/ 14 August 2011

How SA fails its poor mothers

The birth pangs arrived without much warning at all. They cut through her, forcing her to double up, melting the icy chill of early morning with hot pain. The searing cramps were announcing the impending arrival of 22-year-old Noyise Mtshonisi’s first child.

The young woman wished she had someone to talk to, someone who could ease her terror with confident knowledge, someone who could wipe the salty sweat from her brow. But Mtshonisi was alone. Her mother had left for the city and the neighbours were nowhere to be found.

As the pain intensified she decided to get help. With trembling fingers she put a small baby blanket and a bottle of tap water in a plastic bag and stumbled into the darkness, away from her two-room home near the Eastern Cape town of Hamburg, on the coast between East London and Port Alfred.

The nearest state hospital was more than 50 kilometres away, a significant part of that distance was on a crumbling, potholed dirt road. Mtshonisi’s only hope was to reach the clinic, which served the villages of the area so that the nurse on duty could phone an ambulance. But it was a three-hour walk away.

She struggled over the first hill, across the stony ground, away from the pale sun that was slowly rising behind her. The meandering path took her past the foaming sea. She stared ahead of her, focused on the ground, praying to God to spare the life of the burden straining to burst her belly.

For what seemed a great distance, two seagulls followed her, screeching above her head. She asked herself: “Are they warning me about something?”

Halfway, when the labour pains intensified, Mtshonisi rested for a while on a flat, rust-coloured rock. The pains were now much closer together. She took great gulps of water from the bottle. She clutched her stomach, closed her eyes and pleaded to the sky: “Father, help us. Don’t forget us.”

‘Help me …’
Hours later Mtshonisi reached the clinic. Soaked with perspiration, her legs almost lame, she buckled on to the first chair she saw. To no one in particular, she croaked: “Help me, my baby’s coming.”

A middle-aged nurse ambled slowly to a telephone and called for an ambulance. If the woman felt any sympathy for Mtshonisi, she didn’t show it. Rather, the nurse seemed extremely irritated — angry even, at the patient’s arrival.

After all, the nurse was expecting to shut the clinic very soon — promptly, as she always did, at 4pm every week day. But now this intruder had invaded her space, threatening to delay her journey home.

Without a helping hand, the scowling sister ordered Mtshonisi up on to a high steel bed. Then, the nurse began beating her, hard, on the sides of her buttocks. The woman answered Mtshonisi’s agonised screams with screams of her own. “This will make the baby come faster. Now shut up and push,” she shouted. “Sukudinisa umntwana (you’re making your baby tired), come on. Push harder and faster!”

A little more than an hour later, Mtshonisi’s baby boy, Kanyisa, entered the world. She clutched him to her chest.

“Is my baby healthy?” she asked the nurse. But the woman was already gone.

The ambulance had still not arrived.

Soon, hunger pangs replaced Mtshonisi’s birth pangs. She hadn’t eaten anything the whole day and the nurse had not offered her any food. When the nurse finally reappeared, it was to bark at her: “The clinic is now closed. You must leave.”

Mtshonisi didn’t have the strength to argue. She stood up slowly and wrapped the whimpering Kanyisa’s naked body in the small blanket that she’d remembered to bring with her and folded her arms around him. An hour after she gave birth to him, she shuffled back towards the hills she’d crossed to get to the clinic.

“I was so very, very sore and tired,” she said, tears springing to her eyes at the memory.

“I was scared, because I was alone. All sorts of things ran through my mind, about what could happen to my baby — But what choice did I have? I had to just do it; I had to make it back home.”

Mtshonisi stopped a few times to breastfeed Kanyisa, and to rest. When she arrived home later that night, she was dehydrated and “close to unconsciousness” from fatigue.

Fortunately, her mother was home. She handed her baby to the shocked woman and passed out on her bed.

Possible peace
Two years later Mtshonisi was again pregnant. This time she was prepared, she thought. When she went into labour one afternoon, she sent her mother to the local police station to ask the officers there to call for an ambulance. The hospital would surely listen to the police and send an ambulance, she thought, and soon she would be somewhere where she could give birth “in peace,” surrounded by “professional” nurses.

But when her mother returned from the police station more than an hour later, no ambulance had arrived and about three hours later, when Mtshonisi gave birth to a baby girl, Nqophisa, there was still no sign of the vehicle.

“It was chaos,” Mtshonisi said. “Neither I nor my mother knew what to do to deliver a baby. Fortunately, a neighbourhood woman knew a little.”

