South Africa is one of a few countries in the world where a woman can choose what type of birth she would ideally like to have. It is great that we have a choice, but this in itself can make life more complicated. Therefore, it is really important that you gather all the necessary information before you decide what type of birth would be best for you and your baby. Once you have formulated this idea of what would fulfill your needs, you need to find the right caregiver as well as the right venue to accommodate your choices.

It is very important that you do not allow yourself to be bullied into a specific type of birth that you don’t really want. The birth of your baby is an incredibly important milestone in your life and therefore you need to find someone that you feel you can trust to assist you. Ask yourself the following questions: How did I think I would give birth when I first considered having a baby? How would I like to be born if I could choose?

Guidelines recommend that if you are healthy and having a low-risk pregnancy, the suggested route for birth would be a normal vaginal birth. Should there be complications during your pregnancy or during the birth process, a caesarean section (C/S) may be the best option. Make sure that you are familiar with the valid and questionable reasons for caesarean sections. Reasons like ‘your baby is too big’ or ‘you are going too close/over your due date’ are not supported by evidence as good reasons for a caesarean section, and you should question the ethics and motives of professionals trying to sway you with these.

Always remember that there are pro’s and con’s to each type of birth. You need to look at the whole picture as you make your choices.

Facts and stats

The South African private sector has a C/S rate of 60-90%. Additionally, between 10-30% of normal vaginal births are high tech births with intervention, such as induction of labour, epidural anaesthesia, drip, shaving, enema or episiotomy.

This is a serious reason for concern, since the World Health Organisation (WHO) made the following statement: “There is no justification for any region to have CS rates higher than 10-15%.”

A World Health Report by Gibbons et al (2010) examined and discussed the costs and implications of Caesarean sections worldwide. The annual number of CS performed in each country was calculated multiplying the CS rate by the annual number of births. The number of births was obtained from health statistics provided by UNICEF for the year 2008. This report found the following:

  • The recommended minimum necessary CS rate at population level to avoid death and severe morbidity in the mother, lies between 1-5%, according to WHO and others.
  • According to neonatal outcomes, studies evaluating the association of CS rates with neonatal death, have shown outcome improvements up to a CS rate of 10%.
  • Thus, the minimum threshold for a population level CS rate could be considered to fall between 5-10%.
  • Regarding the upper level, the best known recommended upper limit is 15%, suggested by WHO in 1985. Although these figures are based on theoretical estimates, two recent observational studies support that recommendation. Both studies assessed the association between C/S rates and mortality and morbidity in mothers and neonates, and found no reductions in those indicators when frequency of the caesarean section was more than 15%. Moreover, one study showed that an increased rate of intervention was associated with higher mortality and morbidity in mothers and neonates.
  • Until further research gives new evidence, rates higher than 15% may result in more harm than good.

Birth options in private sector

Many women do not realize that there actually are three types of birth from which they can choose in private sector:

  • Normal vaginal birth:   usually done in a hospital’s obstetric ward with an obstetrician (in private hospitals) or by the hospital staff (public sector hospitals)
  • Caesarean section delivery:   with an obstetrician and paediatrician in theatre
  • Natural birth (including water birth): usually takes place in an active birth unit, a freestanding birth centre or at home, with a midwife.

The following professionals can act as birth attendants, and whom you choose together with which venue will play the biggest role in how your birth takes place:

  • An obstetrician: in order to deliver in a labour ward in a private hospital you will need an obstetrician. This is a doctor that has specialized in obstetrics. He/she will provide your antenatal care during pregnancy. In labour you will be cared for by the hospital obstetric nurses, and they will phone your doctor once it is time for you baby to be born, who will then come and do the actual delivery.

Here and there some hospitals may have general practitioners (GP’s) who have a diploma in obstetrics or just in general family practice but do not specifically specialize   in obstetrics, who will conduct deliveries. This is more common in smaller towns where obstetricians may not be available and typical of how things used to be in your parents or grandparents’ time. These GP’s are usually very positive about natural birth and have good experience.

