At Prince Mshiyeni Memorial Hospital (PMMH) in Umlazi, the largest township outside the South African port city of Durban, using midwives to provide maternity services has positively impacted maternal care in the area, but a national shortage of these specialist health personnel has made it difficult to replicate the model elsewhere.
“Midwives are integral to ensuring that we take quality care of our mothers and babies,” Rachel Gumbi, the hospital’s CEO, told IRIN. “The success story of this hospital is because of the teamwork between doctors and midwives.”
The maternity ward at PMMH is one of the busiest in the country, with more than 1,200 deliveries a month, but the staff of 123 midwives and 15 doctors have managed to reduce both infant and maternal mortality rates.
Although 40 percent of the women visiting the hospital’s antenatal clinic are HIV positive, the midwives play a key role in ensuring that 95 percent of those in need of antiretroviral (ARV) medication receive it, and that the rate of mother-to-child transmission of HIV is below 3 percent.
The midwives are involved in every aspect of a pregnant woman's health, from pregnancy screening to post-delivery care and the provision of family planning and pap-smears to detect cervical cancer.
They receive ongoing training through monthly meetings where they discuss difficult cases, and information-sharing sessions that ensure they are up-to-date on the latest policies and protocols. An outreach mentorship programme is also in place for midwives in outlying clinics who may need to refresh their skills.
Such success stories are relatively rare in South Africa. Rather than making progress towards the Millennium Development Goal of reducing maternal mortality by 75 percent by 2015, the number of deaths resulting from pregnancy or childbirth has doubled in the past 20 years.
For every 100,000 babies born, up to 625 mothers die due to childbirth complications. Mortality in children under five has also risen steadily and remains stubbornly high at 104 deaths per 1,000 live births, according to government figures.
Loveday Penn-Kekana, a maternal health researcher at the Centre for Health Policy, University of the Witwatersrand in Johannesburg, believes South Africa’s poor maternal health outcomes are linked to the lack of midwifery services.
“In order for us to address South Africa's maternal health we need to invest in more and better trained midwives,” she said. “Doctors only come into maternity wards from time to time, but it is the midwives who are running the entire service and they are overworked.”
|For us to address South Africa's maternal health we need to invest in more and better trained midwives|
Midwives are classified as nurses in South Africa so there are no figures on their numbers, but it is clear that there are too few. Low enrolment at nursing colleges is part of the problem but many midwives have also left the public sector to work for higher salaries overseas or in managerial positions because of the limited opportunities for career development and advancement in the clinical area.
No more home deliveries
Although pregnant women in South Africa are entitled to free healthcare, Penn-Kekana noted that some face difficulties accessing services because they lack money for transport. The Department of Health has initiated the use of maternal ambulances to transport pregnant mothers to health facilities but challenges remain in rural areas where there are no roads.
“I have no job and it is expensive for me to get to the hospital,” said a woman at PMMH who was expecting her seventh child. “I am happy with the service, but it is sometimes very difficult for me to get to my appointments here… because I have no money.”
In the past, midwives helped women give birth at home, but there are no longer enough of them for this to be possible. “It makes more sense for the few trained midwives to be stationed at facilities so that they can see more women than for them to be scattered across areas,” said Meisie Lerutla, National Programme Officer for Sexual and Reproductive Rights at the United Nations Population Fund in South Africa.
Deliwe Nyathikazi, President of the Society of Midwives of South Africa, noted: "The biggest challenges for us as midwives in South Africa is that there are not enough of us to provide the best care possible. Because people are first trained as a nurse and then given midwifery skills, midwifery is not prioritized.”
A plan by South Africa’s Health Minister, Dr Aaron Motsoaledi, to reopen unused nursing colleges across the country and increase the number of nurses should also result in more midwives being trained.
Lerutla pointed out that “Once we have increased the number of midwives in South Africa dramatically, the practice of midwife-assisted births at home for women in remote areas can be revisited.”