“The night President Ramaphosa announced the lockdown, I was exactly four weeks away from giving birth. I suffered anxiety, instantly. As the numbers of South African infections started to rise, my anxiety intensified. When I got pregnant, I stopped taking my meds for anxiety and depression because I did not want to affect the baby. I suffered two serious panic attacks in one week. The father of the baby left early in the pregnancy.”

There have been many reports about the impact of Covid-19 on people’s lives. Much emphasis is put on the number of infections and the impact of the virus on the economy. Little focus has been put on the impact on maternal and child health.

An interview with a young woman who had recently given birth by caesarean section in a private healthcare facility revealed intense anxiety about the impact of lockdown regulations on pregnant women.

“The fact that nappies were initially not classified as essential goods was even more stressful. I did not have the money to buy nappies in bulk. I am a first-time mother; I am buying nappies for the first time. I asked my friends to give me cash so that I can go and buy nappies in bulk. Later, when this was changed, baby clothes were not included. That is when I thought I will just wrap my baby with a blanket. Maybe his story will be one of a pandemic newborn baby wrapped up in a blanket.”

The UN estimates that over 130 million babies are born worldwide every year. Stats SA reported more than one million births in South Africa in 2018. This was a 2% increase from 2017.

To ensure that maternal health is prioritised as one of the key global health indicators, the UN Millennium Development Goal 5 was used to call on countries to reduce maternal mortality by three-quarters between 1990 and 2015. Like many other countries, South Africa failed to reduce its mortality rate. Women are still dying in childbirth even though an increasing number of women give birth in hospitals.

The basic prerequisites for maternal health such as nutrition, shelter, income, education, access to water and sanitation as well as freedom from violence are far from being realised. One positive thing about Covid-19 is that it reveals the failure of government to address poverty and inequality in the past 26 years. President Cyril Ramaphosa admitted to the failure of government in his “From the Desk of the President” note dated Monday 20 April.

“Yes, there are the residual effects of a fractured and unequal past. But they are also a fundamental failing in our post-apartheid society. The nationwide lockdown in response to coronavirus has gravely exacerbated a long-standing problem.”

Being pregnant with compromised immunity, in an unequal society during the time of Covid-19, increases the risk of affecting birth outcomes adversely. Adding the high rate of teenage pregnancy in South Africa complicates the matter further.

It is too early in the evaluation of Covid-19 to determine its impact on pregnancy. The Sars epidemic of 2002/3 which affected more than 8,000 persons in several countries resulted in maternal deaths, miscarriages, and preterm labour. Before then, there were other viruses in past epidemics which were found to be teratogenic. A teratogen is a physical, chemical, or infectious agent associated with functional birth defects, growth retardation, including other adverse effects on pregnancy such as miscarriages.

A review of medical records of women who gave birth in hospitals in Wuhan, China after they had been infected with the virus reported no adverse pregnancy outcomes. Similarly, none of the babies tested positive. The same results were found in the US in a sample of positive pregnant women who gave birth at the Medical College of Georgia. They too revealed no evidence of intrauterine transmission. Researchers have, however, issued a caution about the probability of transplacental transmission on the basis that current findings are based on a small sample of women at a time when the world knows little about the pandemic.

The youngest case of Covid-19 is a newborn baby who tested positive in the UK. The mother only got her positive results after delivery. It is not known whether the baby contracted the infection during pregnancy or labour.

Since December 2019, Covid-19 has spread to many countries across the world, infecting over two million people. Naturally, pregnant women and their families have been experiencing heightened anxiety and stress. Many of them are concerned about the safety of delivering in hospital. In her response to the impact of the pandemic on birthing, Stephanie Nel, the executive director of the Doulas Association of South Africa, confirmed that this time is stressful for pregnant women.

“This time is filled with deep uncertainty and being pregnant comes with added stress. For many women, the birthing journey will now have to be done alone. Due to changing policies, many pregnant women have to go to their check-up appointments and birthing alone.”

This was the case with Gemma Walker, a 27-year-old woman in New Zealand. Two weeks before her due date, her midwife told her she could not help with a home birth if she was not provided with protective gear. Walker decided to go through her birth process at home, assisted by her partner and mother. The baby was born in her amniotic sac on the floor of their lounge.

Because of the risk of being infected in hospitals, many women are reported to be resorting to home births. A New York midwife who normally takes about 80 clients a year reported more than 100 inquiries in one week. Similarly, online enquiries at the New York Homebirth site increased by about 300% with pregnant mothers asking about bookings for May and June.

