Sensitive Midwifery Magazine - Issue 44 - October 2019 by Sister Lilian Centre

Issue 44 • October 2019

3 ways to make a difference • Woman-centred care • Group antenatal care • VBAC the midwife way

Where do you stand on:

C-section in South Africa

• Breastfeeding in public

the impact

• Online midwifery learning • Ensuring preemies get colostrum

Alleviating

USA

midwife-birth

peaks in Alaska

Trends and tipping points: SA’s birthing future

CONTENTS Issue 44 • October 2019

24. VBAC the midwife way Understanding women’s specific needs and concerns, and safety guidelines

Anterior 4. Our voice »» Editor Margreet Wibbelink explains why this is the final edition »» Meet three key contributors to Issue 44

27. Birth review »» C-sections riskier in some regions of the world »» Managing a midwifery group practice »» Peanut ball helps labour progress »» Babies born by C-section deserve skin-to-skin care too

6. Your voice About achieving woman-centred care, your appetite for online learning, and feelings about being a midwife 8. Guest voice Are you the best midwife you can be, asks Prof. Marie Hastings-Tolsma

28. Let’s make maternity units more woman-centred

Pregnancy

30. Iodine in maternity care The importance of balance

10. Food, the original medicine The importance of nutritional instinct in pregnancy

34. Self-Care 101

Dimensions

37. Horizons »» Working CLEVER could improve perinatal mortality »» Can technology help midwives save lives in childbirth? »» Poverty changes our genes

12. Together it’s better How group antenatal care can help women and midwives 16. Belly talk »» Fertility app proven to be useful »» Obstetric cholestasis – who is at risk? »» No clear risk factor for twothirds of preterm births »» Mourning miscarriage with a Buddhist ritual

38. A midwife’s silence is golden Speech is silver but silence is golden

Birth 18. Birth in Alaska Midwives attend more births than anywhere else in the United States

20. The future of natural birth in South Africa

eSensitive Midwifery Magazine

Issue 44

Mom & Baby 43. First steps »» Sore throat at the turn of season »» SA baby food too high in sugar »» Babies' bladder and bowel basics »» Universal home visits, a proven success »» The benefits of reading to NICU babies »» Post-divorce parenting is not for sissies! »» Six weeks for postnatal recovery is a ‘complete fantasy’ »» Pain in children 45. Whats on the shelf page 46. Measures to minimise scheduled C-section risks to infants

Breast assurance 49. Milky ways »» MOM’s the best »» Dads make a difference »» Breastfeeding has a consistently lower carbon footprint »» The cost of not breastfeeding 50. Liquid gold for premature babies 52. Normalising breastfeeding in public If breast is best, why is it sometimes considered ‘bad’?

SENSITIVE MIDWIFERY MAGAZINE TEAM Managing editor Sister Lilian Editor Margreet Wibbelink Sub-editor Kelly Norwood-Young, Hello Hello Creative Communications Contributors Prof. Marie Hastings-Tolsma, Sister Lilian, Else Vooijs, Patricia Musarurwa, Elke Barnes, Kelly Norwood-Young, Yolande Maritz, Sanele Lukhele, Marjorie Arnold, Prof. Suzanne Delport, Annerié Conradie, Petro Wagner, Margreet Wibbelink Research Kelly Nowood-Young, Margreet Wibbelink, Sister Lilian Business director Alan Paramor Advertising sales Gillian Richards Design Alex Naeve, JBay Studios Printed by Typo Printing Published by Sister Lilian Centre® No part of Sensitive Midwifery Magazine may be reproduced in any format without written consent of the publisher. All rights reserved. Every precaution has been taken to ensure correctness of information and references, but opinions expressed in the digital version of Sensitive Midwifery Magazine do not necessarily reflect standard obstetric practice, though the publishers and editorial team set great store by ethical, responsible maternity care. While we firmly believe that the content found here will help improve midwifery and birthing, responsibility cannot be taken for the application in practice of Sensitive Midwifery Magazine’s information, tips, suggestions and guidelines. The publication is intended for the interest of midwives and related maternity professionals only. Copyright: Sister Lilian Centre®

CONNECT WITH US

Posterior 55. Key references in Issue 44 56. Spicy pineapple salad bowl

www.sensitivemidwifery.co.za

57. Looking towards the future with 2020 vision 58. Sensitive Midwifery Symposium & Seminars 2020 A sneak preview 59. How to become a Certified Sensitive Midwife 60. Last word The Birthing Team Maternity Care Model

Email: info@sensitivemidwifery.co.za Call: +27 12 809 3342; 071 447 3321 Fax: 0866 912 485 Postal address: PO Box 11156, Silver Lakes, Pretoria, 0054

eSensitive Midwifery Magazine

Issue 44

Our voice Sensitive Midwifery’s new logo, the beautiful protea, hinted at change, because symbolically it stands for transformation.

Midwife Margreet

Times too are changing and to stay current we are embarking on new ventures! To embrace the new, one often has to bid some of the old adieu. It’s with a little sadness that we’re letting you know that this is the last edition of Sensitive Midwifery Magazine; print media is dying away and so is the faithful postman.

However, we are very excited to share that the same great content (and more) will be reaching you in new ways … our very own YouTube channel, podcasts, and a regular newsletter, to name just three. Read more about new developments on pages 57-59 of this, our swan-song edition.

Contributors Elke Barnes, who describes herself as a ‘peppy surfer midwife’ tells us all about midwifery and birth in Alaska on page 18.

My dream holiday would be to visit South Africa, meet all you beautiful midwives and surf Jeffreys Bay. If I were the Alaskan Minister of Health, I would eliminate private insurance companies. My grandmother impacted me the most in my life. She was a watercolour artist and a depressionera nurse. I spend my free time surfing, hiking, enjoying good wine, cooking and cleaning the house. My biggest wish would be to have a big, beautiful avocado tree that would produce fruit in Alaska. At times I fly to Kodiak, an island with a population of 6 500, famous for the Kodiak Grizzly Bear and the reality show The Deadliest Catch. There is no midwife on that island and I plan to open an informal birthing suite there.

Sanele Lukhele, a vibrant midwifery lecturer at the University of Johannesburg, writes on how womancentred care can be implemented in South Africa on page 28.

Petronella Wagner, Child and Adolescent Development tutor at UNISA, freelance copywriter and passionate breastfeeding advocate, enthusiastically promotes normalising breastfeeding in public places on page 52.

I would really like to open a midwife-led birthing unit in Soweto so that women in that part of the country can experience beautiful woman-centered births. If I could have my dream holiday, I would go to Paris to shop. The person who has impacted me most is Professor Fhumulani Mavis Mulaudzi of the University of Pretoria. She models integrity, professionalism and authenticity, and I wish I could clone her for the profession. I wish to end poverty so that all babies can have a better chance at life and its opportunities. If I were the Minister of Health I would prioritise collecting statistics on the number of nurses and midwives in clinical practice, academia and administrative posts in order to know the true extent of the nursing and midwifery shortage, and to plan for the future.

I would describe myself as dedicated, passionate and social. My three wishes are that no child in South Africa would be without a loving family, that only honourable and competent people would be selected to govern, and that babies (especially mine) would sleep more like most adults do. The people who have impacted me most in my life are my husband, parents, grandparents and siblings; I love to spend time with my family, and in nature. I wanted to become a psychologist and change the world. I have since realised that I would make a terrible psychologist and that one can only partially change very small parts of the world — and that still means success! I would struggle to survive if I had nothing fun to look forward to. I would rather park three blocks away than parallel park right.

eSensitive Midwifery Magazine

Issue 44

Your

voice

The highlight of our Sensitive Midwifery work is undoubtedly meeting and interacting with all you beautiful midwives and birth workers at Symposium, Seminars and Courses – in East London, Port Elizabeth, Johannesburg, Durban, Bloemfontein and Cape Town, in 2019.

What needs to change to practise woman-centred care

We want – no, need –

woman-centred

care training

By far the majority of midwives attending Sensitive Midwifery Symposium in 2019 would be interested in additional education to practise woman-centred care the ‘midwifery way’, as reflected in this chart:

Symposium delegates highlighted six main areas of midwifery practice needing attention, if woman-centred care was to become a reality in South African hospitals: 1. Working environment • Maternity wards need to be led and run by skilled, passionate midwives • The birth environment must have a positive atmosphere, be comfortable, not be too cramped, be family-friendly, and afford privacy • Safe homes, to which women can be admitted when having travelled from afar to be closer to the maternity unit, but are not yet in active labour 2. Midwife empowerment • It starts with training about woman-centred care, from midwifery curricula to workshops to Sensitive Midwifery Symposium • Midwives need to be more involved with antenatal care • A change of mindset to promote natural childbirth techniques, and to actively advocate for women’s rights in this regard, is required Continued on page 7

eSensitive Midwifery Magazine

Issue 44

• Midwives need to hone their listening and observational skills, and be reminded of the importance of non-authoritarian, respectful care for each birthing woman and her family • In the private sector, midwives need to upskill in attending childbirth as the lead professional, and be given the opportunity to do so 3. Collaboration • Midwife-obstetrician relationships require reciprocal respect and engagement

to natural life experiences that have every chance of a good outcome with excellent, physiological, midwife-led care • More support by health authorities of midwife-based care, and the importance of birth companions, including doulas, for the general population • Giving women the opportunity to express their feelings and be involved in care decision-making

• Welcoming independent midwives into hospitals

5. Managerial matters

• Deploying doulas and actively encouraging birth partners in the maternity unit

• Organisational culture and midwifery policy changes

• Increased midwife deployment

4. Women empowerment • Awareness and promotion of women’s birth rights through evidence-based, authentic pregnancy and birth education on the individual midwife-to-woman, health authority, and maternity facility levels •

Fostering a change of mindset, from pregnancy and birth as medical conditions

• Support of skilled midwives as professional equals (albeit with the speciality of low-risk birth) to the doctors 6. Woman-centred care research • More research to be conducted • Survey pregnant women to find out their peripartum expectations

Being a midwife

Is online learning the CPD answer?

You said:

Asked if they would like Sensitive Midwifery to offer online webinars and courses to keep up to date as a sensitive midwife, this is what Sensitive Midwifery Symposium delegates answered:

• The one thing that brings me joy, my passion and a wonderful experience • A beautiful career, interesting, satisfying and a fulfilling experience everyday • The theory is interesting but for a student doing practicals, it’s more than a bit gross and frightening • It’s a lifestyle, it’s who I am; I love it and feel I was born to be a midwife • Awesome and scary, challenging yet rewarding • It’s a privilege, a way of life; there’s a huge price to pay, as for any passion; it’s physical, emotional, spiritual; midwifery and birth are creation; they’re universal

eSensitive Midwifery Magazine

Issue 44

Guest Professor Marie Hastings-Tolsma, PhD, CNM, is a visiting professor at the University of Johannesburg and teaches in the Midwifery Doctor of Nursing Practice programme at Baylor University in Texas, USA.

espite questionable improvement in maternal and infant health, the main reason for hospital admission in most countries is childbirth – and caesarean birth is among the top in-patient surgery. Powerful players seek to lay claim to the birth industry. With the continued climb of unnecessary surgical births, real money is at stake. While obstetricians play a central role in the effort to mechanise birth, midwives have just as surely played a definitive role in failing to protect women from unnecessary intervention and a lack of compassionate, woman-centred care.

Owning midwifery neglect Despite being the largest group of maternity care providers in South Africa, as well as across the globe, midwives have largely abdicated their responsibility to protect women from unnecessary interventions. We have failed to provide safe, supported birth, and to take our rightful role at the policy table, demanding that women receive compassionate, skilful midwifery care. Midwives have long considered themselves the vanguard of normal birth but it is impossible to justify our collective failure to ensure safe passage for mother and fetus in more recent years. It is frightening to see the speed with which the memory of normal birth is being lost – by both women and midwives.

voice

Mirror, mirror on the wall … Do you see the best midwife of all?

Midwifery leadership is needed now! It is time for midwives to consider strategies which promote our role as the experts in normal birth. Needed are workforce studies which detail the actual numbers of midwives and the nature and scope of midwifery practice. This is a need confirmed by the World Health Organization as an important component to ensure meeting 2030’s Sustainable Development Goals. A growing shortage of midwives is likely masked where nurses and midwives are not differentiated. Also needed is an upscaling of midwifery education to ensure expert knowledge and skills to manage women during parturition. Such upscaling will also be important in providing a midwifery voice in the development of policies which promote woman-centred care and the presence of companions during childbirth. And finally, midwives need to promote and ensure fundamental, non-invasive, low-tech practices which promote normal birth.

What reflection do you see? So I ask you, when looking in the mirror, does the midwife you see provide care that protects women from unnecessary interventions, in a manner that promotes safety, comfort, support and shared decision-making? Does this midwife advocate for women in a manner that brings to life the meaning of midwife – ‘with woman’?

eSensitive Midwifery Magazine

Issue 44

Pregnancy

Food,

the original medicine We weren’t born with a degree in nutrition but we were all born with nutritional instinct, says Sister Lilian, founder of Sensitive Midwifery

his doesn’t mean that a pregnant woman should not care what she eats, nor that there are no warnings needing heeding. Instead, it means that the best nutritional status, with the least potential for any adverse effects, is quite possible for the lay mom to achieve. Information overload robs a woman of a direct line to her three most powerful nutritional allies: instinct, common sense, and Mother Nature’s plentiful pantry.

for individuality – after all, not everyone likes the same foods or responds best to the same mealtime ‘schedule’:

Moms-to-be are primed to eat well

5. Eat smaller meals more often, and chew

The ancient ‘gatherer’ instinct emerges during pregnancy, when beta-endorphin releases pleasure (read, enjoyment of good food) and the ability to rise above limitations others impose on the mom-to-be. Adrenalin and noradrenalin ensure elation and that the expectant mother is focused on protecting her baby, including nutritionally. Noradrenalin will also nurture her instinct to eat healthily. Just as birth should be instinctive, so should eating be, and there are ten guidelines that midwives can confidently use to help empower women nutritionally. Season these with respect

1. Respect taste buds, but with healthy choices 2. Increase plant foods; decrease animal foods 3. Include plant foods from all colour groups 4. Eat as few refined foods as possible, and

choose organic, chemical-free produce food properly 6. Know that dairy is not the ideal calcium

provider, that protein is not synonymous with animal flesh, and that dairy and wheat-rich vegetarian meals are not the healthy choice 7. Fasting can be therapeutic but is not advisable

in pregnancy 8. Avoid drinking large amounts with meals 9. Fruit juices disrupt nature’s way of providing

fructose – eat fruit; drink water 10. Eat healthily most of the time – aim for at least

an 80/20 ratio Continued on page 11

eSensitive Midwifery Magazine

Issue 44

Pregnancy

Cer�ﬁed all natural & safety approved pregnancy skincare Pregnancy red-flag foods • Allergy-risk foods – dairy products, refined grain products, shellfish, egg and peanuts • Mushrooms • Onions and garlic in excess • Nuts – if at all rancid or treated with chemicals and preservatives • Caffeine-containing products may increase anxiety, insomnia and hyperactivity • Exotic foods like patés may have too much Vitamin A • Blue-veined and soft cheeses might contain harmful bacteria • Processed and dry meat products might contain toxic bacteria • Alcohol • Artificial sweeteners; sweet, stodgy treats; and sugary soda drinks

Sister Lilian’s macronutrient guide These guidelines support the principles above, and can help expectant mothers to find a more instinctive way to turn their food into real health. Suggest that each week’s food-intake be distributed along these lines: • Raw, fresh, whole seasonal fruit – 20% • Raw salads – 20% • Vegetables – 15% • Grains, nuts, seeds – 15 % • Pulses, legumes, beans – 10% • Meat, fish, eggs (or if vegan, simply add 7.5% to the grains and/or pulses categories) – 7.5 % • Dairy (or if vegan, simply add 7.5% to the veg, fruit and grains categories) – 7.5% • Healthy fats and oils – 5%

eSensitive Midwifery Magazine

Issue 44

Clinically and Dermatologically cer�ﬁed for: Swollen Legs & Feet Stretch Marks Sore & Cracked Nipples Cellulite Dry & Itchy Skin

Shop online at www.natralogic.co.za use the promo code ”MIDWIFERY” and get 20% oﬀ your purchase

Pregnancy

Together it’s better

Taking pregnancy care to the next level Dutch midwife Else Vooijs, and doula and nursing assistant Patricia Musarurwa, who both work at Healthy Mom and Baby Clinic in Jeffreys Bay, show how group antenatal care can benefit South African women and midwives.

