1. Outcomes of births attended by private midwives in Gauteng, South Africa C Jordaan CS Minnie 24 August 2017 SOMSA Conference, Klerksdorp, NWP

2. Learning objectives After attending this presentation the attendee will be able to:
describe the outcomes of births attended by private midwives in Gauteng over a two year period and
compare these outcomes with the latest Cochrane review on midwife-led care (Sandall et al., 2015).

3. Background
Continuity, choice and control are globally recognised as important factors for quality care during pregnancy and childbirth.
Women should have the right to choose the type of care they prefer, including midwife-led care.

4. Background (cont.)
The obstetrician-led model of care is dominant in the private sector in South Africa.
Private midwife-led care is available in South Africa.

5. Type of midwife-led practices
Solo-practices
Partnerships
Group practice
Caseload (one-to-one) or team approach from early pregnancy until the postnatal period.

6. Private midwives provide care at their own consulting rooms (birth house), women’s homes, some private hospitals or facilities focussing specifically on midwife-led care.
One such midwife-led facility in Johannesburg, Gauteng, is a freestanding birth centre hosting at least 20 independent midwives.

7. The private midwives in Gauteng established, the Private Practicing Midwives’ Alliance (PPMA).
Meetings to develop protocols; discuss case studies and talk about challenges.

8. Midwives Exclusive as example of midwife-led practice
Ons kan teks hierinsit om te verduidelik hoe dit werk. Ek dink dit sal goed wees as jy dit doen Christel, anders sal jy my mooi moet vertel wat om te sê. Ons kan ook nog ‘n skyfie of 2 insit met teks – ook oor Private Midwives organisasie en Genesis as jy dink ons moet.

9. Problem statement
Questions are often asked about the safety of midwife-led care.
There was no evidence on the outcomes of births attended by private midwives in the Gauteng area.

11. Sandall et al. (2015) combined findings regarding outcomes of midwife-led births compared to births attended by other practitioners - 15 trials involving 17,674 women.
We could not get access to information of outcomes of births attended by other practitioners.
Therefore we compared outcomes of midwife-led births in Gauteng with the outcomes from Sandall et al.

12. Objectives The objectives of this study were:
to explore and describe the outcomes of births attended by private midwives in Gauteng over a two year period and
to compare these outcomes with the latest Cochrane review on midwife-led care (Sandall et al. 2015).

13. Method
A retrospective cohort design was selected to audit the birth registers of private midwives in Gauteng province after ethical approval was granted.

14. Data-collected in audit
Data was collected using Sandall et al. as framework:
According to practice
Compared with findings of Sandall et al.

15. Data-collection instrument

21. Data-analysis Type of analysis
Descriptions of births according to practice Hierarchical linear modelling was used as each midwifery practices was analysed as a separate unit of analysis with unique characteristics.
Comparison between the outcomes of the Gauteng group and the midwife-led group from the Sandall et al. (2013). Outcomes were considered significant if the results from Sandall et al. fell outside the calculated 95% CI of the Gauteng sample.

22. Realisation of sample 1724 births during 2012 and 2013
14 midwives in Gauteng
8 different midwifery practices

23. Highlights of description of sample
Each practice has different referral criteria and patient demographics.
All refer women to a medical practitioner or hospital if they develop serious complications such as preterm labour or have medical conditions outside of the midwife’s scope of practice.
Some of the midwives work closely with their backup obstetricians and will conduct co-managed care for women with specific risk factors such as VBACs.
Christel, sal jy hier ‘n paar hoogtepunte insit oor die eerste deel – beskrywing van die praktyke

24. Key findings
Compared with the Sandall et al. (2015) review, the births attended by midwives in private practice were:
less intervention driven with
less medication use in labour and
had no more significant risks to the mothers and infants.

25. There were 3 negative outcomes
higher caesarean section rate (19.3% vs 13.3%),
0.5% higher percentage of postpartum haemorrhage and
0.6% higher percentage of Apgar scores of 7 or lower at 5 minutes
Latter two differences were not statistically significant
Caesarean section in Private practice in SA is xxx

29. Conclusion
As a whole the outcomes of the Gauteng births compared very favourably with the outcomes as reviewed by Sandall et al. (2015).
The outcomes of private midwife-led care in Gauteng compare well with the rest of the world, especially since the private health system in South Africa is generally intervention-driven.
Low risk women in Gauteng can safely select midwife-led care.

30. Sandall J, Soltani H, Gates S, Shennan A, & Devane D. 2015
Sandall J, Soltani H, Gates S, Shennan A, & Devane D Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD DOI: / CD pub4.

31. Any questions?