  • Obstetric nurse/midwife in hospital: these ladies (and occasional gent!) look after women in labour, under the guidance of an obstetrician, as described above. They will mostly not conduct the delivery but will provide the care in labour. A growing trend in South Africa is for private hospitals to provide a service where a woman can delivery with the staff on duty at the time, with an obstetrician just on stand-by. Not many hospitals have this service available yet.
  • An independent midwife: In this case your midwife is the main care provider during your pregnancy and birth, with an Obstetrician/gynaecologist on stand-by should a complication occur.

The following venues are available for giving birth:

  • A hospital labour ward: this will be the option used if you deliver with an obstetrician, general practitioner or obstetric nurse in a hospital, whether you choose a normal birth or a C/S.

If you deliver with an independent midwife you can choose from the following:

  • Active birth unit: usually linked to a hospital, so while it looks more homely, a theatre and neonatal ICU are available should these be needed.
  • Free-standing birth units: These are facilities not affiliated with a hospital in which low risk women can give birth in a more homely setting. Our Birth House falls into this category and aim to provide what its name says – a house for women to give birth in! Our beautiful, relaxed environment and a lovely garden provides an ideal setting for your body to do what comes naturally: give birth to your baby.
  • Home: An option for women who live close enough to our back-up hospitals and who have low-risk pregnancies

Birthing with a midwife

A private midwife is usually employed if a couple wants to have a natural birth, as they are specialists in natural birth. Birth is done using minimum intervention, and then only if really necessary and beneficial to mother and baby.

You will see the same midwife throughout pregnancy that will be involved in your birth (if all goes according to plan), and will have a very special relationship with her by this time. She will have time to get to know you as a couple, understand your wants and needs, your special concerns, your support structure and the motivations behind the decisions you make.

Birth is done in a way that supports the body’s natural and amazingly effective processes, and your midwife will assist you in pregnancy already to prepare for the event and to set a birth plan. Even though she will not be able to guarantee that your birth will go exactly according to plan, she will do everything in her power to assist you. Since she has a relationship with you and has gotten to know you and your partner over the past months of pregnancy, she will have a personal interest in ensuring that your birth is a positive and natural experience, the way you planned it to be.

Your midwife will also assist you with choosing and setting an environment in which you feel completely comfortable and safe. This makes a tremendous difference to a laboring woman’s experience as one’s hormones function optimally in this type of environment. You will be encouraged to bring along something of your own, e.g. you own candles, comfy clothes, or whatever else you feel is necessary to give your surroundings your own personal touch. You may also bring along those you want to share this unique experience with – your husband, your mom or a sister, whoever you feel will be able to support you through labour and birth.

While subtle monitoring of you, your baby and the progress of your birth will be done throughout labour to ensure the safety of you both, intervention will be kept to the bare minimum and there will be no routine procedures, unless medically indicated. This will be discussed with you in detail and the entire birth process will be handled by a team of which you will be a part. By providing you with the correct information, your midwife will make it possible for you to make your own informed choices regarding this very special event.

Your midwife will remain with you throughout the birth process, from the beginning to the end. After the birth, you may choose to either go to the postnatal ward (if in a hospital or birth unit), or to go home, providing all has gone well with the birth.

Your midwife will then come to your home to do follow-up visits during the week following the birth. She will also see you at regular intervals during the first 6 weeks of baby’s life, to ensure that you are healing, breastfeeding is going well and that you are coping both physically and emotionally.

Conclusion

There isn’t one correct way to give birth, and you are the only one that can decide what is best for you, your baby and your family. Studies have shown that a woman’s satisfaction with her birth outcomes are linked less to the outcomes, and more to whether she feels she was actively involved in decision making. The WHO states that low-risk pregnant women have better outcomes under a midwifery model of care.

At Midwives Exclusive we certainly cannot promise a successful natural birth. However, we can help you ensure that you are doing all you can from your side to make it happen and, in case intervention becomes necessary, we can offer you the information, support and care to ensure that it still is a positive birth experience.

Gibbons, L; Belizan, JM; Lauer, J. Betran, AP; Merialdi, M; Althabe, F. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage World Health Report (2010) Background Paper, No 30. Available at: http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf (Accessed: 03 February 2015).