The neighbour’s strategy to deliver the baby was simple: throw a few blankets on the floor, order Mtshonisi to “lie down”, and tell her to “push” until the child was born. There was no toilet in the house and Mtshonisi therefore had to relieve herself on the blankets. “I wanted to feel like someone special,” she said. “Instead I felt so worthless and humiliated, lying there in my own waste.”

The traumatic, degrading births of her first two children were still fresh in her mind when Mtshonisi fell pregnant again last year. This time, the thought of relying on an ambulance or a state clinic to help her didn’t cross her mind. As well as her own experiences, she was haunted by stories of all the mothers and babies in the area who had died as a result of a lack of proper care during birth.

Mtshonisi wished she could afford private care. But she knew that the R600 she earned every month as a part-time domestic worker and the R260 government child grant she received would not come close to funding this.

A friend then told her about “that light-blue house” in Hamburg, on the only tarred road in the holiday hamlet. Mtshonisi remembers her friend telling her: “It opened in October last year. It’s run by a strange woman from Cape Town; everyone was scared of her at first but now it seems as if she is okay.”

It didn’t take her long to make the journey into town. But when the woman with the long blonde hair opened the gate of the blue house and greeted her enthusiastically in isiXhosa, Mtshonisi was taken aback. “My heart beat fast,” she said. “But then, when I sat in that house, I started thinking: ‘This is my dream coming true. This is a proper birth house; this woman knows what she is doing.'”

In the simple house she saw two bedrooms, “proper bedrooms with double beds, soft mattresses and thick cushions”, a lounge, a kitchen and — “best of all” — a bathroom with a shower and a toilet. “And it was all clean,” said Mtshonisi.

She carefully posed a question to the white woman who was smiling at her. “I asked her: ‘Is this the place where women give birth?’ Then Nomzamo [midwife Karen Clarke] nodded: ‘Yes, in the main bedroom.'”

The inhabitants of the cluster of impoverished villages surrounding Hamburg refer to Clarke by a Xhosa name — Nomzamo, which means “the one who tries”.

Having worked for years delivering babies in Khayelitsha and Gugulethu, Clarke identified a need for her services in the Hamburg district and, without any external funds and only her own limited resources, promptly moved there.

Now, when pregnant women in the area go into labour, the first — and often only — call they make is to her. Clarke immediately fetches them in either her tiny Toyota or her “gear-box challenged” Subaru 4×4, depending on how rough the terrain is. She takes them to the blue house where her assistant, Nomvula Gxaka, makes them comfortable. They’re allowed to bring a friend or a family member along for support and all are welcome to sleep over the night after the birth.

Visiting the birth house
When Mtshonisi first arrived at the blue house to consult Nomzamo, the midwife examined her thoroughly and told her that she was three months pregnant. After this, she visited the “birth house” for regular check-ups.

“It makes such a big difference to mothers if there’s continuity and if they know you well by the time they give birth,” said Clarke. “They are so much less afraid and they have much more confidence.”

When Mtshonisi was about to give birth to her third child, Luko, she started perspiring as she went into heavy labour. The patient and soft-spoken Gxaka wiped Mtshonisi’s face with a cold, wet cloth and waved a handheld fan over her.

Clarke massaged her when her back pain became unbearable and held her hand. The midwife and her helper gave Mtshonisi water and fed her a hearty meal of meat and vegetables. “I could go to the toilet in private. There was no one screaming at me and hitting me, no one making me feel guilty about wasting their time because my baby was taking long to come,” said Mtshonisi. “I felt like a human being and not like a machine that was just being forced to push out a baby like a piece of concrete.”

According to Clarke, giving birth is one of the “most terrifying” ordeals a poor woman in the Eastern Cape can experience, especially in rural areas. She said nurses at local state facilities often hurl insults at the pregnant women, “screaming stuff like, ‘lie on your back and look at Durban’ and ‘shut up! You’re bothering us’ and ‘you didn’t shout when you made this baby, why are you shouting now?'”

Clarke said nurses frequently physically assault the women before, during and after they give birth. “They often turn their backs on women who are in pain,” said the midwife. “It’s not just the clinical skills that are missing, but the ethos of care.”

In the bigger state hospitals, Clarke said, “there’s so much anonymity, they’re like birth factories and that decreases the level of accountability so much … their actions get lost in the maze. No one follows up on any complaints.”

Whether an ambulance arrives for a woman in labour is often the difference between life and death. “Time is everything,” said Clarke, when there are birth complications or when a mother is HIV positive and she and her baby need antiretroviral medication as soon as possible to prevent the baby becoming infected with the virus.

