Head of The Birthing Team, Dr Howard Manyonga, talks about the importance of an integrated maternity care model where obstetricians and midwives work as teams to improve health outcomes and reduce the risk of obstetric liability insurance, which is contributing to pushing practitioners out of practice.

Tell us about your background in healthcare. 

I’m an Obstetrician and Gynaecologist. I specialised in the UK and have since worked extensively in the sexual and reproductive health sector in both the public and private sectors in South Africa. I now work solely in the private sector heading The Birthing Team. My interests have always been in health systems strengthening, i.e. looking at service innovation to improve the delivery of healthcare.

Tell us about The Birthing Team and the issues in maternity care that you are trying to solve.

The Birthing Team offers pregnant women an all-inclusive affordable, end-to-end maternity care programme at a fixed price. Our aim is to close the gap between maternity care in the public sector and the expensive private sector. Our model is based on a team structure where pregnancy and birth are overseen by medical teams made up of midwives, obstetricians, paediatricians and anaesthetists. We believe that when maternity care is delivered by a team versus individual practitioners, the risk of poor outcomes is reduced and the patient experience is also improved. Our team structure is very different to what currently exists in the private sector where practitioners don’t work together as a team and as a result there’s a lack of care coordination.

How many hospitals are you currently operating in? 

Since we launched in 2017, we have become operational in three hospitals – the Netcare Rand Hospital in Berea, Johannesburg, the JMH City Hospital in Durban and we recently launched our third centre at the Netcare Femina Hospital in Pretoria. We’re very excited about this particular site because it’s a mother and child hospital and it comes with a lot of opportunities in terms of scalability of the programme and professional development opportunities for staff.

Your services are capped at a fixed price, what happens in the event of a complication?

Before enrolling a patient into our programme, we do a full assessment which includes physical examinations, blood tests and scans. If the mother has a normal pregnancy with no foreseen health risks, she would not need to pay out of pocket during the course of the pregnancy. In the event that complications arise that are beyond the scope of our team to manage heart disease, for example, then we would transfer that patient to a public facility that can provide the necessary management. Our package includes that you’d be looked after in the hospital where they deliver as well as post-delivery care.

How different is The Birthing Team from other facilities offering natural births, such as Genesis?

There is a fundamental difference between The Birthing Team and a maternity hospital run by midwives. In these facilities, you may find midwives working in a single discipline group. Sometimes when you have a group practice, you have only obstetricians or only midwives working together or only paediatricians, for example. But in our teams, we bring all these disciplines into one team and they charge for services as a team as opposed to the midwives who charge as individuals and have to rely on obstetricians who are making a choice whether to support the midwives or not.

We’ve come to understand that there’s a bit of unhealthy competition for patients between midwives and obstetricians. For example, if a midwife has been looking after a patient for a while and a complication develops the midwife will have to refer the patient to an obstetrician and ultimately lose out financially. This means that if a complication presents itself there is a financial disincentive for midwives to refer the patient on to a specialist. Sometimes they hold on to patients for too long and by the time that the obstetrician is called into the picture it’s a crisis situation already. Independent midwives rely on obstetricians coming at their goodwill because typically there are no service level contracts between the midwives and obstetricians. We do it differently; we’ve got formal contracts, etc.

Has the popularity of C-sections reduced the role of the midwife? If so, has this negatively impacted maternity care?

From speaking to midwives, we’ve come to realise that when they are working within the private sector they are only doing a fraction of what they are trained to do. With lower-risk patients, midwives can give the full spectrum of maternity care from early stages of pregnancy all the way to the post birth six-week check-up. But with the high caesarean rate in the private sector, midwives are restricted to working in the labour wards and have basically become assistants to doctors, preparing patients for C-sections. In a way, that is deskilling the midwives and they end up leaving the private sector to go back to the public sector where they can still practice midwifery or they go overseas where those health systems are better able to extract the value out of midwives.

But if the midwife is looking after the majority of the patients who are not at risk then it frees up the obstetricians to really concentrate on the complicated cases. A typical obstetrician in SA delivers between 13 and 15 babies per month, but when you put them into a team, they can easily supervise the delivery of up to 75 or 80 babies.

