Research and recommended reading

Private obstetrics care in South Africa

In view of the escalation in medical and legal costs and medical negligence litigation, concern is expressed about the sustainability and affordability of private obstetric care (private obstetricians) in South Africa by the end of the decade. Private hospital groups can deny obstetricians who are not indemnified, increasing the workload of the already heavily burdened state facilities by an additional 10% nationally. The already overburdened state facilities will have to cope with patients who expect private healthcare. State facilities are unlikely to endure demanding private patients.

 

Patient liability is complicated by the remote medical involvement. The obstetrician relies upon the expertise of labour ward staff of varying qualification and quality. The midwives are primarily responsible to admit the patient and care for the patient during the first stage of labour. Obstetricians are independently indemnified from the midwives who are protected by the employer. The high caesarean section rate is perhaps an acknowledgement of the frailties of the current system.

 

A relatively small number of repeated errors lead to most preventable adverse outcomes and litigation claims. A uniform process, clearly defined unambiguous practice guidelines and changes to the system may alleviate the problem. Proposed changes include a 24-hour labour ward obstetrician. The English system is also recommended where qualified midwives and doctors, including consultants, are used in the labour ward. According to the English system, labour ward doctors (including obstetricians) are not independent contractors, but private hospital employees. A considered system of damages caps for noneconomic damages only also seems to be an appropriate and legally less invasive option.

• Howarth, G. & Carstens, P. 2014. Can private obstetric care be saved in South Africa? South African Journal of Bioethics and Law 7(2):69-73.

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Home birth/birth-centre birth

An understanding of the safety of planned midwife-led home and birth center birth is difficult to achieve as many published studies failed to reliably distinguish between intended and actual place of birth, type of attendant, and maternal risk profiles. A large study in the United States of America found that among 16 924 women who planned a home birth at the onset of labor, 94% had a vaginal birth and 89.1% actually gave birth at home. Eleven percent of the women intending to give birth at home were transferred to a hospital during labour due to failure to progress as primary reason for transfer. Fewer than 5% of the women required oxytocin augmentation or epidural analgesia. Of the 1054 women who attempted a vaginal birth after caesarean (VBAC), 87% of the women delivered successful. The rates of assisted vaginal birth were 1.2% and 5.2% of the women needed a caesarean section. Low Apgar scores (<7) occurred in 1.5% of newborn babies and majority (86%) of the newborn babies were exclusively breastfed at 6 weeks of age.

 

The outcomes of this large study were consistent with the best available literature that shows that for healthy, low-risk women, a planned home birth attended by a midwife can result in positive outcomes and benefit the mother and newborn baby.

• Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. 2014. Outcomes of Care for 16,924 Planned home births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery and Womens Health 59:17–27.

 

Delayed umbilical cord clamping after birth

Early cord clamping was initially introduced as part of the active management of the third stage of labour (delivering of the placenta) which was implemented to reduce postpartum haemorrhage (bleeding). It is standard practice in South Africa to clamp and cut the umbilical cord immediately after birth (the World Health Organization (WHO) recommends 1 to 3 minutes after birth). Waiting before clamping the umbilical cord can bring better outcomes for babies. Clamping the cord too soon may reduce the amount of blood that passes from mother to baby via the placenta, limiting the baby’s iron stores.

 

The benefits of delayed clamping outweigh the slightly increased risk of jaundice. The additional blood the baby receives with delayed cord clamping increases the total body iron stores of the baby for up to 6 months of age. Delayed cord clamping by 30–120 seconds in preterm infants results in fewer babies requiring transfusions for anaemia, better circulatory stability, reduced risk of intraventricular haemorrhage (all grades of bleeding), reduced risk of necrotizing enterocolitis (inflammation of the gut), and less late-onset sepsis. Delayed cord clamping does not increase the risk of maternal haemorrhaging or affects the mothers’ haemoglobin levels.

• McDonald, S., Middleton, P., Dowswell, T. & Morris, P.S. 2013. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD004074.pub3.

• Uwins. C. & Hutchon, D.J.R. 2014. Delayed umbilical cord clamping after childbirth: potential benefits to baby’s health. Pediatric Health, Medicine and Therapeutics 5:161-171.

 

Benefits of skin-to-skin

Benefits for baby

• Better brain development

• Better emotional development

• Less stress

• Less crying

• More settled baby

• Babies are often more alert when awake

• Babies feel less pain from injections

• The baby’s heart rate stabilises

• The baby’s oxygen saturation is more stable

• Fewer apnoea attacks

• Better breathing

• The baby’s temperature is more stable on the mother or father

• Breastfeeding starts more easily

• More breastmilk is produced

• Gestation-specific milk is produced

• Faster weight gain

• Baby can usually go home earlier

Benefits for parents

• Parents become central to the caring team

• Better bonding and interaction with their child

• Emotional healing

• Parents are calmer

• Parents become empowered and more confident

• Parents are able to learn their baby’s unique cues for hunger

• Parents and baby’s get more sleep

• Parents, especially mothers are less depressed

• Parents cope better with babies who need Neonatal Intensive Care

 

Steps to breastfeeding

Exclusive breastfeeding is considered one of the most effective preventive health measures to reduce disease and death in children. Breastmilk is an unequalled ideal food for healthy growth and development of babies. Exclusive breastfeeding for 6 months is the optimal length of time to feed babies where after complementary foods should be introduced up to 2 years of age or beyond. Make sure your facility:

1. Has a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train health care staff in skills necessary to implement this policy.

3. Inform pregnant women about the benefits and management of breastfeeding.

4. Help mothers to initiate breastfeeding within half an hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.