IN 2005 the earlier apartheid-era Nursing Act was redrafted to provide a ‘democratic sheen’. Gone was the French term ‘accoucheur’, meaning ‘one who assists at birth’ usually a ‘male midwife or obstetrician’. Colonial distinctions between midwife and pupil were instead replaced by several new categories including, ‘midwife’, ‘learner midwife and ‘auxiliary midwife’. No allowance for complementary or Traditional Birth Attendants (TBAs) was deemed necessary by the drafters.
According to the World Health Organisation 22% of all births are performed in the world by TBAs particularly in underserviced areas and rural communities. In countries where TBAs have been encouraged to work in more collaborative ways with formal health systems, and community-based ‘Skilled Birth Attendants’ (SBAs), they were able to overcome the rivalry that existed between them and ‘facility-based staff’.
Historically the role of TBAs is one that has been usurped by the Colonial Authorities. In particular the history of Nursing in South Africa reflects an over-emphasis of Western norms and standards (some would say for good reason), with a resulting centralisation of care and authority, and an undermining and de-emphasis of the power of woman-hood. The result is that not everyone can afford a professional midwife in private practice.
“When programmes used broad participatory approaches to design new models of care which included TBAs, and where TBAs were given clearly defined roles (such as birth companions or interpreters for women during labour and birth) they were more readily accepted …” write Tina Miller & Helen Smith in ‘Seminars in Perinatology‘ (2019).
Where the earlier apartheid Nursing Act (1978) failed to define midwifery, the new democratic version defines “midwifery” as certification, referring ‘to a caring profession practised by persons registered under [the Act], which supports and assists the health care user and in particular the mother and baby, to achieve and maintain optimum health during pregnancy, all stages of labour and the puerperium‘ i.e. six weeks from childbirth.
The act itself is, for all intents and purposes, the self-same colonial framework predicated upon the Medical Model introduced into the country by Western Medicine, with the only exemptions from the aegis of the act, being those actions ‘conducted during an emergency.’ It thus blatantly neglects TBAs and consequently forgets almost a quarter of births occurring in the country (and this tentative figure may be even higher!). In the process these births are effectively rendered invisible by the system and its emphasis on professionalism, under a status quo where traditional midwifery is swept under the carpet.
Enter a controversy
Enter the Traditional Health Practitioners Act, enacted in 2007 to “establish the Interim Traditional Health Practitioners Council of South Africa; to provide for a regulatory framework to ensure the efficacy, safety and quality of traditional health care services; …” An instrument which defines TBAs as” a person who engages in traditional health practice and is registered as a traditional birth attendant,” and thus operating much in the same vein of the Nursing Act, save for its emphasis on registration rather than certification.
The latest controversy regards amateur birth practitioners, lay midwives, radical birthkeepers, traditional birth attendants and doulas (hereafter home-birthers) and at the face, revolves around interpretation of the above two acts, our Constitution and also natural law.
The resulting Carte Blanche documentary “Radical Birthkeeper” proceeds apace without any context other than the Medical Model and seems to suggest that home-birthers should be placed in the same category as back-street abortionists, fraudulent plastic surgeons and all those who wish to provide hospice patients the right to die and dignity in death.
Worse still, the documentary creates the impression that our public health system is abundantly resourced and more than willing to provide professional midwives for gratis, is otherwise supportive of home-birth, in a situation where the infant mortality rate for a professional practice is claimed to be “2 in 20 years” (Carte Blanche) or “Zero” (M&G) and that ‘if only the persons concerned had utilised this free service, all would be well?’ I note too that the days of GPs arriving to deliver home births are long gone.
About 99% of maternal and newborn deaths occur in low and middle income countries, globally amounting to about 500 000 maternal deaths and 8 million peri-neonatal deaths per year. While the trend in South Africa is downward, (if one ignores the past two years), the country still experiences some 12 000 perinatal deaths per year, mainly due to complications of pregnancy, labour and delivery.
The documentary is loosely based on a slightly more informative article published by the Mail & Guardian which raises several issues to do with infringement of the Nursing Act, the subject’s efforts to certify their midwifery practice, the role of Traditional Birth Attendants and the Free Birth Society as well as testimony by Angela Wakeford, a registered midwife. No real stats are provided by either of these contributions.
In 2018 I attended a home-birthing workshop held by the local Muizenberg community, comprised mainly of ‘‘alternative types’ including anarchists, environmentalists, yogis, musicians and a few hippies.
The basic premise of the workshop was that women had been giving birth for centuries sans doctors, and deserved recognition for their contribution to what was essentially a ‘labour of love’. In particular that the birth process need not necessarily involve the medical establishment nor constitute a ‘medical emergency’ and that women had a right to choose both the place and manner in which they gave birth, as indeed they possessed the right to health care and equal treatment in our constitution which was predicated on the rights of the individual to a healthy environment.
Thus women were urged to take control of their lives and to decide for themselves, so too were men, tasked with the duty of making it all possible for women to give birth free of pain, fear and coercion. As Ina May Gaskin, whose battle for home-birthing in the USA, proposed ‘take the fear out of childbirth by restoring women’s faith in their own natural power to give birth with more ease, less pain, and less medical intervention.’
I found the home-birther group incredibly supportive, nurturing, helpful and determined in their efforts to provide a sacred entry into the world for my first-born daughter and certainly one which seemed to provide better odds against the birth traumas experienced by so many of my own compatriots.
