Social protection for pregnant women: There are those who are trying to make births better
It begins with a positive pregnancy test, but what does it actually mean to have a positive pregnancy or a positive transition to motherhood? Daily Maverick speaks to some of the women trying to make births better.
For many parents, a wanted positive pregnancy test is met with feelings of both excitement and uncertainty. The journey from positive pregnancy test to a positive experience pregnancy, labour, birth and motherhood is not necessarily a simple one for the nearly one million women who fall pregnant in South Africa each year.
The World Health Organisation (WHO) defines a positive pregnancy experience as having four elements – physical and sociocultural normality, a healthy pregnancy for mother and baby, an effective transition to positive labour and birth and achieving positive motherhood.
“Every pregnant woman wants the same thing – a safe pregnancy, free from worry and anxiety, and the delivery of a healthy baby. However, this is not the case for many South African mothers,” explains Nonkululeko Mbuli, communications and advocacy strategist for Embrace.
“In addition to having to contend with financial stress, food insecurity and malnutrition, housing concerns, inequitable access to quality antenatal/perinatal/postnatal care, lack of access to credible maternal health information, maternity-related discrimination in the workplace and the absence of maternity protection, relational or family issues, and pregnancy complications, expectant mothers are often without the social support and connection they need to have a positive pregnancy, birth and early motherhood experience.”
But there are women like Mbuli working to make sure that this changes, and to increase the chances of a positive experience by supporting mothers’ sense of control over their birth experience, their access to support networks, and their financial security.
Relaxing into birth with hypnobirthing, a doula and a midwife
The evidence to support the importance of a positive birth experience is clear, as a previous Daily Maverick article on pregnancy and motherhood during Covid explored.
Part of this is ensuring continuity of antenatal care. Antenatal visits are vital to reducing both maternal and neonatal morbidity and mortality by providing the necessary support to at-risk mothers, and ensuring they get the referral to services they need. Although the WHO recommends eight antenatal care visits during a pregnancy for continuity of care, and South Africa recently shifted its Basic Antenatal Care training package for medical workers to recommend the same, statistics show that only roughly three quarters of pregnant women (76%) met the former target of four visits, often only late into their pregnancy when health risks have already developed or have gone unaddressed. Data from NIDS-CRAM shows that Covid-19 also negatively affected women’s access to antenatal care, as many mums stayed away from health facilities due to economic inability to travel or fear of getting Covid.
Many mothers thus rely on infrequent, sparse or short health visits to give them enough information and support throughout their pregnancy. Gaps in care arise, as does room for misinformation, which can leave mothers feeling like they’re navigating their pregnancy alone, or can lead them to rely on information sourced online.
Two women trying to address these gaps and to focus on the positives of pregnancy, birth and motherhood are Charlene Yared West, doula and founder of the Relax Into Birth Online Hypnobirthing Course, and Karen Wilmot, professional nurse, midwife and founder of the Virtual Midwife site.
(For readers unfamiliar, a midwife is a trained medical professional that has the skills and knowledge to offer routine antenatal appointments throughout pregnancy and to deliver her baby. A doula is a non-medical skilled birth companion, there to walk the mother through pregnancy, labour and birth, and to assist with mental, emotional support and wellbeing. Yared West explains this in simpler terms: “a doula attends to the ‘upper half’ of the mother, and a midwife attends to the ‘lower half!’”)
In 2020, the two launched a podcast to respond to common queries from expectant mothers. They also launched an online course called Relax Into Birth PLUS, which includes 105 lessons covering hypnobirthing breathing techniques, combatting fear during birth, tools for a relaxed labour and information on the physiology and biology of labour and birth.
“Our course is for couples who want to take a proactive approach to their birth and who believe that the birth experience is extremely important, with lifelong effects on mom, baby and the whole family,” says Wilmot.
In South Africa, most births happen in a health facility and nearly all deliveries (97%) are assisted by a skilled health provider, much higher than World Bank estimates for East and Southern Africa (65.5%) and West and Central Africa (55.1%). In South Africa, most births have either a nurse or midwife present (68%), with only three in 10 attended to by a doctor (29%).
The WHO guidelines on positive pregnancy acknowledge that, whilst access to medical care during pregnancy is undoubtedly valuable, “the increasing medicalisation of childbirth processes tends to undermine the woman’s own capability to give birth and negatively impacts her childbirth experience. In addition, the increasing use of labour interventions in the absence of clear indications continues to widen the health equity gap between high- and low-resource settings”.
In essence, pregnancy and birth can become pathologised, causing stress and anxiety for expectant parents and leaving them with the sense that they are not allowed to ask questions, are not in control of their birth or are not allowed to ask for what they want.
Wilmot explains that this is why their Relax Into Birth PLUS course includes information about how to navigate the hospital system, including “understanding interventions that are available, why they might need them and techniques to learn and practice during pregnancy to avoid unnecessary medical interventions. This includes how to ask the right questions and how to have potentially uncomfortable conversations during antenatal consultations to make sure you and your doctor are on the same page before you go into labour”.
For those using the private sector, Wilmot and Yared West have a specific podcast episode exploring how to know if the gynae they’ve selected is right for the birth they want.