Else Vooijs and Patricia Musarurwa of Healthy Mom and Baby Clinic

n 2016, the World Health Organization (WHO) launched its new recommendations for antenatal care with the subtitle ‘for a positive pregnancy experience’. Wouldn’t you agree it’s interesting that they chose this subtitle? It certainly shows that the ‘experience’ component of pregnancy is important. The 2016 WHO recommendations have some key changes to previous recommendations. Now, it’s advised to have eight or more ‘contacts’ in antenatal care, because ‘perinatal deaths can be reduced by up to eight per 1 000 births when compared to the four antenatal visits of the past’. The WHO also now uses the word ‘contact’ instead of ‘visit’ to highlight that a woman’s ‘contact’ with her antenatal care provider should be more than a simple ‘visit’, instead focusing on an active connection between a pregnant woman and the healthcare provider. The goal is to provide

empowering care and support throughout pregnancy. The new model increases maternal and fetal assessments, helping to more readily detect adverse circumstances and complications; improves communication between health providers and pregnant women; and increases the likelihood of positive pregnancy outcomes.

Not just pretty words Evidence showed that women from high-, medium- and low-resource settings all valued having a positive pregnancy experience, the components of which included: • The provision of effective clinical practices (interventions, tests, dispensing nutritional supplements, etc.) • Relevant and timely information (dietary and nutritional advice, pregnancy ailment relief, birth preparation, etc.) • Psychosocial and emotional support by knowledgeable, respectful healthcare practitioners Continued on page 13

eSensitive Midwifery Magazine

Issue 44

Pregnancy

It was shown by the WHO in 2016 that a positive pregnancy experience as described on page 12 optimises maternal and newborn health considerably. Midwives in particular are wellplaced to offer and implement all three of these components, though many midwives wonder just how they will be able to implement such a service in the busy, under-resourced reality of their days.

Midwives make a plan In 1993, a busy American antenatal nurse-midwife, Sharon Rising, realised that she was repeating herself almost the whole day and that it was hard for her to keep to her schedule. She had already figured out that antenatal care is more than a ‘check-up’. Women wanted relevant information and support too. Sharon wanted to provide more effective prenatal care and so started with antenatal care groups which she called CenteringPregnancy®. This model was neither just a health check, nor just antenatal classes, and there are now 580 health facilities in the USA which have implemented this model of antenatal care. CenteringPregnancy® and similar antenatal models have subsequently spread far and wide. Indeed, many midwives began to challenge the individualised antenatal check-up model, unwittingly implementing similar or partial versions of the CenteringPregnancy® model worldwide, including in South Africa. A variety of names were used, like group prenatal care, pregnancy circles, and pregnancy clubs. Group-based antenatal care allows women to get the care they need, in a supportive and respectful setting. It empowers them to make healthy decisions, allowing them to drive the content of their care, be more informed, learn from each other and even to participate in their own care.

How group antenatal care works Normally, a group will have eight to 12 women at a similar stage of pregnancy. There will be five to 12 group sessions over the course of a pregnancy and each session takes around 90 to 120 minutes. Each session will include the three components; namely, physical assessment (consisting of some selfassessment elements and a physical examination with a professional), education, and peer support.

Not only does this way of giving antenatal care decrease the number of preterm births, but research also shows that it increases prenatal satisfaction and that women make better health decisions in pregnancy and beyond. Midwives too report greater satisfaction, an increase in the quality of care, and better relationships with the women in their care. The WHO recommends that more research on this type of antenatal care is done, because it has already shown so many benefits and good results.

Making circles in South Africa

A midwife from the Netherlands, Margot van Dijk, introduced the concept of group pregnancy care sessions to the Healthy Mom and Baby Clinic (HMBC), located in the thriving town of Jeffreys Bay, in 2014. Prior to this, HMBC had offered birth and breastfeeding classes, but they weren’t integrated with the health checks and there wasn’t that much group participation. It took some doing to get the model going smoothly. Dates had to be booked; the new approach needed to be posed to women to test their interest; work methods had to be structured; and informational materials made or collected. Nowadays, almost 75% of all women coming to HMBC for antenatal care join the groups. Each session’s educational slot uses different work methods and exercises, to encourage women to participate, and think independently. For instance, one session includes the ‘forbidden box’, a crate filled with food and beverages. Each woman is given a few products, reflects on their suitability in pregnancy and then shares her thoughts with the group. Soon the rest of the group add to the discussion, sharing their previous and current pregnancy experiences and helping each other to reach conclusions, facilitated by a caring and knowledgeable maternity professional. HMBC’s five group sessions cover: • Healthy eating and lifestyle for pregnancy and post-pregnancy • Relationships, family planning and dental health • Breastfeeding • Labour and birth (birthing partners attend too, to air their concerns and learn how they can be supportive) • Postpartum period and depression Continued on page 14

eSensitive Midwifery Magazine

Issue 44

Pregnancy

Group leader Patricia Musarurwa comments: ‘Pregnancy is not only about getting booked, doing bloods and having some check-ups. From the early embryonic days, it’s about relationships, the growth of a family, and the health of the nation at large. I have learnt from the moms in our clinic just how important it is to them to be well-informed before they go into labour. Clued-up moms go through pregnancy, birth and parenting in a satisfied mode, and don’t struggle to raise their children. Time and again we hear how useful what they learnt in our pregnancy groups was in the hospital and their early days as a mother. Their active participation in the group helps them to recall tips far more easily.’

From the mouths of HMBC moms

u o y e c i v d a t s The be ust r t o t s i m o can give M er h t e e m o t y t Baby Ci s. d e e n s ’ y b a and B e d i w n o i t a N es r o t s r e p y H 3 3

• ‘The group really helped me know what to expect. I’m a first-time mom and I live alone, so I didn’t know where to start. I got support from the group leaders and from my peers. I learnt how to manage labour and breastfeeding, how to love my baby and all the reasons a baby cries. Now I am able to grow my baby on my own because of this education. I want to encourage other clinics to do these sessions and all women to attend for they have been very helpful for me.’ Ntombizadwa Schoeman • ‘I am very grateful for the sessions because as a first-time young mom, I went into labour with no fear at all. This is because I was taught all the stages of labour, the signs of labour and when to go to hospital. I trusted my body to do what it’s supposed to do. Even now, raising my baby, I use all the knowledge I was given, from breastfeeding to healthy eating. I have not struggled at all with my baby. I feel I was very empowered and I am very thankful for the sessions.’ Nyasha Chinyahara • World Health Organization, ‘WHO recommendations on antenatal care for a positive pregnancy experience’, 2016. Available at: http://apps.who.int. Accessed July 2019. • Benediktsson J, et al, ‘Comparing CenteringPregnancy® to standard prenatal care plus prenatal education’, BMC Pregnancy Childbirth, 2013, 13

53545 Fire Tree e&oe

www.babycity.co.za

eSensitive Midwifery Magazine

Issue 44

Pregnancy

No clear risk factor for two-thirds of preterm births

Fertility app proven to be useful A study was done to assess six-cycle perfect and typical use efficacy of Dynamic Optimal Timing (Dot), an algorithm-based fertility app that identifies the fertile window of the menstrual cycle using a woman's period start date. The app also provides guidance on when to avoid unprotected sex to prevent pregnancy. Current six-cycle results suggest that Dot’s guidance, when used correctly, provides women with useful information for preventing pregnancy. Hennings, VH, et al, ‘Estimating six-cycle efficacy of the Dot app for pregnancy prevention’, Contraception, 2019, 99(1), 52–55

Obstetric cholestasis – who is at risk? While obstetric cholestasis is associated with adverse perinatal outcomes, there has previously been little evidence regarding which women were more at risk and why. Now, a recent systematic review and metaanalysis has found that: ‘The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more’. Because most women with obstetric cholestasis have bile acids below this concentration, their risk of stillbirth is probably similar to that of pregnant women in the general population. Repeat bile acid testing must be done until delivery. These results mean that more informed choices can be made when considering interventions like induction. Ovadia, C, et al, ‘Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses’, Lancet, 2019, 393: 899–909. Available: https://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(18)31877-4/fulltext

Predicting the worldwide 11% preterm birth rate risk is complicated by inconsistencies in measurement of gestational age, preterm definitions, and data collection and reporting, despite the known associations between preterm birth and a wide range of socio-demographic, medical, obstetric, fetal and environmental factors. Efforts to standardise definitions and compare preterm birth rates internationally have yielded important insights into the prevention and epidemiology of preterm birth. This will hopefully soon improve risk assessment and lessen neonatal and child mortality and morbidity, particularly in resource-poor settings, and the deleterious effects of preterm birth on health and welfare in adult life. Vogel, JP, et al, ‘The global epidemiology of preterm birth’, Best Practice & Research Clinical Obstetrics & Gynaecology, 2018, 52, 13–22

Mourning miscarriage with a Buddhist ritual The loss of a loved one in Western cultures is often followed by a funeral or some sort of ritual to mark the family’s grief. Miscarriage, however, is often private. Parents who are coming to terms with pregnancy loss may find comfort in the Buddhist ritual of mizuko kuyo. Following a moving ceremony, parents can visit Jizo figurines (which represent babies never born), leaving gifts and honouring their lost child. Zeveloff, J, ‘Japan has a beautiful tradition for grieving lost pregnancies, and it helped me come to terms with my own miscarriage’, 15 October 2018. Available: https://www.insider.com/japan-buddhist-tradition-jizogrieving-miscarriage-lost-pregnancy-2018-10

eSensitive Midwifery Magazine

Issue 44

Birth

Birth in Alaska

Read more about Elke Barnes on page 4

Midwife Elke Barnes describes the birthing landscape of Alaska, where midwives attend more births than anywhere else in the United States.

ello to my sister midwives in South Africa! I'm writing from the hotbed of midwifery in the United States – ALASKA! We are the 49th state – one of the youngest, since Alaska only became a state in 1959. Our state is huge, larger than your entire country of South Africa. Many know us for our caribou, salmon and glaciers, but what makes me most proud is that we have the most vibrant and active midwifery presence in the USA.

Two types of midwives In Alaska (and the US) there are two kinds of midwives: the Certified Nurse Midwife (CNM) and the Certified Professional Midwife (CPM). The Certified Nurse Midwife comes from a nursing background then attends graduate school to become an advanced practice nurse. CNMs practise in all 50 states. They have a wide scope, including birth, prenatal and postpartum care, as well as well-woman care, gynaecology, and prescriptive privileges from menarche to menopause. CNMs work mostly in the hospital setting, within the medical system, often supervised by doctors. Unfortunately, the Certified Nurse Midwives tend to struggle for autonomy and to be able to practise the midwives’ model of care, though they do have very few regulations or limitations to their practice in Alaska. A Certified Professional Midwife, or CPM, is a community-based midwife who attends births at home and at non-hospital-affiliated birthing

centres. CPMs are ‘direct-entry’ educated without a nursing background, completing a three-year degree programme and a 3 500-clinical-hour apprenticeship. CPMs tend to have a highly holistic approach to midwifery, utilising herbs, bodywork and other non-medical modalities in their care. CPMs are only licensed to practise in about half of the US states. To serve a wider population, many of the Alaskan CPM practices also employ at least one CNM due to their wider scope of care, including prescriptive privileges. CPMs are highly regulated and restricted in practice in Alaska. Midwives attend about 10% of births in the United States but the rate varies widely between states. Alaska has three times the national average with almost 30% of our 11 000 births a year attended by midwives.

History of midwifery in the USA

To understand why Alaska has such high midwifery rates, we need to look at the history of midwifery in the US. In the early 1900s, when birth moved from home into the hospital, US medical societies lobbied to outlaw midwives instead of integrating them. While the European nations were modernising and mainstreaming midwifery, our midwives had their licences revoked, mostly for reasons of financial competition, classism, sexism and racism. Only in pockets of poor and remote places did midwifery continue. One of the strongest places Continued on page 19

eSensitive Midwifery Magazine

Issue 44

Birth

was in the black south where the poor could not afford to go to the hospital, and hospitals refused to help birthing women who could not pay. The highly skilled black 'granny midwives' continued to deliver the majority of poor families until the 1960s. Another pocket of traditional midwifery that survived was in rural and remote places, such as northern Wisconsin, Idaho and Alaska. With access to hospitals difficult (due to rugged landscapes, long distances, bad weather and shortages of doctors), people continued to birth at home with traditional midwives. As Alaska became a US state and became more populated in the 1960s, the Indian Health Services (IHS) dominated its health care. IHS is a government entity that provides socialised medicine to the indigenous and their descendants. Unlike the mainstream medical system in main US, the IHS system adopted a more culturally competent system to childbirth by keeping and training midwives within their system. The modern IHS hospital midwives provide all care for low-risk patients, prenatally, during birth and postpartum. Since IHS hospitals function with limited funding and don’t rely on the 'pay per service' model, lower intervention and lower cost of employing midwives makes sense financially as well as culturally. The Alaska Native Medical Center in Anchorage boasts a C-section rate under 18% and a VBAC rate of over 80%, despite serving a high-risk population.

A strong midwifery presence Alaska not only boasts the highest number of midwifery births but also the highest out-of-hospital birth rate in the US. One area called the Mat-Su Valley has a population of just 100 000 yet is home to five birth centres. A whopping 20% of the births in that area are out-of-hospital. Anchorage has six freestanding birth centres that serve a population of 380 000 people. In contrast, the State of Illinois has 13 million people and only three birth centres. Our state was one of the first to establish licensure of direct-entry midwives and birth centres in the early 1990s, which may be another reason our midwifery presence is so strong. In my personal practice, I serve a wide range

of races, cultures and socioeconomic classes but all are low risk. We serve everyone from recent immigrants who don’t speak English to high-income professionals, as well as commercial fisherwomen who spend most of the year living on boats or off the grid in the wilderness. I base my practice out of a small birth centre in Anchorage with two other midwives. We offer birth centre delivery but prefer home birth because of its intimacy. We think it’s important to provide a facility for people who don’t have a good place to give birth. My travelling practice is mostly to the Island of Kodiak where there is no resident midwife. I plan to open an informal ‘birthing suite’ there in the future. I have worked many years to forge a good relationship with the medical community. I do co-care with all my clients so they have a doctor to see when I am not in town and in case they need transfer. My clients see the back-up physicians about four times before birth and bring the baby in during the first week after the birth to establish baby care. We are autonomous providers in Alaska and this back-up is not required in Anchorage, but sharing care with the doctors has helped me build an excellent level of trust and my clients benefit greatly from it.

