality. If these few suggestions were implemented in South African hospitals, they would dramatically change the nature of birth that women experience in this country.

Some highlights: (more…)

28 June 2007

Caesarean rates in the USA and UK have rocketed to around 25 per cent of all births, usually because of a cautious ‘just-in-case’ approach. This rate is also driven by the obstetrician’s mantra of ‘Once a caesarean mother, always a caesarean mother’.
In reality, it’s reckoned that just 5 per cent of all births need surgical intervention to protect the life of the mother or unborn baby, and the World Health Organization has stated that every country should be looking at caesarean section rates of no more than 10 per cent.

So what happens when the mother-to-be is given all the facts, and is allowed to decide on the method of delivery herself? This radical idea has been tested by a group of mavericks from Bristol University, who tested the theory on 742 pregnant women who all had a caesarean section before.

Convention would have dictated that all would have had a caesarean, but once the women had been given all the facts, 158 - or 21 per cent - went on to have a natural birth. Just 63 had an emergency caesarean - in other words, the surgery was necessary - and the rest had an elective caesarean, in which they chose the procedure.

Amazing what happens when you let people in on the know.

(Source: WDDTY - British Medical Journal, 2007; 334: 1305-9).

Home births are a rare phenomenon in the Eastern Cape, but Bonita Boni found a few women in East London who have dared to defy conventional wisdom by birthing their babies their own way with the help of a midwife. IMAGINE lying in a bath of warm water, illuminated by candle light and warm, indulgent faces, and one of them is giving you an exceptionally gratifying massage.

This is not the scene of an exotic spa holiday but that of East Londoner Esme Macdougall’s home birth as she recalls it.

“I could almost describe it as a spiritual, almost romantic experience,” she says.

Macdougall is an example of many pregnant women who prefer looking beyond the confines of a maternity ward to give birth.

Depending on their needs and temperament, women can use a midwife for a home birth or a doula (a woman experienced in childbirth who provides physical, emotional and informational support before, during and after the birth) or an obstetrician in a hospital.

Although it was Macdougall’s first pregnancy with daughter Galaya Skye, who’s now a year old, using the services of a midwife was her first choice.

“One of the members of the dance troupe I was in had a home birth and she would tell me how peaceful her baby was and that got me thinking about one day having a home birth myself.”

For Gonubie resident Tanya Dunn, the reasons were quite different.

“A private hospital charges around R20000 and we didn’t have medical aid. We were not keen on the public hospital as we felt you couldn’t get the type of attention you needed,” explains Dunn.

But the decision to go the home birth route was not cut and dry.

Although her family encouraged it, Dunn was still nervous. It was only during the last stages of her pregnancy that she finally made up her mind.

“I knew Nicole (Angling) and that she would give me special care and finally I called her and asked if she was still interested,” she says.

After getting the go-ahead from her doctor, Dunn gave birth to Michaela two weeks ago.

Dunn’s mother, sister and husband were present during the labour and birth.

“They were all very supportive. They took walks with me during the early stages of my labour together with one of the midwives. And my husband even got to cut the umbilical cord,” she says.

Dunn was lucky to have her family accept her decision to have a home birth from the onset.

There is still a lot of scepticism as well as fear for the pregnant woman when it comes to a midwife-assisted birth, explains Nicole Angling, a midwife in private practice who assisted both Macdougall and Dunn through their deliveries.

“Many prospective parents, particularly those having their first baby, dismiss the idea of having a home birth because they think that it is not as safe as a hospital birth,” she says.

Certainly, most gynaecologists would outright refuse to monitor a woman who prefers a home birth, citing fears of safety for the unborn child and mother as the main reasons.

For Macdougall, her family only came around after much convincing.

“At first my husband was against it. He was a bit sceptical in the beginning,” she says, “I had to prove to him that it was safe, so I made sure I did plenty of research … I was sold to the idea and soon he was too.”

“Home births are a safe, alternate option to a hospital,” says Angling, who holds a degree in advanced midwifery and is registered as an independent practitioner.

She also says that before a home birth regular pre- and post-natal consultations are conducted to determine whether the expectant mother is suitable for a home birth.

But they are still instructed to visit their obstetrician and the midwife visits regularly at 12, 20 and 36 weeks to discuss any fears and concerns the couple might have.

Then finally, if it’s been determined the pregnancy is a safe one, two midwives assist with labour and birth.

So what are the advantages of having a home birth?

Home-birth guru Sheila Kitzinger, whose book Birth Your Own Way is regarded by many midwives as the authority on the subject, has this to say: “Whether birth is difficult or easy, painful or pain-free, long-drawn-out or brief, it need not be a medical event. It should never be conducted as if it were no more than a tooth extraction.