The WHO guidelines emphasise the importance of this ability to choose, specifying that quality care doesn’t only mean the provision of technically competent medical care, but care that enhances women’s experience of pregnancy and childbirth. This includes communication that is clear, care that is delivered with respect for women’s dignity, choices, and autonomy, and the availability of social, emotional, and practical support.
In Wilmot’s words, “True satisfaction about the birth experience is not about how your baby is born, but how you feel about the way your baby is born.”
Yared West further explains that this sense of trust in the care she’ll receive on the day of delivery is critical for the physiology of labour, not just for the sense of mental wellbeing.
“The delicate balance of hormonal flow during labour can be affected if they are afraid… fear can affect the uterus and the working thereof. As a doula, I work towards dispelling fear around the birth. I’m passionate about ensuring that women feel confident and calm about their upcoming birth and know how to use hypnobirthing as a very practical tool to have a better birth, no matter what turn it takes.”
Helping mothers embrace motherhood, one day at a time
Often, after the birth, focus and attention shifts away from the mother’s wellbeing to the wellbeing of the baby. This may mean that mothers’ struggles and challenges – whether they are physical or mental health related – are missed, downplayed or ignored.
An estimated six in 10 mothers in South Africa are parenting their children alone, and four of these are under the age of 30. Between 30 and 40% of new mothers in South Africa are affected by postpartum depression. Finding communities of support, information and belonging during the postpartum time and throughout parenthood is vital to a positive transition to motherhood.
Embrace is a social movement that started in Cape Town in December 2013 in response to the lack of social support available to families raising young children who were located in some of the most vulnerable and marginalised parts of the city. Funded by the DG Murray Trust, the objective was to set up a network of support for parents and caregivers of children in their first 1,000 days of life. What began as a city-wide initiative has grown into a national movement that connects mothers across the country’s racial, socio-economic and geographic divides.
“Representation matters and when mothers are constantly bombarded with images in the media, in popular culture and on social media of always smiling, always happy, perfectly capable mothers, it creates unrealistic expectations of what motherhood should look like and when internalised, mothers who can’t live up to these impossible standards are unable to enjoy a positive experience of the transition to motherhood,” explains Mbuli.
“[At Embrace] our vision is for South Africa to become the best place to grow into motherhood, where the power of mothers is realised in terms of social, economic and political life,” says Mbuli.
“We have three focus areas, namely, birth, breastfeeding and belonging, and we aim to broaden the public discourse in a way that demystifies birth and supports the building of a continuum of care for breastfeeding and carefully considering social connectedness within the context of early motherhood.”
Embrace’s website and social media channels provide mothers with information on the state of motherhood in South Africa, pregnancy and the journey to birth, tips on breastfeeding and, importantly, information on how to mobilise to support other mothers. During Covid-19, with partners in the sector, they launched a collaborative project called Messages for Mothers to keep mothers informed, connected and encouraged using digital channels.
“We acknowledge the complexities of motherhood and don’t shy away from the truth that, yes, motherhood is beautiful and deeply satisfying, but we cannot ignore the fact that this is also a major life change. By giving mothers and pregnant women the full spectrum of the motherhood experience, and holding space for mothers to feel and to speak freely about their personal vulnerabilities, and really, about the mess and the realities of motherhood, we let mothers know that they are not alone, that their experiences are valid and that there is support and help available to them. Our message is that needing help does not make you a bad mom.”
Supporting women financially during pregnancy
Emotional support and confidence about the body’s ability to birth are important, but so is financial support and food security during pregnancy and beyond.
Research from South Africa shows that many women of reproductive age suffer from iron deficiency, anaemia, vitamin A deficiency, and iodine deficiency. Food insufficiency has been linked to depressive disorders among pregnant women, high gestational weight gain, gestational diabetes, disordered eating, as well as higher prenatal stress and problematic infant feeding practices.
“Pregnancy is expensive, and research shows that poverty has a huge impact on maternal health outcomes and early childhood development,” says Mbuli. Yet, despite the fact that pregnancy and the months after birth reduce a woman’s income and income generating potential, pregnant women are excluded from receiving the child support grant, leaving many in a financially stressed position.
In response to the crisis of food insecurity caused by the pandemic and lockdown, Flash and the DG Murray Trust pioneered the CoCare Voucher Programme, targeting communities most at risk of food and economic insecurity. CoCare voucher recipients received electronic food vouchers which they were able to redeem at a partner store of their choosing, including their local spaza shop.
“Embrace sponsored and coordinated 5,000 care packs. Through this pilot programme, pregnant women were able to receive much-needed support at a time of increased vulnerability.”
Registered mothers were also recruited to participate in a University of Stellenbosch study measuring the positive impacts of the provision of food vouchers on maternal and early childhood health. This research will contribute to the evidence-base for the introduction of a maternity support grant, and is forthcoming.
Mbuli argues that to truly support a positive pregnancy and transition to motherhood, “we need to adopt a deliberately pro-mother agenda, where motherhood is at the centre of discussions about and at the core of activism for gender equity. When we speak about economic justice, we must view it through a gendered lens. We must speak about social protection for pregnant women.” DM
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