Birth stats to boast about A fairly recent study from the University of British Columbia paints a beautifully accurate picture of the relationship between access and integration of midwifery care and the quality of outcomes stateby-state in the US. Not surprisingly, the states with the highest access and integration of midwives also enjoyed the best outcomes and lowest intervention rates. As Alaska has the highest midwifery births per state, we have almost the lowest C-section rate at 23.3%. Alaska’s neonatal mortality is 2.6/1 000, half of Alabama’s at 5.6/1 000, which also has the lowest number of midwifery births in the nation. This relationship is no surprise to us! I encourage you to explore the results of the AIMM study, including interactive maps, which can be found at www.birthplacelab.org. I hope you enjoyed learning a bit about Alaska’s midwifery scene. Follow me on Instagram (@birth. goals) or check out my website (www.birthgoals. com) to learn more about my practice. Feel free to drop me a line. Or better yet, come visit!

eSensitive Midwifery Magazine

Issue 44

Birth

The future of

natural birth

in South Africa Sensitive Midwifery writer Kelly Norwood-Young provides a snapshot of birth trends in South Africa today, and how these might influence the future of natural birth and midwifery in the country.

onsidering the current situation regarding C-section rates, litigation and indemnity insurance, doctors practising defensive medicine, and financial constraints that restrict women’s birthing choices, it is easy to feel despondent about the future of natural birth in South Africa. However, before we panic or throw up our hands in despair, we must remember firstly, that there have always been midwives who have risen to meet the needs of women (and their own need to live out their birthing beliefs), and secondly, that they have an important role to play as the keepers of natural birth.

The influence of obstetrics Of course, the medical model of birth continues to affect birth and midwifery today. In the private

sector, C-sections are skyrocketing: one recent 2019 report revealed that 74% of babies born to members of Discovery medical scheme are delivered via C-section – numbers which are supported by the Council for Medical Schemes’ recent annual report, which shows that in 2017, about six out of 10 mothers had C-sections in private hospitals. In the public sector, C-section rates are lower (one in four mothers undergo the procedure) but are still climbing high above the rate of 10–15% recommended by the World Health Organization. While there are numerous factors at play, National Department of Health’s deputy director general for communicable and noncommunicable diseases, Yogan Pillay, has admitted that many doctors are simply scared of delivering babies Continued on page 21

eSensitive Midwifery Magazine

Issue 44

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 afford them. While some medical aids are now offering 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 midwifeled 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 afford 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 affects 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

eSensitive Midwifery Magazine

Issue 44

Birth

media has opened up the space for a new type of community support in the form of online groups. ‘Natural Birthing South Africa’ (www.facebook. com/groups/naturalbirthingsa) is one such group. Midwives, doulas, and thousands of other members (many of whom have had successful normal births and/or VBACs) communicate, post their questions and concerns, and receive helpful, evidence-based information. Johannesburg-based mother and birth photographer Vanessa Venter started this group in June 2015, after she embarked on her own VBAC journey and noticed that there’s so much regret for unnecessary and unwanted C-sections, and that natural birth isn't as it’s often portrayed, and isn’t as risky as women are often led to believe. While Vanessa cautions that members approach their care providers with any concerns about their or their babies’ health, she notes that the group aims to provide a platform for members to research their options further: ‘Armed with more information and support, women aren't as scared to speak up about their desires for birth, and to ask their care providers questions they wouldn't have thought to ask in the first place. Women are looking to be heard and have their choices respected without doctors resorting to fear-mongering.’ Vanessa sees many posts about concerns women’s doctors have raised, like 'big baby' or 'small pelvis', how they can induce labour naturally because their doctors have put time constraints on them, as well as questions regarding which medical aids cover natural birth options the best and which pay for midwives.

As women become educated about their birth options and rights, they are seeking support for physiological birth - and this is where midwifery is flourishing. Though some segments of South African society are still incredibly patriarchal and the medical system itself still tends to be hierarchical, what women want (more specifically, what they demand) will surely continue to drive the birthing culture in this country. Women want trusting relationships with their caregivers, and to know that they and their babies are safe. In the past, there may have been the perception that the medical model of birth equated to safety, but

this mask is now slowly (and surely) slipping. Of course, midwives know (and the evidence reflects) that what makes birth safe is not unnecessary intervention, but rather, respecting women, letting birth unfold, and knowing what to watch out for.

Beating the system

Midwives have a long history of finding ways around the system, as Sister Lilian explains: ‘That’s why some moved to private practice; some forged relationships with other midwives, doulas and supportive doctors; some negotiated with hospitals for admission rights and others started birth homes; and some lobby the authorities to be recognised as an independent and equal profession. It’s what led us to start educational and support initiatives like the Sister Lilian Centre and Sensitive Midwifery. Midwives, for all the balls we may have dropped, have never allowed birth to be completely stolen from women!’

Back to birth basics We’ve seen a rise in natural birthing options, such as maternity clinics, active birthing units and birth homes, in the past couple of decades, and yet, more recently, we have also seen how some of these are not managing to keep their doors open – one example being Origin Family-centred Maternity Hospital, the first privately owned natural birth and women’s wellness centre in the Western Cape. In 2015, Henny de Beer left her private midwifery practice in Johannesburg to help set up Origin. However, in December 2018, Origin closed its doors after 34 months. Henny explains: ‘Origin was a stand-alone unit. There wasn’t a hospital affiliated with us, and as a luxury unit, the overhead costs were too large.’ It was difficult to find investors, especially as ‘it is hard to make money out of normal births: the pay-outs that medical doctors and midwives get from medical funders is low; a hospital makes its money out of theatres and ICUs’ and when it came to a clinic like Origin, potential investors were looking for quick returns. ‘It needed more time but the overheads were too high to keep it going,’ says Henny. Henny also explains how Cape Town doesn’t have the pool of private midwives that Johannesburg has, and that private midwifery practices in Cape Town are very regional. Securing back-up doctors in Cape Town was a concern too: Continued on page 23

eSensitive Midwifery Magazine

Issue 44

Birth

‘Though Cape Town’s C-section rate is still better than Joburg’s, with more doctors practising normal births, constricted traffic infrastructure makes travel in Cape Town very difficult. Often, we found that doctors were worried it might take too long to get to Origin in an emergency.’ Ultimately, for midwives setting up natural birth facilities, Henny’s advice is to keep overheads low. Indeed, despite challenges, there are more and more birth houses popping up around the country and while most of these are concentrated in Gauteng, even Bloemfontein boasts the Estherea Women’s Wellness Clinic. There is also an emerging trend of a ‘home-away-from-home home birth’ – that is, birthing at the midwife’s home (Natasha Stadler in Cape Town, Yolande Maritz in Pretoria, and Kathleen van Heerden in Boksburg, are just a few midwives offering this option to clients). Some midwives even book a room in a B&B for out-of-town clients. Sensitive Midwifery Magazine editor Margreet Wibbelink says, ‘I believe home birth, and birth homes, are the future of midwifery in South Africa. Going back to basics and keeping birth simple – but safe – is after all, what natural birth is about.’

Birth’s tipping point Some midwives interviewed for this article expressed concern about a decrease in skilled midwives, the lack of role models, and where

young midwives are going to learn about natural birth in the current climate. Some midwives also feel saddened by what they see each day (especially those who work in settings where natural birth is thwarted by obstetrics). But these midwives must be encouraged by the bigger picture. Initiatives that support natural birth are continuing around the country, and each year, at Sensitive Midwifery Symposium, there is a rush of young, enthusiastic midwives, eager to learn and become ‘real midwives’. In 2018, Sister Lilian and new General Manager and Midwife Specialist, Margreet Wibbelink, launched a post-basic ‘Certified Sensitive Midwife’ Course, which they and the first students believe will provide the easiest way to reclaim midwifery confidence (see more on page 59). Natural birthing in South Africa has certainly reached a delicate tipping point. Even doctors are starting to talk about solutions to the current setup – recognising that it is a situation that does not make sense. If all players honour the evidence; doctors begin to rely on midwives again; and midwives work on building good, trusting relationships with doctors so that both can work in collaboration, we could be looking at a very different, positive picture in future. Key references on page 55

eSensitive Midwifery Magazine

Issue 44

Birth

VBAC

the midwife way Pregnant women considering a vaginal birth after a previous C-section have specific concerns and needs, explains Yolande Maritz. Yolande Maritz is an independent midwife specialist of 15 years and 2 000 births, and the owner of You & Me Birth Home in Pretoria East. Find out more on www.youandmebirths.com.

idwives supporting these women must be able to offer sensitive care that nurtures and empowers, safely. There is a golden rule in my practice: if it is not safe, it is not allowed. As an example, I often refer to cases when moms request inductions simply because they are feeling impatient and anxious to meet their babies. No, I say, explaining that we cannot induce labour for that reason, especially if the woman hopes for a successful VBAC. Inductions increase the risks way too much and are not safe. If you’re a midwife taking on VBAC clients, you must be up to date on evidence-based practice, and you must adhere to safety guidelines. Not only is VBAC considered safer, with fewer complications, than a repeat C-section, but research shows that 60–80% of women who have previously had a C-section can have a successful vaginal birth, meaning VBAC is an option for many women.

That said, there is more to a successful VBAC than purely medical knowledge. Care providers must acknowledge the journey a woman has been through and understand that she will have unique concerns that need to be addressed if she is to begin her next birth with a sense of empowerment.

Setting off

In the birth world, where doctors have created the false idea that all VBACs are dangerous, the midwife might be the only person believing in the mother, the birth, the baby, and that the VBAC will be successful. Many women in South Africa tend to be quite uneducated about pregnancy, the birthing process and their birthing rights. To midwives, it can feel like they are indoctrinated by a fear-mongering society, and that making decisions, based on what they want for themselves, their birth and their babies, has become incredibly difficult. Thankfully, some women do question and seek guidance on birthing matters, especially if these are out of the ‘norm’, like a VBAC. Here, midwives have an important role to play – holding a woman’s hand and showing her the way to a new outlook on pregnancy, birth and beyond. First and foremost, midwives must understand that VBAC clients need longer appointments. They have a lot of emotion (often disappointment and Continued on page 25

eSensitive Midwifery Magazine

Issue 44

Birth

fear) to work through, and tend to need a lot of reassurance and guidance to overcome mental blocks. Building a relationship before birth, and helping her to prepare are paramount, so you cannot whisk through a VBAC appointment. During antenatal consultations, I make a point to gather information, set the safety parameters, and address emotional as well as physical concerns. Here are nine ways I recommend doing this: 1. Get the records; get the FULL story. You will

be surprised what you might find out. Clients mostly don’t understand medical terminology. Be sure to discuss their medical history with them in easy-to-understand language. Address her fears head-on. Fear can be self-defeating, so you need to address every fear she might have. Give the fear or emotion a name. Work with the VBAC dad – he might be the stressor. Men often want the ‘easy’ way out, and feel helpless seeing their partners in labour. Ask him to name and discuss his fears with you too. Very often, men just do not get why their partners want a vaginal birth. Midwives can facilitate insight and support. Bust fear with facts. Educate your clients with evidence-based facts, demonstrate labour techniques, and create a learning environment where they feel safe and acknowledged. Listen carefully, especially to what’s NOT said. Sometimes fears are expressed without words. For example, when she says, ‘My labour did not progress after the induction and my baby went into distress,’ she may mean, ‘I feel my body was not ready and my birth was forced. I almost lost my baby.’ You can interpret this for her, saying, ‘Your body is not broken; you are designed to give birth at the given time. Your baby is strong and will follow your body as soon as the time is right.’ Words like these are very helpful: ‘You fear to fail, but you are stronger than you think. You can do this. I am with you all the way.’ Suggest art therapy. Drawing or painting her previous birth experience and/or her expectations for the next birth can be a wonderful way to process things. Advise that she sees a chiropractor at least three times during pregnancy. They need to

know they have done everything they can to improve their VBAC success, and body alignment helps free energy pathways in many women. 8. Emphasise that VBAC clients will need to

be relatively fit for birth. Any birth requires stamina, but VBAC moms-to-be need even more. Encourage her to keep up her physical activity, even if it’s only walking. 9. Explain that mental preparation is key. She

may be fit enough to carry her baby, but her mind must also be strong. If she is prepared for the healing birth she is seeking, she is more likely to achieve it. Midwives need to explain to clients during pregnancy that successful VBACs are often based on a positive mindset. You need to remind her constantly that her body has not failed her; it is designed to do what her heart and womanhood are seeking.

Guiding her through A client who seeks your support and guidance for VBAC needs to trust you. Part of preparing her for the birth will involve developing a relationship with her, so that she can use you, if necessary, as her anchor during birth. Even if she doesn’t realise it, you may unexpectedly become her focus point. You need to be able to guide her into the unknown – to be able to surrender to the power of birth. Women who seek VBACs are usually doing so because they dread the idea of the previous birth experience recurring. It may have been traumatic – and this is all she knows of birth. While this is not her first baby, it is her first vaginal birth and she needs to know that it can be different this time.

"I believe that VBAC women have longer, gentler births because nature is compensating for the scar." Hopefully, she will have addressed most of her fears during her antenatal appointments with you, but they may resurface during birth, and it will be up to you to dispel these. Fear can be a great enemy, withholding women from empowering birth experiences. Never forget that fears are busted by facts. Continued on page 26

eSensitive Midwifery Magazine

Issue 44

Birth

She has never birthed naturally before, so the various birthing positions she can use might not be obvious to her, especially if she previously laboured in a hospital environment where she was made to lie on her back. She may not know that vomiting is normal during labour. As her midwife, you need to reassure her and her family that nothing is wrong, and that physiological birth is not to be feared. Having had a previous C-section, which makes walking difficult at first, she may not realise that she can walk upright immediately after her vaginal birth. The midwife can lead her and her family gently through this journey.

Five other ways to build the best VBAC birth environment 1. If you have a gut feeling, trust it! Be honest 2.

with yourself and your clients. Identify the psychological hurdle and keep her focused until it’s passed. If she only progressed to 5cm previously, she may hold back until then, for instance. Ensure privacy and quiet. This is important for any birth but for a successful VBAC it’s high priority: this might be her ONLY hope to have more children and no more C-sections. Encourage her ways of striving for success. Affirmations, birth balls, snacks, a resting place, music… Your vocabulary is an important part of success. Your client needs to hear that she is brave, courageous, educated, built to birth. She needs to hear you saying: ‘I believe you can. Your body did not fail you last time. The system did.’ She needs to know that you know she is not broken, and that you have faith in her.

