Outcomes of births attended by private midwives in Gauteng

Abstract

Pregnancy and childbirth are critical life events and women and their families require physical as well as emotional support and care. The concepts continuity of care, choice and a sense of control are prominent in the literature on women’s satisfaction with as well as outcomes of care. Midwives have globally been identified as important role players in women-centred care for low risk pregnant women. To be able to offer their women safe, supportive care they need not only a certain degree of autonomy, but also the support of other health care professionals such as obstetricians to whom they can refer women with risk factors or complications. Maternity care has become “medicalised” and the overuse of interventions such as caesarean section is prevalent in many countries. South African women make use of either the public or private health sector for care during pregnancy and birth. The public sector is overburdened and women do not have a high level of continuity of care. The private sector is mainly obstetrician-led and intervention-driven, even for low risk women. The estimated caesarean section rate is higher than 70%. Private midwife-led care is available in South Africa, but is concentrated in the major cities. Private midwives practise at hospitals, birth centres, “active birth units” and women’s homes. No evidence could be found on the outcomes of private midwife-led care in South Africa. The objectives of this study were to explore and describe the outcomes of births attended by private midwives in Gauteng over a two year period and to compare these outcomes with the latest Cochrane review on midwife-led care. A retrospective cohort design was chosen to audit the birth registers of private midwives in Gauteng and conduct quantitative analyses. Gauteng midwives’ patients, when compared with the Cochrane review that juxtaposes midwife-led care with other models of care, had a significantly lower percentage of interventions such as induction of labour (9.6% versus 18.6%) but caesarean sections were performed significantly more frequently (19.3% for the women in Gauteng versus 12.5% for the women in the review). Women in Gauteng also made significantly less use of medications in labour. Maternal and neonatal outcomes were reassuring. Significantly more Gauteng women had intact perineums (53.4% versus 31.4%). A higher percentage of postpartum haemorrhage was found in the Gauteng sample (7.9% versus 6.2%). The difference is significant, although, only three women were admitted to high care units as a result of postpartum haemorrhage. Overall foetal loss (4.3% versus 6.7%) and neonatal ICU admissions (0.3% versus 2.9%) occurred significantly less frequently in the Gauteng sample. The study findings indicate that private midwife-led care in Gauteng compared well with that in the rest of the world in terms of intervention rates and outcomes.