The resurgence of home births rekindles the debate about the medicalisation of childbirth which started when countries promulgated laws that prohibited midwives from practising without the supervision of medical practitioners. This move has been criticised by feminists who argue that the replacement of midwives, who are largely women, by obstetricians, who are mainly men, is a way of reinforcing the medical model of childbirth.

A move that upheld medicalised obstetrics at the expense of midwifery replaced natural birth with a technological and interventionist birth practice. The number of women giving birth by means of caesarean sections has since grown phenomenally. Records of women who tested positive both in China and the US reveal that more than 80% opted for caesarean section birth as a way of reducing the transmission of the virus.

South Africa has one of the highest rates of caesarean sections. There is therefore a possibility that the pandemic can be used as an excuse to perform more caesarean sections even when there is no medical indication for the procedure.

“My initial wish was to have a home birth, but I didn’t know where to go to find a midwife. I then went to hospital. Even then, my plan was to have a natural birth. I did not have support and my mental state was unstable. At first, they said my partner could come to the labour room. I told them I am a single mother, but they would not listen. It is government policy, I was told, only your partner or husband can be there. In a few days, the rules had changed, no one was going to be allowed.”

It is unclear how hospitals will cope with birthing during the time of Covid-19. Some hospitals have come up with strict measures that are meant to limit the transmission of the virus. These include cutting down the length and frequency of in-person antenatal visits, banning spouses, doulas or birth partners in the labour room, adhering to a no-visitors policy, wearing protective clothing as well as isolating the baby from the mother at birth.

“I had asked that my mother come with me, they told me to email head office and ask for permission. When the doctor suggested that I have a caesarean section, I had no option but to agree. Fortunately, my mother was there but she was told to leave as soon as I came out of surgery. The most challenging thing after birth was registration of the baby. We are given 30 days to register the baby otherwise we are fined. Home Affairs is not an essential service. Their services are not available in hospitals. Now I am expected to go to Home Affairs offices. I am breastfeeding, I can’t walk because of the pain of the operation. This is my first baby, I don’t even know what to do… I am recovering from so many shocks.”

In view of the emerging new normal practice of birthing that is not tied to the hospital as the only place of choice for pregnant women, it will be interesting to see if countries will be willing to invest in non-hospital sites of delivery such as birthing centres and home births. Included in this is the revitalisation of indigenous practitioners who were suppressed by the colonial, patriarchal, and profit-driven medical model of birthing.

The question of an inadequate number of midwives to attend to pregnant women at a delivery site of their choice is a major challenge because it brings in the question of models that allows a collaboration between midwives and traditional birth attendants. Even though traditional birth attendants are legal in South Africa, their knowledge and practice have been wiped out by apartheid and post-apartheid health policies. This, despite the fact there is enough evidence that western medicine can be reconciled with traditional health care practices.

A review of more than 50 years of global birth activism has demonstrated that medical birth interventions will not reduce maternal mortality sufficiently without a bi-directional collaboration with indigenous midwives. Considering that both have value in the management of pregnancy, labour and postnatal care, it is important that we formulate post Covid-19 strategies that harvest their respective strengths.

In my search for local interventions that speak to the reality of African women, I visited several Africa-based midwifery sites, including the Society of Midwives of South Africa. The society has uploaded guidelines developed by the Royal College of Obstetricians. It comes as no surprise that such guidelines do not cater for the needs of the lives of the majority of women in Africa. For instance, pregnant women who require self-isolation are advised to stay at home, to separate from other household members and to refrain from using public transport when they travel to and from health institutions.

Just like any kind of crisis, the current pandemic opens possibilities for legislative and policy review of birthing practice in South Africa. On one hand, there is a concern that the pandemic may be used as an excuse to increase the rate of caesarean section births even when this is not necessary. On the other hand, the increasing number of women birthing safely at home may be confirmation that medicalised birth is not so much about women’s safety but profit maximisation in a healthcare system which has become unaffordable and inaccessible for the majority of pregnant women. While we congratulate Health Minister Dr Zweli Mkhize and his team in the way that they communicate about curbing the spread of the transmission, what is urgently needed is comprehensive and holistic guidelines on how to manage pregnancy, labour and postnatal services in and out of hospital settings. DM

Mmatshilo Motsei is an author, healer, and birth activist with a keen interest in integrating indigenous and contemporary solutions as a response to modern-day developmental problems.