Be especially careful with the birth of the placenta in a VBAC because there is a slightly increased chance that the placenta might be adhered to the C-section scar, and uterine prolapse can be caused by pulling on the umbilical cord. Ultimately, though very important, a midwife’s job is not as simple as just keeping clients safe. A midwife needs to be a cheerleader, and to be able to read what her VBAC client needs — skills which aren’t taught but will be honed by experience, insight and compassion.

eSensitive Midwifery Magazine

Issue 44

Birth

review

C-sections riskier in some regions of the world A systematic review and meta-analysis published earlier this year has revealed that in certain low- and middleincome countries, a third of all babies delivered by C-section do not survive, and that women undergoing the procedure are 100 times more likely to die than those having a C-section in the UK. Torjesen, I, ‘Caesarean section is highly risky for mothers and babies in low and middle income Countries’, BMJ, 2019, 364. Available: https:// www.bmj.com/content/364/bmj.l1499

Peanut ball helps labour progress

For women labouring with an epidural, a peanut-shaped exercise ball can decrease the length of labour and increase the chances of achieving vaginal birth, one randomised, controlled study has found. This nursing intervention not only resulted in significantly fewer C-sections, but the women who used it demonstrated shorter first stage labour (by 29 minutes) and second stage labour (by 11 minutes), compared to those who did not use the ball. Tussey, CM, et al, ‘Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural’, The Journal of Perinatal Education, 2015, 24(1). Available: https://connect. springerpub.com/content/sgrjpe/24/1/16

Managing a midwifery group practice Despite well-known benefits of continuity of midwifery care, one Australian study shows that less than 10% of women have access to this model of care. Staff retention and satisfaction (important to achieve continuity of care) are strongly related to the quality of management. The study concluded that managers of midwifery group practices require certain attributes to effectively manage these unique services, whilst also juggling the needs of the organisation as a whole. Having transformational leadership qualities with vision to lead the practice into the future are key. The study shows that there needs to be better support and preparation for this role if midwifery group practice is to be a sustainable option for women and midwives. Rest assured, Sensitive Midwifery won’t let this one slip off the agenda! Hewitt, L, et al, ‘Women and Birth. What attributes do Australian midwifery leaders identify as essential to effectively manage a Midwifery Group Practice?’, Women and Birth, 2019, 32(2), 168–177

Babies born by C-section deserve skin-to-skin care too Skin-to-skin care (SSC) during caesarean delivery is becoming increasingly popular in many countries because of numerous benefits. A recent study reported on perceived stumbling blocks to SSC implementation intraoperatively and in the recovery room. Lack of staff perseverance to promote non-disruption of the mother-baby dyad is a significant factor resulting in low rates of early SSC at caesarean births. While the possible risks of the neonate being smothered on the mother’s breast, sudden postnatal collapse due to airway obstruction and accidental falls are acknowledged, SSC is safe with vigilant health care. At St Mary’s Hospital in Durban, nurse-midwife Evashnee Naidoo has successfully taken the lead in implementing SSC at C-section births. She shared the protocols for this at Sensitive Midwifery Symposium in June 2019 and wrote about it in Issue 43 of Sensitive Midwifery Magazine. Elsaharty, A, et al. ‘Skin to skin: A modern approach to caesarean delivery’, Journal Obstetric Anaesthesia Crit Care, 2017, 7:13-9

eSensitive Midwifery Magazine

Issue 44

Birth

Let’s make maternity units

more woman-centred Read more about Sanele Lukhele on page 4

If we are to be ‘with women’ as midwives, we must advocate for and adopt woman-centred care, says midwifery lecturer Sanele Lukhele.

oman-centred care, the best model of care during the peripartum period, is an approach where a woman is kept at the centre of her birth experience. This means that the healthcare practitioner and the woman share in the decisionmaking regarding her care, with the understanding that childbirth is a natural physiological event. Woman-centred care is supported by national and international policies such as the Batho Pele principles, the Patients’ Rights Charter, the Better Births Initiative and the recent WHO recommendations: ‘Intrapartum care for a positive childbirth experience’. Sadly, this approach is not used in most public and private maternity settings in South Africa, where the biomedical model tends to influence doctors, nurses and midwives to view pregnancy and childbirth as high-risk conditions, even in a low-risk woman. This inevitably leads to rigorous monitoring of women during childbirth, and intervening at the earliest sign of supposed pathology.

Achieving woman-centred care Transforming a maternity unit to being womancentred depends heavily on buy-in from the midwives who work in that unit. A study done on perspectives of midwives regarding womancentred care revealed that some midwives feel ill-equipped as they don’t have enough knowledge of what woman-centred care entails. Training on this model of care, as well as its benefits, could go a long way to making the practice a success within maternity units. Studies have shown that midwives have also cited lack of time and increased workload as barriers to woman-centred care, with inadequately staffed maternity units having a direct impact on the implementation of this practice. For birthing units in low- and middle-income countries, the International Federation of Gynaecology and Obstetrics suggests the following staffing ratios: one midwife for eight patients in the latent phase, one midwife for two patients in the active phase of labour and two midwives for one patient in the second stage of labour. Continued on page 29

eSensitive Midwifery Magazine

Issue 44

Birth

Technology-focused care is another hospital policy that impedes woman-centred care. The latest intrapartum care guidelines in South Africa have discouraged the use of routine cardiotocography for low-risk women who are in spontaneous labour. Fetal-heart monitoring should therefore only be done intermittently using a doppler ultrasound device or Pinard fetal stethoscope. Intermittent auscultation allows women to maintain an upright position during labour, which in turn increases patient comfort, assists with pain management and decreases the duration of the first stage of labour.

Making a case for caseload midwifery Another avenue for improving woman-centred care is continuity of care through the caseload midwifery care model. Caseload midwifery is continuity of care by a primary midwife. Midwives who use this model of care work in partnerships or groups. The woman is introduced to all the midwives in the group to enable care from a backup midwife if her primary midwife is unavailable. This helps to allay anxiety in the birthing woman as she has had enough time to get to know and bond with the midwives antenatally. This model has proven to have incredible benefits for both mom and baby.

The most beautiful thing Sanele has ever seen Last year, I had the opportunity to work in an active birthing unit after having worked at a district hospital, and as an obstetric nurse in the private sector. This particular birthing unit practises caseload midwifery. In this unit, woman-centred care is the order of the day. Every woman who comes to give birth has a birth plan, which is respected as far as possible. The mind shift I had to make during that period was massive. I had to unlearn the defensive medicine that had become so inherent during my time as an obstetric nurse. I had to learn to trust the birth process – something I had never practised as a student or even later as a qualified midwife. I witnessed a truly natural birth for the first time in this active birthing unit. I soon learned that a normal vaginal delivery is not necessarily a natural birth: •

Natural childbirth is a process whereby midwives allow labour to progress with no interventions. There is a trust in the woman’s body and its capabilities. Normal maternal and fetal monitoring during labour still happens as per the care guidelines.

•

Research has shown that women who have continuity of care by a primary midwife are less likely to have a C-section, use analgesia during labour, or have an episiotomy, and fewer infants are admitted into the neonatal unit after birth.

The space in which the woman is labouring is treated with the utmost respect: people cannot simply walk in at any given time; if you happen to enter the room for whatever reason, you do so very quietly. This allows women to feel safe, helping their bodies to function optimally by producing endorphins and oxytocin during labour.

•

The woman wears her own clothing, and can eat as and when she wishes.

•

The woman has a birth companion of her choice. She may choose to have a doula as well.

Are we with women?

•

Warm water (e.g. using a shower) is used for pain relief and the women has the option to get into a warm bath once she is in advanced labour.

•

Fetal heartrate monitoring is done intermittently with a doppler ultrasound, even when the labouring woman is in water.

•

The woman listens to her body and adopts whatever position she feels is most comfortable while she is in labour. When she is ready to birth, she births in whatever position her body is telling her to.

•

Once the baby is born, if all is well, skin-to-skin care is promoted while delayed cord clamping is practised.

The word midwife means ‘with woman’. It is therefore our mandate to stay true to our profession by continually entering into collaborative relationships with the women entrusted to our care. When a woman is involved in her care during childbirth she feels in control, safe, respected and that her dignity is intact. Midwives should be supported in executing woman-centred care, particularly by receiving the necessary training. Since hospital policies and procedures play a significant role in promoting woman-centred care, hospital management should also ensure that midwives practise in a conducive environment.

Natural birth is the most beautiful thing I have ever seen.

eSensitive Midwifery Magazine

Issue 44

Dimensions

Iodine in maternity care

When it comes to iodine intake, there’s a lot of food for thought, writes Sensitive Midwifery’s Kelly Norwood-Young.

odine is a micronutrient required by the human body for normal thyroid function. Common sources are iodised salt, grains (including bread), dairy products, saltwater fish and seafood, kelp and other sea vegetables. Although it is possible to get enough iodine from food, many people are unknowingly deficient in iodine, and pregnant women (who need a higher intake of the trace mineral) are more susceptible to this deficiency. Breastfed babies, too, will only receive enough iodine if their mothers are getting enough. And yet, in maternity care especially, ensuring adequate intake through iodised salt or supplementation is not as simple as it seems, since there are also significant risks to consuming too much iodine.

The dangers of deficiency Iodine deficiency disorders affect more than 2.2 billion individuals worldwide (38% of the world’s population). Across all age groups, severe or prolonged iodine deficiency can result in goitre (swelling in the neck due to an enlargement of the thyroid gland), hypothyroidism (which affects thyroid hormone production), as well as many other health challenges. Even a mild deficiency

can cause slowed metabolism, fatigue, weight gain, sore muscles, dry skin and brittle nails. Pregnant women require even higher amounts of iodine, which, as the World Health Organization (WHO) notes, is ‘essential for the production of maternal and fetal thyroid hormones that regulate the development of the fetal brain and nervous system’. Insufficient iodine intake during pregnancy has been linked to congenital abnormalities, perinatal and infant mortality, impaired mental function, and cretinism. Numerous studies have noted how maternal iodine deficiency can affect brain development adversely. One 2004 study suggested that mild iodine deficiency in mothers may also be associated with attention-deficit and hyperactivity disorders in offspring, while another more recent study (2013) found that pregnant mothers who were deficient in iodine were more likely to have children with learning difficulties and lower IQ scores. Importantly, research has shown that prenatal iodine deficiency has been identified as the leading cause of preventable brain damage worldwide. Women with adequate intrathyroidal iodine stores are able to adapt easily to the increased demand for thyroid hormone during gestation, with total Continued on page 31

eSensitive Midwifery Magazine

Issue 44

Dimensions

body iodine levels remaining stable throughout pregnancy. However, as one 2008 article notes, ‘in areas of even mild to moderate iodine deficiency, total body iodine stores, as reflected by urinary iodine values, decline gradually from the first to the third trimester of pregnancy. This dietary iodine deficiency results in impaired thyroid hormone synthesis.’

The risks of excess iodine While the dangers of iodine deficiency are evident, the risks of too much iodine are just as real. Acute iodine poisoning is rare, occurring only with doses of many grams, but symptoms are serious: fever; nausea and/or vomiting; diarrhoea; burning of the mouth, throat, and stomach; weak pulse; cyanosis; and coma. More generally, excess iodine intake (more than 1 100 mcg of iodine per day – with the recommended daily intake being 150 mcg) may cause thyroid dysfunction – and the elderly, pregnant and lactating women, as well as individuals with preexisting thyroid disease are more likely to experience adverse effects.

The Wolff-Chaikoff effect This occurs in response to ingestion of large amounts of iodine, and sees the thyroid reducing thyroid hormone levels to protect against hyperthyroidism. While for adults and children this is temporary, fetuses and newborns have immature thyroid glands that have not developed this protective effect, making them more susceptible to iodine-induced hypothyroidism. A study published in 2015 discovered an increased risk of maternal subclinical hypothyroidism and maternal hypothyroxinaemia associated with iodine excess, and warns that ‘excessive iodine exposure might also be detrimental to maternal thyroid health and recommends a lower limit for maternal iodine intake during pregnancy than that currently advised by the WHO’. Even the WHO, which takes pains to point out how important iodine is to infant survival and

development, has acknowledged that ‘routine iodine supplementation in pregnancy may not be without risk’, with congenital hypothyroidism in newborns being linked to high maternal intakes of iodine. Interestingly, Oregon State University also ascribes iodine-induced goitre and hypothyroidism in newborns to high exposure to iodised antiseptics. A 2012 study looking at excess maternal iodine supplementation noted how fetuses and newborns are ‘more susceptible to iodine-induced hypothyroidism’, finding that: ‘Although infants recover normal thyroid function after acute iodine exposure (e.g., a few days of topical iodine application), continuous excessive iodine exposure to the fetal and neonatal thyroid gland may cause long-term harmful effects on thyroid function.’

So what about salt? With iodine being so important to human growth and development, WHO and UNICEF have recommended universal salt iodisation – an easy, inexpensive method to eliminate iodine deficiency – as a global strategy. Following these recommendations, more than 120 countries around the world have implemented widespread salt iodisation. In South Africa, mandatory iodisation of table salt at 40–60 ppm was introduced in 1995. Within three years, a 1998 survey showed that optimal iodine nutrition was achieved nationally. A 2014 WHO review on the effect and safety of salt iodisation to prevent iodine deficiency disorders found that ‘exposure to iodised salt was associated with reduced risk or prevalence of goitre, cretinism, low intelligence or low urinary iodine excretion, as well as increased mean IQ and increased median and mean urinary iodine excretion. There was no clear relationship between iodised salt and any adverse effects, including increased hypothyroidism or hyperthyroidism.’ Despite this, the WHO still acknowledges that for some, there remains concern that large-scale salt iodisation could potentially result in excess iodine intake. Continued on page 32

eSensitive Midwifery Magazine

Issue 44

Dimensions

Non-iodised salt vs iodised salt Non-iodised salt (like sea salt) is often just sodium chloride, though it may be mixed with other ingredients and/or be processed to give it a finer texture. Non-iodised salt never expires, whereas iodised salt must be used within five years. With the risks of both iodine deficiency and excess intake of iodine in mind (even if there is little evidence to show that iodine overdose can occur through iodised salt), it does seem reasonable to expect accuracy during salt iodisation. And yet, a 2001 study analysing iodine concentration in household salt in South Africa not only found considerable variation in different areas of the country, but also revealed that managers at iodisedsalt production sites lacked sufficient knowledge regarding health aspects of salt iodisation. In 2008, the authors of a review entitled ‘Progress towards eliminating iodine deficiency in South Africa’, noted that the accuracy of salt iodisation in South Africa could be improved through better ‘internal quality control of the iodine content of salt at the production sites and by regular external monitoring of the iodine concentration in salt’. Additional ingredients in salt Iodisation involves spraying salt with a potassium iodate or potassium iodide solution, and adding dextrose (a sugar), which acts as a stabiliser and stops the potassium iodide from oxidising and evaporating. A concerning additive in table salt is chemical anti-caking agents, which retard moisture absorption and prevent clumping. While these are often classified as ‘safe’ if present below a certain threshold, Sensitive Midwifery questions what long-term health effects there may be for people consuming these chemicals regularly. More research is certainly needed.

The safety of supplements Health experts recommend that women take a multivitamin containing 150 mcg iodine in the form of potassium iodide, which tallies with the recommended daily intake of iodine in all adults (although pregnant and breastfeeding women have increased iodine needs). Importantly though, the WHO has stated that routine iodine supplementation in pregnancy could come with risks. Although the tolerable upper limit for iodine ingestion in adults is 500 mcg per day according to the WHO and the European Food Safety Authority (or 1 100 mcg iodine daily if you’re following the US Institute of Medicine guidelines), the upper limit during pregnancy and lactation is uncertain. Since iodine is, of course, also being consumed via iodised salt and other foods, women must stick to safe dosages and discuss nutritional supplements with their healthcare providers.

Getting the balance right As there are significant risks to ingesting too little or too much iodine, getting the right amount is a matter of balance. As always, eating a healthy, balanced, and varied diet is the first step to ensuring sufficient nutrient intake. Of course, nutritional iodine intake can be difficult to monitor, especially when food iodine content is not labelled. Processed foods may also be fortified with bromine, an element that disrupts iodine absorption. Where there are concerns that diet may not be meeting the body’s requirements, iodised salt and/or iodine supplementation are options, but women and their healthcare providers must be aware of the dangers of maternal over supplementation. Key references on page 55

eSensitive Midwifery Magazine

Issue 44

Dimensions

Self-Care 101 Finding balance in the demanding joint venture of being a midwife and a partner, mother, friend is challenging; we asked writer Marjorie Arnold, who has a special interest in this topic to share her self-care thoughts.

o start off, we need to understand what self-care is, what it entails and how to practise it. Self-care may be the new buzzword and hashtag to every expensive purchase, spa day or a weekend getaway, making us feel like it’s a self-indulgent act, a guilty pleasure – but the fact is that self-care is actually not a luxury; it is a nonnegotiable part of living a healthy life.