Statistics
Department of health statistics show that about one in three pregnant women in the Hamburg district is infected with HIV, but Clarke is convinced that the figure is higher. “More than half the women I see are infected with HIV,” she said.

“It’s a tough life here and people are very aware of death,” said Clarke. One out of every three mothers she’s come into contact with has lost a child younger than two, she said. Nokuzola Mvaphantsi’s (29) one-year-old son died recently of pneumonia. She and her family tried their best to save him, scraping money together to take him to the nearest hospital.

“He was in and out of that hospital,” she said. “Whenever we got there, the nurses would tell us, ‘The doctor is on his way’, but the doctor never came. Instead there were just student doctors … Eventually he died.”

Mvaphantsi still thinks about his birth, the trauma of which she partly blames for her baby’s death. “It was in the early hours of Christmas morning. We called for an ambulance at 1am, but it only came at 6am. The boy was born at 3am, right in my house.”

The unexpected birth sparked a crisis. No one was sure what to do. They wrapped the severed umbilical cord, the placenta and the baby in a blanket. The ambulance paramedics took Mvaphantsi and her child to the nearest hospital.

But it was Christmas morning. The nurses were “very late” in getting to work. “They ignored me. They first ate Christmas lunch,” she said. The mother and baby, still wrapped in the blanket with the placenta and umbilical cord, waited in a passageway on a wooden bench.

Only at about 4pm, said Mvaphantsi, did a nurse approach her and, she said, the nurse “seemed like she had been drinking” and reeked of liquor. Mvaphantsi said that the nurse demanded of her: “Why didn’t you have your baby yesterday? Today is too late.” The nurse sauntered away.

Mvaphantsi said: “I will never go back to that hospital, no matter what. Because of that hospital, my child never lived a healthy life.”

Eastern Cape
A Human Rights Watch report released recently painted a dire picture of the state of maternal healthcare in the Eastern Cape. Between 2001 and 2007 the province had the highest increase in maternal deaths. It also had — and has — the most children dying under the age of one.

The organisation’s fieldworkers found that much of what has happened in the Hamburg district in recent years is happening all over South Africa. But the report said it is particularly in the Eastern Cape that maternity patients face a “range of abuses” by health workers that “put them and their newborns at high risk of death or injury”.

Although 87% of deliveries in South Africa happen in health facilities, the report highlighted that one out of three deaths was “evidently avoidable”.

Clarke said that although South African nurses have “mostly” passed through the training, which should ensure that they care properly for mothers and babies, there are other “human skills” and materials they lack that prevent them from doing a good job.

“Nurses in state hospitals have become desensitised. Perhaps it’s their way of coping with the overcrowding, work pressure, as well as the lack of equipment and drugs. They have removed themselves from the situation to survive. Their hearts are no longer in their work. They are robots,” said Clarke.

For the most part, she said, instead of “quiet, dignified and careful birth attendants”, pregnant women at public health facilities are confronted with “harsh, hostile and overworked nurses and absolutely no privacy”.

The Human Rights Watch report recommended the appointment by the health department of a full-time “special” officer to oversee confidential inquiries into maternal deaths and that the Human Rights Commission conduct a public inquiry into the abuse of women in health facilities during pregnancy, delivery and after birth.

Clarke said health workers who mistreat mothers should be held accountable. But rather than simply pursuing “cruel” nurses and punishing them, with often ineffective mechanisms, she’s convinced that the establishment of more small birth houses such as her own, which operate within communities, “where everyone knows the nurse and someone will do or say something if she mistreats someone”, offer a more viable, long-term solution to the situation.

Clarke bemoaned the fact that she’s the only midwife in the Hamburg district. “South Africa has a serious shortage of adequately trained midwives. Most so-called midwives working in state hospitals are actually nurses with only six months of training in midwifery,” she said. “This situation is costing a lot of lives —”

In her house across a dry field strewn with broken bottles, Noyise Mtshonisi changes eight-month-old Luko’s nappy. The child falls asleep on her back while his mother washes his soiled nappy. Mtshonisi gazes down the hill, to the almost full graveyard below her home. She knew some of the mothers and babies buried there. She knows she and Luko could “easily” have been there too.

Some of the graves are still fresh with loose dark-brown soil and gravel scattered in heaps around them.

Mtshonisi said, with a sigh: “I am poor, but I am not stupid and I have questions. I would like to ask someone big, someone maybe in the government: Why, after so many years of our suffering, are the conditions in the hospitals around here just getting worse? Why are our lives so cheap?”

She pegs her baby’s nappy to a wire fence, where the wind blows softly. “Pregnant women aren’t asking for much,” said Mtshonisi. “Just small pockets of niceness.”