The use of caesarean delivery and reliance on obstetricians to offer standard care drives up costs. A midwife might cost, let’s say R200 an hour, but an obstetrician is going to cost up to R2,500 an hour. Right now we’ve utilised obstetricians to do a lot of the midwifery and the midwives themselves do very little midwifery. So in a sense that represents a gross under-utilisation of what essentially a scarce resource at a systems level and that’s a big problem.

What is driving the high cost of maternity care and high liability insurance?

A lot of the high costs are due to structural issues tied to obstetricians working alone and having to schedule elective births because they can’t be available 24/7, as well as the high cost of liability cover, which can reach up to R1 million per annum. This contributes to specialists charging higher fees, making private healthcare unaffordable for non-scheme patients and in some instances even insured patients end up paying out of pocket to cover what the medical schemes don’t cover.

Another consequence of the high cost of practicing obstetrics is that practitioners have to take up a high volume of patients, which comes with its own set of challenges, especially when it comes to documenting treatment decisions and adhering to best practice guidelines. These practice guidelines are developed in teaching hospitals and academic centres and assumes that practitioners are working as a team, which doesn’t hold true in the private sector. Despite best efforts, when obstetricians are working on their own this can inadvertently lead to gaps in care, with higher risks and potentially avoidable complications. There will be missed opportunities in a situation where an obstetrician is compared to a team, because in a team you’re better able to monitor that patient and adhere to best practice guidelines much better than as an individual practitioner. It’s this structural inadequacy that’s driving up costs and compromising quality. The Birthing Team addresses this.

How can better record keeping of medical records reduce malpractice premiums and improve outcomes?

Currently, medical records have to be kept for about 20 years after the birth, which is quite difficult to do with paper records. So when the records are either incomplete or the records have been removed or destroyed, it’s impossible for the indemnity provider to prove that the correct procedures were done and that despite the best effort on the part of the doctor, there were complications. Therefore, the cases cannot be defended and defence lawyers settle rather than go to court. Take the Department of Health (DoH) as an example. The DoH is facing a high number of medical claims suits and one part of it is frankly because the clinical actions can’t be defended because there are no records to prove that clinicians followed standard protocols. Proper record keeping is a key strategy in clinical risk management. To that end, we have developed a workflow system that enables the team to track and perform all tasks and to keep a complete record of the clinical data. Should a suit ensue, we use that data to demonstrate our adherence to best practice, which is really your only defence.

Is that the reason why obstetricians are leaving the practice?

Obstetricians are quitting obstetrics because, among other things, the cost of indemnity is just so high. This may be partly due to poor outcomes and unrealistic patient expectations that have not been properly managed. It’s also quite hard for patients to accept that in some situations things go wrong despite best efforts. Even in the best delivery systems, unforeseeable complications can develop. Some of these only present after birth and it’s quite difficult to figure out whether it was something that happened during pregnancy or during birth. Be that as it may, it is the obstetricians who end up facing litigation. Unless we develop and implement team-based approaches that address the root causes, the system will not change and we’ll continue to lose obstetricians.

Is poor patient engagement driving up some of the high costs in maternity care?

A major patient complaint is that there’s not enough time for the lone gynaecologist to fully engage with the patient. Consultations are quick and therefore there isn’t much exchange of information about birthing preferences and what patients can expect, etc. – its time consuming. Our approach puts the patients at the centre of their own care and focusses on patient education to empower pregnant women to make informed decisions, including reducing unnecessary obstetrician interventions. The educational component in our programme includes antenatal classes where we bring all the expectant parents together as a group and educate them because we really want to manage their expectations.

Managing expectation relies on the practitioners having a relationship of trust with the patient. The best way to build trust with patients is through continuity of care and giving the patient adequate time to ask questions, etc.; these are things that practitioners who work alone and who are under pressure are not always able to do, whereas you can in a team. Our patients spend a lot of time with our midwives and the emotional support that comes from those relationships is what builds the trust and that helps you to manage expectations and to educate the patients. Patient engagement is absolutely critical.

Do you have any future plans that you would like to share with us?

Currently our service is open to uninsured patients, but we are exploring partnering with selected medical schemes to expand our services to scheme patients that prefer to have a team look after them. We’re quite excited with that development. We’re also planning to launch The Birthing Team in a number of facilities in the large metropolitan areas in the second half of 2018. We have quite an exciting pipeline of projects for 2019 which I’ll share with eHealthNews at a later stage.

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