Self-care, at its core, is self-compassion, the decision to prioritise yourself. Simply put, selfcare is the deliberate act of doing small things that restore your own body, mind and spirit. Self-care is not selfish Self-care is not a selfish act but rather a necessity to ensure our own wellness. If we do not take care of ourselves, we cannot keep on giving without running the risk of suffering from burnout. Self-care should also not seem like another daunting task to add to your list as you frantically try to perform at a high level and meet the expectations of your team, employer, friends and family … and yourself. You may be thinking, ‘But where do I fit self-care into my already over-extended daily life?’ Of course, between work and personal life, it is sometimes hard to get enough sleep, get the bills paid on time and eat properly. You can start by taking a deep breath, and having compassion for yourself.

Self-compassion is the centre of self-care Having compassion for yourself is not only an essential part of practising self-care; it is also fundamental to being an effective healthcare provider. Continued on page 35 eSensitive Midwifery Magazine

Issue 44

Dimensions

Practising self-compassion means: • Allowing yourself to be human, being less critical of yourself, and reducing the stress you create when you hold yourself to unachievably high standards • Changing the relationship you have with yourself – from being a harsh, judgemental critic to an understanding friend • Realising that your mental, physical and spiritual health is your own responsibility, and the cornerstone of being an empathetic caregiver

and ceilings. Take a few minutes each day and just marvel at the clouds in the sky, breathing in the fresh air, feeling the sun on your skin. We are part of this beautiful world and often we get trapped in our routine that keep us locked in passageways, rushing from one room to the other. When you get home, take your shoes off and walk on the grass, or sit and enjoy your cup of tea outside. 5. Sleep well. The never-ending lists of tasks that

flood our schedules has led to sleep being viewed as lazy and self-indulgent. Sleeping well should be a daily practice and not something we associate with lazy weekends or holidays. Getting enough sleep, consistently, is the key to good physical and mental health. Lack of sleep is associated with fatigue, depression, type 2 diabetes and many other illnesses. The good news is that sleep is also the cure of many ailments.

How to honour yourself You can honour yourself with time, food, movement, nature and sleep: 1. Take time. Time has become a luxury and yet nowadays, we waste it by mindlessly watching TV or scrolling through social media, comparing our lives with others. Take time daily to be quiet with yourself, to relax and renew through something like a tea ritual or enjoying a cup of coffee; slowly progress to a few minutes of reflective meditation that helps you reduce your stress and gives you a sense of calm. This does not mean that you should not spend time with other people, especially those whose company you find rewarding. Connecting with people on a deep level allows both parties to be a resource for each other. 2. Eat healthily. Honour your body by eating

wholesome, nourishing food. Consider whether you need to remove the shame around food and change your relationship with food. By eating with the purpose of nourishing our bodies, we ensure our health. This, in turn, allows us to be there for patients and other people in our lives. 3. Get moving. Walk, run, swim or dance –

whatever physical activity gets you up from your chair and smiling! Moving our bodies is essential, not only for our physical health but also for our mental health. Take the stairs, walk the dog, put your favourite song on and move your body! 4. Escape into nature. Honour yourself by

spending time in nature. Many of us are primarily indoors, under artificial lights, spending our days between walls, floors

Sleep is the single most effective thing you can do to reset your brain and body for health,’ says Matthew Walker, a professor of neuroscience and psychology at the University of California, Berkeley.

Self-care for sensitive caregivers There is real science behind the importance of self-care. If we accept that self-care is an unselfish necessity, in order to be sensitive, selfless caregivers, we can change our perception of self-care: it is not self-indulgent pampering, but rather, essential for living well. Self-care means practising being kind to your body, mind and spirit, and establishing the fundamentals of taking care of yourself. Over the next year, Sensitive Midwifery will share some of the different rituals, practices, aids, products and even some envy-worthy hashtag ideas that promote the radical idea of loving yourself enough to take care of yourself. We want to provide resources for you to thrive, to be able to keep giving without burning out. Follow Sensitive Midwifery’s Instagram account (www.instagram.com/sensitivemidwifery) and tag us in your self-care photos. Let’s start taking the shame out of taking care of ourselves in order to take care of others.

eSensitive Midwifery Magazine

Issue 44

Home

About Us

Symposium

Magazine

Academy

Membership Packages

Blog

Sensitive Midwifery is the midwifery division of the Sister Lilian Centre, an advice, support, advocacy and educational company serving mothers, fathers, babies, toddlers and growing families in South Africa and further afield. Sensitive Midwifery was conceived in 1995 and born 40 weeks later in 1996!

our logo’s symbolism The protea makes a lasting impression on all who encounter it because it symbolises transformation, courage, daring and diversity. Midwifery is not only sorely in need of transformation in South Africa and many other parts of the world, but it is the profession that has guided families in one of the most transformative times of their lives - pregnancy, birth and becoming parents. It takes courage for midwives and women to trust the natural process of pregnancy, birth and motherhood and to do what is intuitively right in an era that values technology and medicalisation more than physiology. It requires daring to stand up for your profession, and to advocate for mothers, fathers and babies when all around you follow the path of least resistance. Every pregnancy, birth, mother, father and baby is unique — and therefore, Sensitive Midwifery will stand by you as you find the wisest ways to embrace diversity. The colours of the protea have profound meaning too. White stands for purity, honesty and integrity; pink for femininity, motherly love and compassion; and green for harmony, nature and good fortune. What better symbolism could accompany a midwife in her hugely important work?

our vision

Sensitive Midwifery and the Sister Lilian Centre sees a world that values midwifery and creates and raises children in a way which liberates the best in each and every individual.

To be leaders in improving midwifery, birth, parenting, health and family life, because families grow the next generation and shape the future of humankind.

Intuition, Integrity, Individuality. We consciously set out to make a difference, with impeccable service delivery and an inclusive approach in all we do.

Dimensions

Horizons Working CLEVER could improve perinatal mortality A study conducted in 10 midwife-led obstetric units in Tshwane District, South Africa, claims to have solutions to improve maternal care. A socalled CLEVER health system improvements and perinatal outcomes intervention package was implemented and reviewed. CLEVER is the acronym for Clinical care, Labour ward management, Eliminate barriers, Verify care, Emergency obstetric simulation training, and Respectful care. The study showed that efficient teamwork, leadership and team simulation training are regarded as essential interventions to improve perinatal mortality, and that clinical governance with formal feedback could result in adherence to highquality obstetric care practices.

Can technology help midwives save lives in childbirth? That was the overarching theme of the first-of-its-kind EdTech Talk organised by Laerdal Global Health, the International Confederation of Midwives and the Maternity Foundation during the 2019 Women Deliver Conference in Vancouver in June 2019. Every day, more than 800 women and 7 000 newborns die of causes related to pregnancy and childbirth, while research shows that 80% of maternal deaths can be averted through access to quality midwifery care. Scaling up the skills and knowledge of health workers is a crucial step to help reach Sustainable Development Goal #3, which focuses on healthy lives and wellbeing for all. The 2019 Women Deliver Conference was told that new technological innovations offer unprecedented possibilities for reaching health workers across low- and middle-income countries with quality educational technology, widely known as EdTech. Sensitive Midwifery enthusiastically embraces EdTech, while keeping true to its conviction that quality, intuitive midwifery is the first-line defence against poor birth outcomes.

Oosthuizen, SJ, et al, ‘Midwife-led obstetric units working CLEVER: improving perinatal outcome in SA’, S Afr Med J, 2019, 109(2):95–101

Poverty changes our genes A new study has found that poverty leaves a mark on almost 10% of the genes in the genome, challenging the idea that genes are fixed at conception. Lead author Thomas McDade noted that while we know that socioeconomic status is ‘a powerful determinant of health’, the ‘underlying mechanisms through which our bodies “remember” the experiences of poverty are not known’. More research is needed to determine the specific health consequences of poverty on our genes, but many of the genes identified in this study are connected to processes related to immune responses, as well as the development of the nervous system and skeleton. Northwestern University, ‘Poverty leaves a mark on our genes: Study's findings challenge understandings of genes as fixed features of our biology’, 4 April 2019. Available: www.sciencedaily.com/releases/2019/04/190404135433.htm

eSensitive Midwifery Magazine

Issue 44

Dimensions

A midwife’s

silence is golden Speech is silver; silence is golden, claims an ancient idiom.

s part of the successfully pioneered Certified Sensitive Midwife Course in the Eastern Cape in 2019, students were tasked with reflecting on silence as an attribute of midwifery practice. Their thoughts, summarised here by Sister Lilian, were insightful and profound. Beautiful prose came easily to inspired student and Port Elizabeth independent midwife Juanita Mackenzie, who jumped right in with the compelling thought that ‘a good midwife is comfortable with silence; she doesn’t have the need to fill the silence with chatter but instead is adept at reading women and their partners, and providing specialised, bespoke support to each one’. Yes, there will always be a time for words, but Juanita finds that extraneous words make labour, which is often long and tiring, more so for both

the mother and the midwife. In contrast, ‘There is power and freedom in comfortable silence ... and the woman will feel a confidence that enables her to labour freely,’ claims Juanita.

It’s about mindfulness Key to being a mindful person in any sphere of life is the attribute of quiet introspection, serene contemplation of inspiring forces outside of oneself, and regular silent meditation. Also on the course was Nondi Gaba, manager within Maternal, Newborn, Child and Women's Health, (MNCWH) and in the Integrated Nutrition Programme (INP) of the Eastern Cape Department of Health, where she is responsible for Maternal, Neonatal, Reproductive, and Adolescent and Youth programmes. ‘Midwives need to be quiet-natured and not abuse their Continued on page 39

eSensitive Midwifery Magazine

Issue 44

Dimensions

power, nor impose their values on women but rather suggest, advise and assist where necessary. They should model themselves on the concept of the “knitting midwife” who was said to sit in silence, calmly knitting in a corner, respecting the woman and the natural process of birth. Silent midwives are not bossy, nor authoritarian; they facilitate birth instead of directing women what to do,’ is how Nondi describes the mindfulness she finds essential to good midwifery. Two other independent midwives also had words of pure gold to share. Anneri du Plessis who practises in George says that ‘the ideal birth attendant is a silent, low-profile midwife. She keeps her own adrenaline levels low and provides a sense of security in the birth room. The word midwife means to be with women, not away from them; it also means advocating for them and simply being there for them. During labour that can mostly be accomplished without saying a word.’ Giving voice to many students’ thoughts, doula and midwife Colleen Pedersen comments on how in-depth antenatal discussions, excellent preparation and relationship-building is what enables a midwife to be silent, observant and less intrusive during labour. Juanita reminds us that if you want to develop effective relationships, you must build trust, and to build trust, you must listen, which requires silence. ‘Silence allows for connectedness,’ she explains.

Self-care enables good midwifery Sensitive Midwifery Symposium in 2019 has had self-care of the midwife as one of its sub-themes, precisely because running on empty can only mean you’ll come to a grinding halt sooner or later, often amidst overbearing noise in your own soul, which will likely overflow into disquiet in the birthplace. After a particularly busy spell of birth accompaniment, independent midwife Michelle van der Westhuizen concludes: ‘We cannot pour from an empty cup, so my cup must be filled. I have poured from this cup four times in ten days and it needs replenishing. Knowing my own personality type and needs helps me to fill this cup.’ Now that’s creative self-awareness! Michelle adds that while it may seem that being a silent midwife is an inherently quiet activity, a lot is really taking

place, and that means a midwife is actively giving of herself all the time. ‘Anticipating and following the needs of the labouring mom and her partner, and sometimes a granny and tot as well, may use more energy than not being in tune with them. Taking deep breaths and short breaks helps. Stay hydrated and have healthy snacks. I avoid caffeine at births and only have tea,’ she advises.

Finding your inner calm Nondi Gaba points out that a more respectful, quiet environment is possible to achieve in almost any midwifery setting. It’s all based on truly knowing and supporting the physiological changes of pregnancy and birth, as a midwife will not panic and will be able to create a soothing homely environment, free of noise and loud talking and footsteps, if she internalises this. Dutch midwife Else Vooijs, volunteering at the Healthy Mom and Baby Clinic and also on the Certified Sensitive Midwife Course, puts a finger on it when she raises the issue of fear – midwifery fear. Else believes that inexperience and lack of in-depth knowledge combine to make a midwife anxious, and that ‘noise’ is often used to try to mask it. This leads to a directive model of care, which is seldom silent or calm. ‘By embracing silence, we show our clients that we don’t need to fear it,’ adds Juanita. In Colleen’s words, ‘If a woman feels observed, it affects her ability to relax and become instinctual. A silent midwife enables this necessary privacy.’ In his 1981 book, The Secret Life Of The Unborn Child, medical doctor Thomas Verny wrote: ‘The unborn child is a feeling, remembering, aware being, and because he is, what happens to him – what happens to all of us – in the months between conception and birth, moulds and shapes personality, drive and ambition in very important ways.’ Course student and midwife Linette Louw explains that Verny’s words remind us that the baby, too, is subject to prevailing birth circumstances, and that how midwives conduct themselves may have lasting effects on them. All the more reason to cultivate the attributes of the ‘silent midwife’ – respectful care, protection, calm – she feels. Continued on page 40

eSensitive Midwifery Magazine

Issue 44

Dimensions

Midwife musings Here are some more pearls of wisdom from Certified Sensitive Midwife Course students on the topic of The Silent Midwife: ‘Moms in labour can be as diverse as the sun and the moon. Some may benefit from positive affirmations (verbal or nonverbal); others may need touch or massage; some need quiet; others prefer mindless but soft chatter. Make sure that what you provide is what each one needs by being in tune with the mom, and just sometimes, you might need to check with her – and that’s okay too.’ Michelle van der Westhuizen ‘It’s not only about silence, but about which words one uses when one speaks. Midwives should avoid medical jargon which could be intimidating to a woman, or even disrespectful (for instance, when a woman is labelled “a 34 weeker” instead of addressing her by her name – this often adds to her fear.’ Nondi Gaba ‘A midwife cannot always be quiet. She has the responsibility to advocate for her client, help her fight for her right to a birth experience of her choosing. This is where she must speak out, loud and clear.’ Linette Louw ‘Being deeply aware that birth is not about those who tend it, but about the family who is giving birth, and that they are the ones who will carry their birth memory with them, helps me to give silent support.’ Colleen Pedersen Of course, in the birthing space, words are at times necessary, but put in perspective of the golden power of wise silence, speech is indeed, at best, silver.

eSensitive Midwifery Magazine

Issue 44

eSensitive Midwifery Magazine

Issue 44

eSensitive Midwifery Magazine

Issue 44

Mom & Baby

steps

Are you familiar with babies’ bladder and bowel basics?

Sore throat at the turn of season A common spring and summer complaint in babies and small children, clinic sisters are sure to be asked for advice. The main culprit in the early years is mucusproducing foods, such as wheat-based products, highly processed foods, sweet and savoury treats, and foods with added colourants and flavourants. Encourage parents not to be tempted by the convenience of fast foods, but rather to opt for simple, healthy meals. Knowing that antibiotic use is preferably to be limited, suggest to parents that they select one of the many safe sore throat herbal or homeopathic remedies that will help to nip symptoms in the bud!

It often seems like parents turn to health professionals for advice on toilet training way before their little ones are ready. Bladder control mostly comes before bowel control and most toddlers are ready to start using a potty or the toilet sometime between two and three years. Sufficient maturity of the area of the brain that controls voiding is necessary for ‘success’. Babies go through five stages of awareness before they have voluntary excretory control: 1. In the early days, despite a glazed look in the eyes when passing urine, or fierce concentration when having a poo, babies are blissfully unaware of voiding. 2. In time, they become more aware shortly after voiding and tugg at the nappy to show discomfort. 3. Next, they gain awareness while passing urine or emptying their bowels, and look down in wonder at their nether regions. 4. Next, babies become restless just before voiding, but mostly don’t make it to the potty in time. 5. Finally, babies are able to alert parents to their need to go to the toilet — now potty use can start.