Needless to say, on 15 July 2019 my daughter was birthed at our home in my studio on Beach Rd, Muizenberg, to a welcoming committee comprising both mother, doulas and lay midwives after a labour which lasted barely 36 hours.
The cord-cutting ceremony and spirit-raising songs which came shortly after she was gently revived and coaxed into this world instead of being assaulted by doctors and medical personnel was particularly poignant as was her arrival which began shortly after the full moon rose over False Bay.
I began to spread the word of this tremendous life affirming, natural birthing process, in particular the good vibes surrounding an informal DIY network organising within the broader False Bay community.
It is partly because of these prognostications and positive messaging that the subjects of the recent Carte Blanch documentary ‘Radical birthkeeper” and Mail and Guardian article “Radical Birthkeeper behind twins deaths” met a rather tragic fate. An unforgivable situation arose, at prima facie, one created by the home-birther community being referred to a home-birther candidate and vice versa under the pretext of ‘normalisation of sacred birth external to the Medical Model’ and thus apparently a contravention of the Nursing Act of 2005, an act whose framework is essentially a restatement of the apartheid-era Nursing Act of 1978.
Given the prima facie case of negligence in approach and safety by the chosen or appointed practitioner, only matched by the open bias and lack of context of the Carte Blanche documentary – cast within the strictures of the Medical Model, and thus serious allegations of malpractice — there are a number of questions — some criticism and observations which I wish to lodge below. Not because I am involved in home-birthing per se as anything more than an interested and affected party — but rather because I feel it is in the general interests of the community at large, and also that of South African justice, that I raise such questions:
1. Did the couple not attend any similar home-birthing workshop and were they ever pointed out the dangers of home-birthing or coached on what a ‘plan B’ might entail? In particular were they ever informed they were engaging the practice of “Free-birthing” external to the current Medical Model?
2. Given the high infant mortality rate within the broader public health system, in particular the 40% up-tick in maternal deaths and 10% increase in stillbirths reported by SA Health Review caused as a direct result of under-servicing by the public health sector during the National State of Disaster, were any of the documentary claims made about the medical system versus home-birthing factual or even realistic?
3. Given that contrary to the documentary and information in my possession (and confirmed by the M&G), the couple do appear to have utilised the private health system for an early prenatal ultrasound at a medical centre in private practice in Masiphumelele, Cape Town (technician’s name with-held, registration in dispute) but elected to not conduct a follow-up scan, which may have shown the presence of twins in breech position — to what extant are the parents responsible for their choices and why did Carte Blanche fail to report this fact?
4. The question on what effort at all was expended by anyone involved with the couple in the community, by screening out any potential complications, is really one of why were there no efforts made by either candidate home-birther or Carte Blanche to gain access to the medical folder held by the private practitioner and no follow-up scan indicated? (Note: Regardless of the status of the lay midwife, the protocol is surely to open such a folder once the pregnancy is reported?)
5. To what extent were the expectations of the couple realistic given their own status and capacity — their failure to utilise the public health system and the fateful election not to proceed with private health care, and thus apparent failure or inability to communicate the contents of this appointment or a lack of follow-up, to the home birthing practitioner?
6. Regardless of the contested legal status under the Nursing Act, was the approach by the home-birther during the labour process not a demonstration of ‘too radical’ an approach, a too strong belief in ‘nature over medicine’ and ‘keeping space’, rather than an indictment of home-birthing and the Free Birth Society in general?
7. Were there any assumptions created by the couple having attended an unregistered medical centre for a prenatal, which may have led the home birther astray? And was the later failure to ‘open a file” in Retreat not the result of the failure to gain access to the Masiphumelele maternity file in the first place? In addition, how were the four hours which passed between Retreat and Mowbray Maternity, the birthkeeper’s responsibility, given the sanctions already placed on her by the medical system?
In closing, I wish to raise the following observations.
No money changed hands, a fact which seems to have eluded the documentary makers.
The documentary may have the perverse effect of driving home-birthing underground. In fact what the documentary revealed was, that following a previous incident alluded to, the community is to some extant, already operating underground – a result of the colonial-era Nursing Act, (an act which fails to define midwifery as anything more than a certification process and which was merely redrafted by parliament in 2005). The result is that home-birthing is becoming as unobtainable as private health care — narrowing all pregnant women’s freedom of choice and control over their own birthing process.
I have no doubt that with better care, better protocols, knowledge-sharing, freedom from coercion and access to community health facilities, the tragedy could have been avoided and yes the couple deserved better. However, they elected not to continue with private health care, to do a home-birth outside of the regulated system, and thus should equally face the consequences of their actions.
As immigrants, they also deserved more from their adopted community and from the South African health system in general, but as immigrant newcomers, were they also not suffering under a bizarre and fanciful illusion that what was being provided by this adopted community was somehow formalised health care, instead of the alternative, informal and extra-ordinary care it purported to be?
From information in my possession it does seem abundantly clear these individuals viewed their lay midwife, not as a ‘birthkeeper’ but rather as a professional nurse, and yet by the same token, they saw no merit in continuing their care under the auspice of their own private doctor or healthcare technician?
We have all failed here in some way, whether it was due to lack of intercultural communication, language barriers, a failure on the part of the birther community in availing diagnostics or the lack of one individual’s attention to communicating the general premise behind home-birthing:
Elect to give birth in hospital and you hand over your decisions and choices to doctors and the medical establishment. Take control over your own birth-giving and health care and you are left with the consequences of your own decisions.