On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.3 Cape Town Mar. 2011
Maternal and perinatal health
To the Editor: It is encouraging that our very high maternal and perinatal mortality rate has been identified as an important part of South Africa's fourfold national epidemic. I hope that, as the Department of Health sets out to find solutions to the former, it will recognise that some very basic issues need to be acknowledged.
Obstetric care is best delivered by people who have a passion for the care of mothers and the maternal/infant dyad, because success demands the most careful attention to detail, and self-sacrificing work, when attending to obstetric emergencies. Doing such work well consequently imposes a high personal cost on those who engage in it - especially in the public sector. It is very important that their morale is maintained in every way possible, to prevent rapid staff attrition.
However, it is very difficult to maintain high morale when obstetric and midwifery staff are given little control over the patient care process. Before 1996, for example, the advanced diploma midwives and obstetric doctor team in KZN rural hospitals had full authority to evaluate the care given to mothers in all clinics in their district, provide in-service education to correct defects, improve management protocols, and provide full feed-back on all referrals. After 1996, however, that integrated relational structure was replaced with a complete dichotomy in the vast majority of districts in the province. It has subsequently become difficult to make any impression on district care from the hospital level. And the district midwifery service has too often been administered by cadre deployments, who have little passion or skill for their jobs. This is yet another example of the disempowerment of clinicians as a result of burgeoning bureaucracy that has diminished the primacy of excellence in clinical care in the decision-making process of the whole organisation - simply because bureaucrats are not at the coalface of care, and have none of its sense of urgency. This change has slowly crept up on us since the 1980s.
The great majority of midwives who are passionate about their job are passionate about the rights of the fetus. Therefore, in planning improvements in the service, it is important that they are not pressured in any way to be involved in TOPs.
South Africa has superb in-service training manuals for midwifery and neonatal care. Training is desperately needed by the majority of SRNs who did the new integrated course to deliver a high standard of care. We fall down on the implementation of that training in our hospitals. Our experience in KZN hospitals has been that advanced diploma midwives were the best persons to administer those courses. However, they are generally soon lost to the system because they are excellent personnel and, until recently, there has been no career path for them, so they become managers instead.
Training programmes for advanced diploma midwives should therefore be given more prominence, and distance training programmes resurrected. Careful consideration should also be given to dislocating the training of midwives from the overburdened integrated nursing training, and again making it a hands-on, full-year diploma course.
J V Larsen
Private Bag X010