Universal home visits, a proven success

A recent analysis of commercial baby foods on South Africa’s shelves has shown that the vast majority of these contain added sugars, going against global weaning guidelines set by the WHO. The study concluded that there is an urgent need to regulate sugar in South Africa’s baby foods, especially as this affects health in childhood and later in life.

A trial was undertaken to test the impact of universal home visits – carried out by trained female and male ‘home visitors’ – in Bauchi, a state in northern Nigeria. These were different from other home visits because they covered all households and pregnant women in an area, ensured that the most marginalised women were reached, and were based on local evidence about risks – like heavy work or domestic violence during pregnancy – that households themselves could tackle. Male visitors shared the same evidence about risks with the pregnant women’s spouses. The trial was successful, improving the health of mothers.

The Conversation, ‘We tested baby food sugar levels in South Africa. This is what we found’, 28 May 2019. Available: https://theconversation. com/we-tested-baby-food-sugar-levels-in-south-africa-this-is-what-wefound-117032

Cockcroft, A, et al, ‘Impact of universal home visits on maternal and infant outcomes in Bauchi state, Nigeria: protocol of a cluster randomized controlled trial’, BMC Health Services Research, 2018, 18: 510

SA baby food too high in sugar

eSensitive Midwifery Magazine

Issue 44

Mom & Baby

Six weeks for postnatal recovery is a ‘complete fantasy’ Dr Julie Wray, a researcher at Salford University in England, interviewed women at different stages of postpartum life. She found that the standard six-week recovery period is a ‘complete fantasy’ and it can take a full year to recover from childbirth – not just physically but mentally too. Many feel the pressure to get back on their feet soon after childbirth and feel it may be necessary to head back to work as early as six weeks. The research shows that more realistic and womanfriendly postnatal services are needed. Recovery after childbirth is different for everyone, but regardless, women should be supported beyond the current six to eight weeks after birth.

steps

Paxman, L, ‘Women need a whole year to recover from childbirth despite the 'fantasy' image of celebrity mothers, study claims’, 17 February 2012. Available: https://www.dailymail.co.uk/health/article-2102517/Women-need-yearrecover-childbirth-study-finds.html

The benefits of reading to NICU babies New research has found that moms who read to their NICU babies reported better bonding, and displayed reduced rates of PND. Infants’ blood-oxygen saturation also improved during and after reading sessions. Campbell, D, ‘How reading to NICU babies can benefit moms in a big way’, 26 April 2019. Available: https://www.mother.ly/news/howreading-to-nicu-baby-can-help-moms-too

Post-divorce parenting is not for sissies! To help parents minimise collateral damage risk, suggest that both parents be as involved as possible in their children’s lives, and to shelter children from any animosity they may feel towards their ex. If children struggle to adapt to the split, they may begin to act out, or withdraw into themselves. If you’re concerned, advise that they’re taken to see a trained counsellor. Parents living on a reduced income may need to work longer hours and see their child less. Encourage them not to feel guilty, instead making sure that the time they do spend with their child is meaningful. Juggling work, chores and childcare alone can be tremendously stressful but in time will become easier, especially if they take regular mini me-breaks to renew their energy, eat healthily, sleep enough, let go of unnecessary stress, ask family and friends for help, and join a support group. Parents should avoid rushing into another relationship as it may confuse their children even more.

Pain in children It is very upsetting to a parent to see their little one battling pain, whether the cause is serious or not. Make sure you give them responsible information about medication use, and encourage them to let time heal the less serious causes. Parents shouldn’t give over-the-counter pain medication for longer than two to three days without seeing a doctor, nor give their child more medication than advised on the package. Remind them to always store all medicines in a locked cupboard or medicine chest, to buy medications in childproof containers, and to: • Always use medicine droppers or spoons to ensure they give the correct dosage • Never share one child’s medicine with another child • Never tell their child that medicine is a ‘sweetie’ Other ways to help relieve pain include elevating swollen, injured limbs; giving the homeopathic remedy chamomilla for teething; using warm baths or cool compresses; and gently massaging the painful area.

eSensitive Midwifery Magazine

Issue 44

What’s new on shelf? ARDO Breastfeeding products are designed and manufactured in Switzerland to offer innovative, durable and well-thought-out products. ARDO breast pumps are: • World Health Organization compliant in support of breastfeeding • Manufactured with a closed system which offers a barrier against contamination • Hospital grade, and there are manual and electric breast pumps in the range • Very quiet (45dB), for discreet expressing Available from www.mediplus.co.za, www.ardo.co.za, and www.takealot.com; Contact us on info@ardo.co.za for a distributor in your area

Zinplex Junior Cough Bee Calm Syrup is an expectorant

Flora Force Fenugreek, for breastfeeding mothers, should noticeably increase breast milk within 24-72 hours after commencing use of the product. Flora Force Fenugreek and can be used until breast milk production is stimulated to an appropriate level. Mothers love it, midwives find it very helpful as they encourage breastfeeding!

to help relieve coughing through loosening of mucus and phlegm in the airways, while boosting the immune system. It contains Ivy Leaf extract, Vitamin C and Honey, and is colourant-, flavourant- and tartrazine-free. The Cough Bee Calm Syrup is suitable for children aged two years and older.

Available at DisChem, Clicks, leading Pharmacies and Health shops and online at floraforce.co.za, faithful-tonature.co.za, takealot.com and mrsmilk.co.za

Available in DisChem and selected pharmacies.

The B.O.N Skincare Range

Flo Baby Saline spray is designed for

now has a new product. This nourishing hand and body tissue oil cream is enriched with natural Grape Seed, Rose Hip Oils, and Sigesbeckia Orientalis Extract and Shea Butter. Shea Butter provides the skin with essential fatty acids and the nutrients necessary for collagen production.

babies from as young as newborn and can be used as often as necessary (particularly before feeding and sleeping) to clear baby’s nose. Flo Baby contains saline plus extra minerals required in the nose. It contains no preservatives and delivers a gentle micromist. The advanced pump technology means it sprays at any angle - even upside down when baby is lying down.

These natural ingredients not only rejuvenate the skin but also improve skin hydration, wrinkle depth, skin firmness and elasticity, as well as reducing the appearance of scars. In addition, this hand and body cream is suitable for sensitive skin and the whole family. Available at Clicks, Dis-Chem, Independent Pharmacies & Health Stores and online store at www.bonnaturaloils.co.za

eSensitive Midwifery Magazine

Available in DisChem, Baby City and all leading pharmacies

Issue 44

Mom & Baby

Measures to minimise risks to

infants of scheduled C-section

Professor Suzanne Delport – retired neonatologist and strong breastfeeding supporter – outlines procedures peripartum health practitioners can follow to mitigate risks to newborns of scheduled deliveries in the private sector.

cheduled deliveries occur commonly in the South African private sector, with the majority of women with low-risk pregnancies receiving a non-indicated caesarean section before spontaneous initiation of labour. The aim is to perform a ‘non-injurious’ delivery which will ensure a ‘healthy’ newborn infant. This is an erroneous belief since unanticipated, lifethreatening complications may afflict the newborn precisely due to the absence of labour.

Consequently, meticulous surveillance from birth until discharge is of the essence because a ‘healthy’ appearance belies the fact that these infants are unprepared for an extrauterine existence. Admission to special care units to facilitate surveillance of these infants is the norm, resulting in overcrowding of these units as well as intensive care units. The inflated induction and caesarean section birth rate contributes to the unavailability of beds for other ill newborn infants, and to the Continued on page 47

eSensitive Midwifery Magazine

Issue 44

Mom & Baby

strain on nursing resources, while both could be prevented by performing more vaginal deliveries. If performed under safe circumstances, a vaginal delivery remains the delivery mode of choice: not only do complications necessitating admission of the newborn rarely occur, but caesarean delivery is associated with long-term adverse health effects to both the mother and infant, notwithstanding a lack of evidence from randomised controlled trials – it would be unethical to assign low-risk healthy pregnant women to such trials!

Midwives should be aware of the vulnerability of ‘healthy’ newborns born in the private sector as a result of caesarean section overuse, using it to strengthen their educational and advocacy roles. In addition, measures should be in place and routinely applied to help protect the mother-infant dyad from pregnancy to the postnatal phase, and infants through to childhood.

a medicalised environment increases the risk of a caesarean delivery. Admission to special care units to facilitate surveillance and manage complications of these infants is the norm, resulting in overcrowding of these units as well as intensive care units. While the expected date of delivery (EDD) can be estimated from the first day of the last menstrual period (LMP) it needs to be confirmed by an accurate early ultrasound examination. Thereafter, the adjustment of the expected date of delivery by any service provider is NOT evidence-based and should not be permissible. This practice increases the risk of an unfavourable outcome and death for the newborn infant due to iatrogenic prematurity. A scheduled delivery should not take place before a gestational age of 39 weeks. If an accurate gestational age is not available, a scheduled delivery is contraindicated. A suitable labour companion should be identified during pregnancy.

1. Pregnancy In the light of societal and service provider pressure to select C-section as a ‘safer option’, women, and primigravidas in particular, should be informed about the benefits of a vaginal delivery following spontaneous onset of labour. The reasons for choosing a C-section delivery (by women and service providers) should be investigated and addressed to facilitate an informed choice. Counselling should take place in non-threatening and calm circumstances. The undisputed complications to both the mother and her infant of a non-indicated caesarean delivery should be highlighted, as well as the long-term deleterious effects. In general, the choice of service provider and place of delivery determine the mode of delivery; admission to a private hospital will most likely result in a C-section – either as a scheduled pre-labour procedure or after a failed induction of labour. Women with low-risk pregnancies who desire a vaginal delivery should be made aware that

2. Delivery Active measures should be implemented to maintain maternal normothermia and decrease the risk of neonatal hypothermia. These include pre-operative and intra-operative active warming and the administration of warmed intravenous fluids. The ambient temperature of a theatre should be 23 ⁰C and that of a delivery room 26 ⁰C. Prophylactic antibiotic therapy should be administered intravenously within 60 minutes of the skin incision to effect therapeutic blood levels at the time of surgery with the objective to prevent endometritis and wound sepsis. The drug of choice is cefazolin (2g), and this dose should be repeated three hours after surgery. Women who deliver by the vaginal route, do not need antibiotic prophylaxis. The pharynx and upper airway of an infant born through clear amniotic fluid should not be suctioned. Delay clamping of the cord for 30–60 seconds of delivering the infant. Refrain from the iatrogenic transfer of vaginal microbiota (‘vaginal seeding’) to the newborn

Mitigating vulnerability

Continued on page 48 eSensitive Midwifery Magazine

Issue 44

Mom & Baby

after C-section in an effort to establish a ‘normal’ microbiome. Safety of this practice as well as its effectiveness are not supported by robust evidence. 3. Stabilisation of the infant The oxygen saturation should be monitored in all infants by preductal pulse oximetry (SpO2) on the right hand after birth. No infant should leave the delivery room/theatre without a documented SpO2. Normal oxygenation implies an SpO2 of 90–93% in room air and a respiratory rate of 50–60 breaths per minute in a non-crying infant. Record the SpO2 and supplemental oxygen requirement 4–6 hourly for 24 hours. Refrain from a clinical assessment of oxygenation by noting the colour of the infant’s tongue. An infant with a pink tongue can have a low SpO2, necessitating supplemental oxygen. Inadequate oxygenation and can only be diagnosed by an SpO2. Guard against an SpO2>95%. Skin-to-skin care on the mother’s chest (if she is normothermic) should be initiated after the infant’s stabilisation in an effort to initiate surges of oxytocin and prolactin in the mother-infant dyad to facilitate bonding, lactation and a positive maternal feeling. These surges are blunted after the first hour in the event of C-section and fail to recur thereafter. 4. Proactive breastfeeding support Initiate nipple contact and colostrum intake immediately after delivery to optimise the prognosis for successful short- and long-term lactation. Most mothers secrete colostrum at birth which should be aspirated with a 1cc syringe and administered to the infant should suckling be ineffective at this time. Proactive professional lactation support should be available at all times and in particular before difficulties with breastfeeding arise. Reactive support in response to problems are less effective at this time. Refrain from supplementary formula feeds at all times.

5. Surveillance of the newborn infant Monitor oxygenation (by SpO2), thermoregulation, glucose metabolism and breast milk intake at 4–6 hourly intervals for at least 72 hours after a scheduled delivery. Record the infant’s weight daily, as well as urine output (at least six wet nappies over 24 hours) to ensure that the intake of breast milk is adequate. If more than 10% of the infant’s birth weight has been lost by 72 hours, inadequate intake of breast milk should be diagnosed and treated to prevent jaundice and hypernatraemic dehydration. Bilirubin levels should be recorded in all infants before discharge irrespective of whether jaundice is present. The value should be plotted on a percentile chart to determine the risk after discharge of hyperbilirubinaemia necessitating intervention. The availability of nursing personnel and relevant equipment for effective monitoring of caesareandelivered infants is mandatory. 6. Neurodevelopmental surveillance Infants born before spontaneous onset of labour by means of a scheduled delivery should be offered neurodevelopmental surveillance until school-going age, as delays can only be diagnosed by this means. This is important due to physiological and organ immaturity (including the brain). Early remedial intervention improves the long-term prognosis.

Decreasing the burden

To decrease a wide range of potential health and developmental adverse effects, the overuse of caesarean deliveries in the private sector should be acknowledged, reported and addressed. Meticulous surveillance by midwives and nurses to minimise risks to these newborn infants is essential to further decrease the burden.

