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.