“For childbirth has much deeper significance than the removal of a baby like a decaying molar from a woman’s body. The dawning of consciousness in a human being who is opening eyes for the first time on our world is packed with meaning for the mother and father, and can be also for everyone who shares in this greatest adventure of all.”

“During the labour we (the midwives) adjust to the mother’s routine unlike hospitals where it’s the other way round,” explains Angling.

With such appealing advantages, why aren’t more women having home births?

“Not everyone can have a home birth,” explains a private practice midwife who does not wish to be named.

“You have to have a strong mind because people might tell you horror stories to discourage you. Also you must have a low-risk pregnancy,” she says.

“We adhere to strict guidelines,” says Angling.

“During the first consultation with the patient and her partner, we ask them a series of questions, like do they suffer from blood pressure or diabetes.”

Angling also says the first meeting is a lengthy one and the mother is instructed to visit her doctor regularly to ensure she is still experiencing a low-risk pregnancy.

Both midwives agree that there are other considerations that must be discussed between them and their patients, such as:

A pre-existing medical condition, for example a heart condition.

A poor obstetric history, for example pre-eclampsia, prematurity, threatened miscarriage or bleeding in late pregnancy.

Home birth would also be contraindicated if the mother was expecting more than one baby, had a previous caesarean section, or had any previous surgery on her uterus or if she was carrying a breech baby.

“Even if everything still looks fine we still take plenty of precautions,” explains Angling.

In case of an emergency, midwives ensure that they have an ambulance on standby and also alert the hospital that has been chosen.

But even with so many regulations and guidelines midwives must adhere to ensure their patients’ safety, home birthing is still a contentious issue.

In countries like the UK, home birthing is now on the rise, but it was only after last year when their department of health issued a statement saying it wanted “to end assumptions that a hospital is always the best place to have a baby” - an assumption prevalent since the 1970s in that country.

In a historic shift in the politics of childbirth, Patricia Hewitt, the UK Secretary of State for Health, said doctors would be told to offer all pregnant women the chance to deliver their baby at home with the help of a midwife and their own choice of pain relief.

In the Netherlands, home birthing tends to be the rule rather than the exception.

In South Africa, the opposite holds true. According to the South African Nursing Council (SANC) website, midwives who practice outside the security of a hospital facility have the skills and the confidence to deal with complications.

Accordingly, they have a personal responsibility to improve their practice by continually updating their skills and their knowledge.

However in South Africa hospital births are still dominant.

Bigger cities such as Johannesburg and Cape Town have turned home birthing into an industry. At Linksfield Clinic in Johannesburg, an alternative birthing centre has been established where women are allowed the middle ground between a home and hospital birth with rooms equipped with double beds and baths for water births. Cape Town has similar facilities.

Until recently, East London had few options. Two years ago, when a woman enquired about home births, a general practitioner gleefully told her that the only available midwife had left town two years previously and that there was no one else willing to assist.

Dunn and Macdougall, however, have no regrets.

“The more relaxed you are the less pain you will feel. But every mother is different. That’s why we offer water baths to ease the pain - it makes the mother feel weightless - and massages,” says Angling.

“I’m an earthy person so I had aromatherapy oils that I’d selected to soothe me and we played a mixture of classical and praise and worship music. Trust me when Galaya was coming, it was the praise and worship we were listening to,” says a laughing Macdougall.

Macdougall, who’d had her pet Jack Russell around her during her labour, allowed him to sniff the new addition to the family.

Dunn also played music during her labour and the encouraging prayers and support from her family and the warm baths saw her through the pain.

“My family said I was very brave afterwards,” she laughs.

“There’s nothing like a home birth. It’s completely different. It’s not a hospital birth at home,” says Angling. “There’s relationship with your midwives and the level of support you get is awesome.

“Plus the best part is that a positive birth means the mother will have a positive outlook on her new baby and the change it has brought to her life.”

Nicole Angling’s website is: www.betterbeginnings.co.za

The South African Nurses Council (national): 012 420 1000 or www.sanc.co.za/

Advantages

Labouring in familiar surroundings.

Not having to make a decision about when to go to hospital or interrupt labour to get there.

Being looked after by a midwife who will have gotten to know you during your pregnancy, and who will also look after you after the birth.

There is the choice not to be separated from your partner and baby after the birth.

Pregnant in America

A NEW film, Pregnant in America, is due in the United States and is described by its filmmaker as: “The betrayal of humanity’s greatest gift - birth - by the greed of US corporations. Hospitals, insurance companies and other members of the healthcare industry have all pushed aside the best care of our infants and mothers to play the power game of raking in huge profits.

“His wife pregnant, first-time filmmaker Steve Buonaugurio sets out to create a film that will expose the underside of the US childbirth industry and help end its neglectful exploitation of pregnancy and birth.”

Website: www.pregnantinamerica.com

Daily Dispatch - East London 15th June 2007