Comprehensive references: Professor Delport has provided exhaustive references to substantiate her concerns about the effects of unwarranted C-section delivery prior to spontaneous labour commencement. Sensitive Midwifery urges all readers to use these to educate unenlightened colleagues. See them on page 55.

eSensitive Midwifery Magazine

Issue 44

Breast assurance

Milky

ways

MOM’s the best For preterm and extremely preterm infants, mother’s own milk (MOM) is the best food, followed by pasteurised donor breast milk (DBM) when MOM is unavailable. Now, a recent study has shown that MOM could be used to personalise the microbiota of DBM by incubating donor milk with 10% of MOM for four hours, thereby re-establishing the potentially beneficial naturally occurring microbes. Cacho, N, et al, ‘Personalization of the Microbiota of Donor Human Milk with Mother’s Own Milk’, Frontiers in Microbiology, 2017, 8. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541031/

Breastfeeding has a consistently lower carbon footprint It’s well-known that breast milk substitutes (BMS) are associated with negative influences on breastfeeding and subsequent health concerns but, as with all processed foods, production and consumption of BMS comes with an environmental cost. A recent study evaluated the carbon footprint (CFP) of production and consumption of BMS in comparison to breastfeeding. Unsurprisingly, breastfeeding showed a lower CFP in all countries studied. Dairy farming contributes most to the CFP of breast milk substitutes, and sterilisation of bottles contributes most to consumption phase emissions. Karlsson, JO, et al, ‘The carbon footprint of breastmilk substitutes in comparison with breastfeeding’, Journal of cleaner production, 2019, 222, 436–445

The cost of not breastfeeding

Dads make a difference A study investigated parents’ perceptions of what constitutes support for breastfeeding, in particular paternal support. Mothers concluded that ‘dads do make a difference’ by anticipating and fulfilling associated maternal needs, encouraging mothers to do their best, as well as showing paternal determination and commitment. Fathers reported ‘wanting to be involved’, but also wanting more information and help with learning their role. Sharing the experience of childbirth and supporting each other with infant feeding was perceived as the best outcome for the majority of new parents. Something to bear in mind as you advise parents! Tohotoa, J, et al, ‘Dads made a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia’, International Breastfeeding Journal, 2009, 4:15. Available: https://doi. org/10.1186/1746-4358-4-15

A new study has calculated that inadequate breastfeeding costs the global economy almost $1 billion each day ($341 billion a year) in lost productivity and health care, and also leads to the early deaths of nearly 600 000 children and just under 100 000 women each year. Canada-based health economist Dylan Walters, who led the study of more than 100 countries, said, ‘The world must act to mobilize financial resources necessary and political commitment to achieve the World Health Assembly Global Nutrition Target of exclusive breastfeeding prevalence of 50% by 2025 because it is a human right, it saves lives, and improves the prosperity of economies.’ Using data from Walters’ six-year study, an online tool known as the ‘Cost of Not Breastfeeding’ has been developed, allowing users to explore data on the impacts of not breastfeeding in 34 countries. Find it at www.aliveandthrive.org. Beh Lih Yi, ‘More breastfeeding could save the world $1 billion every day’, 12 July 2019. Available: https://www.reuters.com/article/us-globalhealth-breastfeed-idUSKCN1U70ZV

eSensitive Midwifery Magazine

Issue 44

Breast assurance

Liquid gold

for premature babies Nurse and midwife Annerié Conradie’s special interest in breastfeeding and antenatal education led her to start a private practice in 2016, after working in a private hospital for 14 years. She completed her South African Certified Lactation Consultant qualification in 2018, and loves supporting new mothers and babies on their breastfeeding journeys. Annerié is wife to Francois, and mom to two daughters, Incke (14) and Kristin (11).

egardless of what it is called, colostrum is tailored to the specific needs of a newborn, and especially beneficial to the premature infant. It’s highly concentrated, full of protein and nutrientdense. This low-in-fat, easy-to-digest first food has numerous benefits for a newborn as it improves absorption of nutrients, gastrointestinal function, neurodevelopmental outcome, and plays a crucial role in building a baby’s immune system.

Benefits of breast milk for preemies Human milk is the best choice of nutrition for all babies. Its unique composition is not only advantageous to the premature infant, but is potentially life-saving. Breastfeeding should therefore be considered as important as any medical intervention for premature infants. Preterm infants have not developed fully in utero, meaning they have different needs and challenges to term infants. A premature baby has an immature and/or dysfunctional gastrointestinal tract, which can cause difficulties with digestion and absorption of nutrients. Early, optimal nutritional management is crucial and colostrum expression should take place as soon as possible following delivery. Specific biofactors only found in breast milk (e.g. lactoferrin, antibodies, lysozyme, cytokines and antioxidants) can reduce the infection risk of

How do we make sure premature babies get colostrum? After all, the risks they face increase if they don't! the preterm infant. Breast milk contains enzymes that assist with digestion; epidermal growth factor, which helps with intestinal maturity; and essential fatty acids that aid in the development of the brain and eyes. Premature babies fed mainly on breast milk have significantly lower intestinal permeability than those predominantly given formula, which means that fewer (potentially disease-causing) particles can pass through the lining of their intestines into their bloodstream.

Why are the most needy disadvantaged? Now that’s a relevant question, and the answers lie in concerted and creative addressing of the most common obstacles that prevent premature babies from receiving colostrum! These obstacles are: • The adverse effects on initiation of lactation caused by mammary growth that may be incomplete in a substantially shortened pregnancy • Inhibition of lactation due to maternal stress, fatigue and anxiety • Lack of staff to assist the immobile mother with initial manual expression in the postnatal ward • Unclear guidelines regarding who is responsible for assisting the mother in the NICU or postnatal unit • The attitude of NICU staff to breastfeeding, as well as sub-optimal lactation knowledge and expertise • No protocol allowing lactation consultants (not employed by the hospital) to assist in NICU • Mom not being able to visit her baby in the hospital • Sub-standard expressing equipment of the hospital and at home Continued on page 51

eSensitive Midwifery Magazine

Issue 44

Breast assurance

Promoting baby-friendly protocols Regular update sessions on how to implement kangaroo mother care (KMC) is just one of the many ways in which premature-care-unit staff can be supported by management to be ‘liquid-gold friendly’. Another is to hold regular training on lactation topics like expression, evaluating quality of feeding at the breast, initiating breastfeeding and the use of a supplemental nursing system (SNS). In fact, it’s imperative to demonstrate manual expression to all postnatal unit staff. Protocols and responsibility regarding handling of expressed breast milk (EBM) and time intervals between expressions should be clear and part of the induction programme – and regularly revisited. Not all staff members are equally positive about baby-friendly protocols and KMC. Ensuring that this does not depend on ‘who is on duty’ is key to maintaining a baby-friendly environment, and preventing frustration and confusion for the parents. Parents often comprehend very little information just after admission as they are in shock, so staff should repeat information, even if given already. Having a written admission to NICU, breast milk and expression protocol that all staff have access to is a good idea. All staff should also be educated and assessed on the pumps used by the facility (i.e. different settings, fitting of the flanges, and the content of education given to the mothers on the use of the pump). In fact, hospitals should consider employing a certified lactation consultant to optimise outcomes.

• The benefits of EBM (this should be discussed with the expectant mother during the antenatal period, especially where a risk of prematurity is anticipated) • Method and frequency of expression, both manual and electric • Having realistic expectations regarding the initial milk volume for each expression for the first 24–48 hours postpartum • The expected duration of feeds • The importance of taking in enough fluids during the day, having a balanced diet and carrying on with a multivitamin • Positioning the baby at the breast, ensuring a good latch, as well as how to perform breast compressions and the benefit of breast compressions during feeds (breast compressions maintain a continuous flow of breast milk, which in turn, helps a baby to stay alert and interested in feeding) Staff can offer further support by encouraging continuous skin-to-skin (where possible); ensuring privacy while the mother expresses milk, and offering her a comfortable chair; as well as praising her for her efforts, regardless of the amount produced — every drop counts! If volumes expressed stay lower than expected, staff must ensure that the expression technique is correct, and if unsure, they must get the advice of a lactation consultant.

Supporting mothers leads to success

Breastfeeding’s a no-brainer

Counselling mothers of preemies as soon as possible increases the incidence of lactation initiation and contrary to popular belief, does not increase maternal stress or anxiety. Feelings verbalised by most mothers regarding their inability to breastfeed their premature babies immediately after delivery include: sorrow, guilt, disappointment, frustration, sense of loss, insecurity, as well as fear of touching, holding or harming their delicate babies. Health professionals need to recognise that these feelings may not be automatically obvious to the observer. Mothers of premature infants should be educated on:

Contact Sensitive Midwifery for references if required

There’s more than enough research that proves that premature infants benefit short term as well as long term, by receiving colostrum and ultimately, breast milk. There is an urgency for staff to be well educated in this field, and where expertise is lacking, to request specialised lactation assistance. Admission to the NICU is often unexpected and hits most parents hard. Education, support, assistance, attachment parenting, and creating opportunities for fathers to support mothers can help to ensure that the infant not only receives the very valuable ‘liquid gold’, but that a successful breastfeeding journey is established.

eSensitive Midwifery Magazine

Issue 44

Breast assurance

Normalising

breastfeeding in public

Child and Adolescent Development tutor Petro Wagner asks, if breast is best, why is it sometimes considered ‘bad’?

xclusive breastfeeding until six months has significantly increased over the past two decades in South Africa: only 7% of six-monthold infants were exclusively breastfed in 1998 compared to 32% in 2016. However, these figures still paint a picture that is far from optimal as the vast majority of South African babies under six months are not exclusively breastfed. It is evident that women still face many obstacles which hinder them from reaching the ideal of exclusive breastfeeding for six months and continued nursing until two years and beyond.

One challenge is that small babies need to feed often, while these little gulpers’ mothers (who are also the producers and vessels of their food) need to leave their homes from time to time. This is not necessarily a problem, except that dishing up this convenient refreshment in public entails what some see as a form of nudity – and this makes some mothers and onlookers feel uneasy. If dedicated nursing mothers feel threatened, judged or exposed while feeding their babies in public, it may end up having one of two outcomes: they rather stay at home (which hampers the Continued on page 53

eSensitive Midwifery Magazine

Issue 44

Breast assurance

wellbeing of these women and their families as a whole), or they quit breastfeeding altogether. As the author of a UK study confirms, ‘Breastfeeding in public relates to duration rates, since … the decision to continue to breastfeed over time is bound up with women’s ability to integrate this activity with their preferred ways of engaging with the world post-birth.’ If consuming breast milk (from its ‘natural containers’) were as tolerable in public as drinking water, mothers’ lives would be a great deal more comfortable; babies may end up breastfeeding for longer; and a positive cycle would be established as future mothers would become habituated to women nursing wherever they go – increasing the probability of them following suit. It is therefore imperative to address the social taboo around breastfeeding in communal spaces.

Why is public breastfeeding ‘problematic’ for some?

In short, breastfeeding entails the undressing of sexualised body parts. Let’s quickly go to the beach: a public space where relative nudity is quite normal. When visiting the seaside on a sunny day, most women – even the ones who feel comfortable with showing lots of skin – will wear bikinis that cover at least their nipples. That is because it is considered quite scandalous (by Western standards) to ‘bare one’s breasts’ openly. No wonder breastfeeding outside of private spaces is often perceived as indecent. And it therefore makes sense that nursing mothers may experience societal embarrassment and social isolation, which research has sadly found to be two major barriers to breastfeeding. In South Africa, support for breastfeeding is wonderful on policy level, but attitudes towards breastfeeding in public are often still problematic. Chantell Witten from the South African Civil Society for Women's, Adolescents' and Children's Health calls this our ‘last hurdle’. Other hindrances to breastfeeding in public in some circumstances include more practical issues: women need an appropriate, comfortable and clean place to sit and feed, which is sometimes not available in free spaces.

The role of professionals in ‘breasting’ the status quo Midwives and postnatal nurses are significant leaders in the drive to normalise public breastfeeding. Firstly, these professionals could offer new mothers proper information about the advantages of breastfeeding for mom and baby. If women are adequately motivated, they will be more likely to overcome any breastfeeding challenges – be it blocked ducts, returning to work, or getting weird looks in public. Equally important is help with getting breastfeeding off to a good start. If a mother can correctly latch her baby and knows which positions are most comfortable, she can more boldly replicate this outside of the home. Conversely, if she is already struggling, the additional stress of being in public may prevent her from even trying. Specifically motivating women to nurse while out and about is another important role of healthcare professionals. They should assure women that the law is on their side, and they could even prepare new mothers for possible negative reactions from strangers by helping them to rehearse staying calm and giving a polite but stern reply. Encouraging women not to feel ashamed while engaging in one of the most natural maternal practices is vital, but remaining sensitive to women’s reservations about public nursing is also necessary. Perhaps a better response than, ‘Get over it; it's natural!’ is to teach women how to breastfeed while showing the bare minimum. There are many techniques, clothing options, undergarments, feeding covers and other accessories which allow for discreet feeding if that is what a mother prefers. Midwives and nurses would be wise to know the ‘tricks of the trade’ and stay abreast of new trends. Lastly, postnatal workers should be careful not to villainise the general public in mothers’ minds. Rather, teach them to ask for help when needed (e.g. asking a shop assistant for a chair). In my own and many interviewed women’s experiences, many people are kind and helpful towards nursing women – particularly when specifically asked for assistance. Continued on page 54

eSensitive Midwifery Magazine

Issue 44

Breast assurance

How society can be more breastfeeding-friendly

Breastfeeding-friendly places are inviting on both physical and socio-emotional levels. As Australian breastfeeding researchers put it, ‘Changes are needed on the ground, and in hearts and minds.’ In the physical dimension, a comfortable, safe and relatively quiet place for a nursing mother to sit may be all that is needed. In many communal buildings, the ‘problem’ of public breastfeeding is solved by feeding rooms. While this may be helpful to some women in certain circumstances (e.g. one needing to feed while containing older siblings), these separate rooms may seem to perpetuate the removal, rather than support the integration, of breastfeeding in shared spaces. These cubicles are not always nearby or comfortable, and sometimes also contain smelly nappy changing stations. Matters of ‘hearts and minds’ may be the trickier challenge as attitudes and beliefs are not easily changed. More research may be needed to uncover why certain individuals or cultures are antagonistic towards public breastfeeding and what it may take to change their thinking. This information could be used to launch appropriate campaigns. The popular South African chain restaurant Spur has recently set an example of how businesses can support their breastfeeding customers by traing their staff on breastfeeding support, and putting up signs to say that breastfeeding is welcome, explaining to the public why this is important. If more establishments could follow suit, it would certainly make a difference in shaping public opinion. Lastly, nursing women are needed to pioneer a movement of unashamed breastfeeding in public. Researchers confirm this: ‘Many women find it reassuring to see other women breastfeed in a place, offering them evidence that they can too.’ Contact Sensitive Midwifery for references if required

eSensitive Midwifery Magazine

Issue 44

Key references in this issue The future of natural birth in South Africa – page 20 • Gonzalez, L, and Grant, L, ‘A changing birth: What’s behind SA’s skyrocketing c-section rates?’, 9 January 2019. • Grant, L, ‘This map tells you which districts have the highest c-section rates’, 9 January 2019. • Wasserman, H, ‘The C-section rate among Discovery members is now up to three times higher than at American celebrity hospitals – here’s why’, 20 April 2019.

• •

•

Let’s make maternity units more woman-centred – page 28 • Cook, K, et al, ‘The impact of choice and control on women’s childbirth experiences’, The Journal of Perinatal Education, 2012, 21(3): 158–68 • Fontein-Kuipers, Y, et al, ‘Woman-centered care 2.0: Bringing the concept into focus’, European Journal of Midwifery, 2018, 2(5): 1–12 • Maputle, MS, et al, ‘Woman-centred care in childbirth: A concept analysis (Part 1)’, Curationis, 2013, 36(1): 1–8 • Newton, MS, et al, ‘Understanding the “work” of caseload midwives: a mixed-methods exploration of two caseload midwifery models in Victoria, Australia’, Women and Birth, 2016, 29(3): 223–233

•

Iodine in maternity care – page 30 • Aburto, N, et al, ‘Effect and safety of salt iodization to prevent iodine deficiency disorders: a systematic review with metaanalyses’, World Health Organization, 2014. • Darnton-Hill, I, ‘Iodine in pregnancy and lactation’, World Health Organization, July 2017. • Jooste, P, et al, ‘Progress towards eliminating iodine deficiency in South Africa’, S Afr J Clin Nutr, 2008, 21(1): 08–14 • Lee, S, et al, ‘Iodine intake in pregnancy—even a little excess is too much’, Nat Rev Endocrinol, 2015, 11(5): 260–261. • McCall, B, ‘Pregnant mothers and the dangers of iodine deficiency’, 7 December 2015.

•

Measures to minimise C-section risks to infants – page 46 • American College of Obstetricians and Gynecologists, ACOG Committee Opinion No. 561, ‘Nonmedically indicated early term deliveries’, Obstet Gynecol, 2013, 121:911–915 • American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion No. 700, ‘Methods for estimating the due date’, Obstet Gynecol, 2017, 129: e150–e154 • American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion No. 688, ‘Management of suboptimally dated pregnancies’ Obstet Gynecol, 2017, 129: e29–e32 • Bhutani VK, et al, ‘Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns’, Pediatrics, 1999, 103: 6–14 • Buckley SJ, ‘Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care’, Washington DC: Childbirth Connection Programs, National Partnership for Women & Families, 2015 • Caughey AB, ‘The safe prevention of the primary cesarean’, Clin Obstet Gynecol, 2015, 58: 207–210. doi: 10.1097/ GRF.0000000000000111

•

eSensitive Midwifery Magazine

Competition Commission South Africa, ‘Health market inquiry: provisional findings and recommendations report’, July 5, 2018. Dawson JA, et al, ‘Pulse oximetry for monitoring infants in the delivery room: a review’, Arch Dis Child Getal Neonatal Ed, 2007, 92: F4–F7 Dewey KG, et al, ‘Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss’, Pediatrics, 2003, 112: 607–619 Duffield A, et al, ‘Optimal administration of cefazolin prophylaxis for caesarean delivery’, J Perinatol, 2017, 37:16–20. doi:10.1038/ jp.2016.210 Dureya EL, et al, ‘The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial’, Am J Obstet Gynecol, 2016, 214: 505.e1–e7. doi:10.1016/j. ajog.2016.01.190 Hofmeyr GJ, ‘Caesarean Section’ in Cronje HS, Cilliers JBF, du Toit MA, (eds), Clinical Obstetrics a South African Perspective, 4th ed., Braamfontein: Van Schaik Horn E-P, et al, ‘The incidence and prevention of hypothermia in newborn bonding after caesarean delivery: a randomized controlled trial’, Anesth Analg, 2014, 118: 997–1002 Kelleher J, et al, ‘Oropharyngeal suction versus wiping of the mouth and nose at birth: a randomized equivalency trial’, Lancet, 2013, 382:3260330. doi:10/1016/S0140-6736(13)60775-8 Konstantelos D, et al, ‘Analysing support of postnatal transition in term infants after c-section’, BMC Pregnancy and Childbirth, 2014, 14:225–30. doi:10.1186/1471-2393-14-225 McDonald SJ, et al, ‘Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes’, Cochrane Database of Systemic Reviews, 2013, Issue 7. Art No.: CD004074. doi: 10.1002/14651858.CD004074.pub3 Morrison JJ, et al, ‘Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section’, BJOG, 1995, 102: 101–106 Renfrew MJ, et al, ‘Support for healthy breastfeeding mothers with healthy term babies’, Cochrane Database Syst Rev, 5: CD001141. doi: 10.1002/14651858.cd00141.pub4 Rose O, et al, ‘Developmental scores at 1 year with increasing gestational age, 37-41 weeks’, Pediatrics, 2013, 131: e1475–1481. doi: 10.1542/peds.2012-3215 Sakala C, et al, ‘Hormonal physiology of childbearing, an essential framework for maternal-newborn nursing’, JOGNN, 2016, 45: 264–275. doi:10.1016/j.jogn.2015.12.006 Sandall J, et al ‘Short-term and long-term effects of caesarean section on the health of women and children’, Lancet, 2018, 392: 1349–57 Stinson LF, et al, ‘A critical review of the bacterial baptism hypothesis and the impact of cesarean delivery on the infant microbiome’, Front Med, 2018, 5:135. doi:10.3389/ fmed.2018.00135 Swanson JR, et al, ‘Transition of fetus to newborn’, Pediatr Clin N Am, 2015, 62:329–343. Available: http://dx.doi.org/10.1016/j. pd.2014.11.002 Walker KF, et al, ‘The dangers of the day of birth’, BJOG, 2014, 121: 714–718

Issue 44

Posterior

Spicy pineapple

salad bowl

Deliciously satisfying and healthy! 1 large, ripe Queen pineapple, with a lengthways ‘lid’ cut off (leave leaves intact) ½ cup pineapple pieces 1 red chilli, finely chopped a few thin strips of candied ginger ½ cup small butternut pieces (peeled and chopped) ½ cup small sweet potato pieces (peeled and chopped) ¼ tsp curry spice 1 tbsp olive oil • With a sharp knife, cut out the pineapple flesh from the pineapple ‘bowl’. Discard the core, and cut the flesh into chunks and place in an ovenproof dish. Scatter the ginger and chilli over the fleshy pieces and place under a hot grill until you notice the pineapple browning slightly. Turn the pineapple pieces and place back under the grill to brown the other side. Remove and allow to cool. • Pour olive oil into an ovenproof dish, tossing in the butternut and sweet potato pieces. Shake over the curry powder and rub into the veggies. Place in the oven at 180˚C until just cooked – use a sharp knife or skewer to check after 15 minutes. Remove and allow to cool. • Place the quinoa in a fine-mesh sieve and rinse Nasturtium humus • 1 can organic chickpeas (or cook your own) • 100 ml extra virgin olive oil • 1 medium lemon, juiced • 50 ml sweet vinegar (sushi, apple cider or balsamic) • 1 tsp agave syrup (optional) • 1 clove garlic (optional)

½ cup red quinoa 1 cup water or veggie stock 1 ripe avocado fresh lemon juice ½ cup nasturtium humus 5 rocket leaves 3 nasturtium leaves 1 nasturtium flower under cold water until it runs clear. Place in a saucepan with the water or veggie stock; bring to the boil and then simmer for 15 minutes, or until all liquid is absorbed. Leave in the saucepan to cool. • Halve the avo, remove the pip, and cut the flesh into thin slices. Drizzle over a little lemon juice for zing and to keep the avo’s colour. • Start to assemble the bowl by laying down the rocket leaves in the base of the pineapple, taking care to let some leaves protrude above the rim. Next, spoon in the quinoa close to the leafy side of the pineapple. Work your way around clockwise, adding the butternut/sweet potato mix, the pineapple, a dollop of nasturtium humus, the avocado, and a final dollop of humus. Garnish with the nasturtium leaves and flower. • 10 nasturtium leaves • sea salt and ground pepper to taste Drain chickpeas, empty into a blender jug and add all other ingredients. Blend until a smooth, creamy dip consistency is reached. Add a little more lemon juice, vinegar or agave syrup to balance flavour if necessary. Check for seasoning.

eSensitive Midwifery Magazine

Issue 44

Posterior

Looking towards the future with 2020 vision

t its heart, Sensitive Midwifery – the symposium, magazine and other initiatives – has always been about encouraging natural, respectful midwifery. In order to continue our call to support sensitive midwives, we’ve been taking a look at changing trends (from today’s economic challenges to technological opportunities), while keeping our eyes on our core goals. For a couple of years now, Sensitive Midwifery has been navigating a time of transition. Our legendary Sister Lilian – who over the course of her career, has left a significant mark in the South African midwifery landscape – has been taking hands with the next generation, so that the Sensitive Midwifery brand can continue to thrive. However, we must face that marketing trends are rapidly changing and it’s extremely tough to keep up with the rising costs of publishing and educational conferences. After two years of mentoring Midwife Specialist Margreet Wibbelink to take over the helm, a new structure for Sensitive Midwifery will be implemented from 2020. The online space will feature prominently, but we'll still continue organising meetups, because we believe in real connection time and face-to-face interaction, no matter how much times are changing! We’ll be offering valuable content and training courses that are both rigorous and riveting in both spheres. Our vision is to keep you up to date and fully empowered, so that you can practise sensitive midwifery in every setting.

All eyes – and ears – on the 2020 vision

• Sensitive Midwifery’s acclaimed mix of evidence- and intuition-based content to continue in all our initiatives • Our much-loved two-day annual flagship Sensitive Midwifery Symposium in Johannesburg to continue • The other three Sensitive Midwifery Symposium events to be replaced with FREE half-day Sensitive Midwifery Seminars in various provinces of South Africa • That while it’s sad to say goodbye to the beautiful Sensitive Midwifery Magazine, we will be launching Sensitive Midwifery’s very own Birth&Baby YouTube channel, plus a Birth&Baby Podcast! • To receive regular midwifery community emailers, which will have evidence-based, interesting midwifery content and links to our Birth&Baby Blog, YouTube channel and Podcast. • Our Sensitive Midwifery Facebook and Instagram updates to continue • Sensitive Midwifery Academy to be offering innovative, upscaling midwifery training courses – online, as well as face-to-face (see more about the Certified Sensitive Midwife Course on page 59) • To receive a few Sensitive Midwifery educational items like posters, topic-specific guides, gestational wheels, etc. each year • To find various membership opportunities, to ensure that every midwife and maternity care worker can be part of the Sensitive Midwifery Community

As part of our commitment to grow and support sensitive midwives, you can expect:

eSensitive Midwifery Magazine

Join us on the Sensitive Midwifery journey!

Issue 44

Posterior

Johannesburg

13 & 14 May 2020

2020

PROGRAMME HIGHLIGHTS Wednesday 13 May 2020

Thursday 14 May 2020

• Equity in midwifery - personal, professional and for all people in our care • PMTCT update – make sure you know the latest protocols • Task shifting in maternity care – the changing face of scope of practice • The Simplicity-Quality-Quotient in practice – three indisputable ways to change birthing outcomes for the better • The truth about induction and epidurals – latest evidence • Aromatherapy in maternity care • Independent midwifery on the rise - a viable all-sector solution for South Africa

• How to unify and professionalise midwifery • FEAR – facing and overcoming this 'dystocia' of maternity care • Eclampsia – the full picture • Respectful maternity care – do unto others … • Time tested ways of improving the quality of ante-and postnatal care • Hypnobirthing – learn the techniques • Implementing holistic care of the premature baby – lead the way

Would you like to be a presenter in 2020? Email us and explain how your topic reflects that you are leading the way to a better midwifery future where you work. Send to info@sensitivemidwifery.co.za

2020 Sensitive Midwifery Seminars Booking is essential for these free half-day seminars as limited space is available. On the Seminar agenda in 2020:

Save these Seminar dates:

• Keynote address: The power of midwifery • You are what, and how, you eat • Nutrition and menu planning for you and your clients • Food as medicine

Port Elizabeth • 21 February 2020 Cape Town • 21 August 2020 Johannesburg • 9 October 2020

For more information and to book T: +27 12 809 3342 M: +27 71 447 3321

eSensitive Midwifery Magazine

E: info@sensitivemidwifery.co.za W: sensitivemidwifery.co.za

Issue 44

Posterior

Sign up for the Certified Sensitive Midwife Course There is vast evidence to support the need for more midwife specialists in South Africa and the world. That’s why Sensitive Midwifery Academy is proud to offer to all midwives its new post-basic Certified Sensitive Midwife Course, which was successfully pioneered in the Eastern Cape.

REASONS TO DO THE CERTIFIED SENSITIVE MIDWIFE COURSE 1. Current and future nurse-midwife training

doesn’t yield midwives experienced or knowledgeable enough to be fully confident practitioners in any sphere of midwifery 2. Advanced midwifery does not suitably address

the expert but ‘basic’ midwifery skills that make for the safest, most satisfying experience of labour and birth 3. No official qualification teaches the profound

value or the positive outcomes of being an authentic midwifery specialist

WHO SHOULD DO THE CERTIFIED SENSITIVE MIDWIFE COURSE? All basic-trained nurse-midwives in any sector (independent practice; private and public hospitals; education; government), in the antenatal, intrapartum, postnatal, or parenting advice fields.

BRIEF OUTLINE OF THE CERTIFIED SENSITIVE MIDWIFE COURSE MODULE ONE: Holistic preconceptual and antenatal education, care, risk detection and management MODULE TWO: An in-depth study of physiological labour and birth, risk detection and management

MODULE THREE: Midwifery management of adverse events and complications during labour and birth (up to six hours post-birth) MODULE FOUR: Holistic postnatal mother and baby hospital and home care, and breastfeeding support (from six hours to six weeks post-birth) MODULE FIVE: Holistic clinic and independent practice education, support and care of the mother and baby (from six weeks to six months post-birth)

ENDORSEMENT FROM EASTERN CAPE MIDWIVES • This course taught me that the calmer and more respected the mom, the better the birth, postbirth bonding time, and postnatal adjustment. I can now confidently let her experience unfold. Michelle van der Westhuizen (Independent Midwife) • This is the right way to prevent complications and embrace a midwife’s real role - midwives won’t even need to become advanced midwives! I feel empowered to help my community. Nondi Gaba (Manager of the Eastern Cape’s Maternal and Child Health Programme) • Great to see how important to midwifery natural postnatal care is. Carin Espag (NPO Postnatal Clinic Sister) • The course imparted 30-40 years of Sister Lilian’s wisdom, gave me trust in women being built for natural birth and showed that it’s important to get back to basics. Else Vooijs (direct entry trained Dutch midwife) • The course was incredibly enriching for a medically trained midwife, and created a safe, normal place for women and midwives. Juanita Mackenzie (Independent Midwife)

TO FIND OUT MORE, REGISTER FOR THE ONLINE COURSE, OR BOOK THE COURSE FOR A GROUP, visit www.sensitivemidwifery.co.za, email info@sensitivemidwifery.co.za, or call +27 (0)12 809 3342

eSensitive Midwifery Magazine

Issue 44

Posterior

Last word The Birthing Team maternity care model Obstetrician and MBA qualified Dr Howard Manyonga has extensive local and overseas experience in the public-, NGO- and private-health sectors. He has private practice and health systems management experience; has headed Women’s Health at the WITS Reproductive Health and HIV Institute; and was the COO of Marie Stopes South Africa. As executive team member with health services management company PPO Serve, Dr Manyonga led the development and rollout of The Birthing Team maternity care model. His grandmother was a traditional midwife.

ince The Birthing Team (TBT) was established in 2017, 800 babies have been born through its affordable maternity product. Now available in four cities across South Africa, TBT is an independent commercial company at each site, owned by the clinicians who work in it. Each TBT company partners with a particular private sector hospital to offer an end-to-end maternity service, based on a global fee. This maternity product model is evidence-based and promotes natural childbirth, recommending operative deliveries only when they are medically necessary. Another major difference to the TBT model (except for a small number of private midwife units in large metropoles), is that midwives are the primary caregivers, only involving medical officers or obstetricians when necessary. These midwives work to the top of their professional scope of practice in a collaborative manner with anaesthetists, paediatricians and allied health professionals, to provide TBT’s maternity product. Where there is a TBT, the labour ward is transformed into an affordable yet highly productive system, supported to improve patient experience and clinical outcomes.

How it all works PPO Serve and hospital leadership manage the change, together with the local champion, to embed team structures and processes. These include weekly meetings. New processes are

also introduced for administrative and support staff, to ensure adherence to the requirements of the product. To achieve this, PPO Serve works collaboratively with the management and training departments to ensure accountability and alignment with the larger hospital system’s requirements and programmes. The team also develops relationships with other providers in its own environment to ensure transitions of care are managed seamlessly, to reduce costs and patient safety risks. The team uses the PPO Serve Intelligent Care System (ICS), a web-based workflow system that is preloaded with customisable assessments and care plans which enables some real-time decision support. PPO Serve provides management and system support, including analytics and reporting, in order for the frontline team to identify and work on top priorities to continually improve their own performance.

Benefits for midwives and patients All TBT midwives receive supportive supervision as they regain their confidence to work independently, in a team. This enables each midwife to care well for, and maintain continuity of care through all phases of a woman’s maternity journey. Consequently, midwives rotate through the antenatal clinic, labour ward, postnatal ward and postnatal clinic, and also become proficient in provision of breastfeeding support, baby immunisation and contraception services.

eSensitive Midwifery Magazine

Issue 44

Home

About Us

Symposium

Magazine

Academy

Membership Packages

Blog

our vision

Sensitive Midwifery and the Sister Lilian Centre sees a world that values midwifery and creates and raises children in a way which liberates the best in each and every individual.

To be leaders in improving midwifery, birth, parenting, health and family life, because families grow the next generation and shape the future of humankind.

Intuition, Integrity, Individuality. We consciously set out to make a difference, with impeccable service delivery and an inclusive approach in all we do.