South Africa maternal and infant healthcare record criticized

By Robyn Dixon, Los Angeles Times

Sept. 16, 2011 12 AM PT

Reporting from Johannesburg, South Africa — Bridget Moleboheng woke up at 5:45 a.m. in the hospital operating room. Gradually her senses returned. A splitting headache. An oxygen tube in her mouth and medical equipment attached to her body. But all of it was turned off.

“A nurse came in and said it was a miracle I was still alive.”

When Moleboheng arrived to give birth the day after Christmas last year, she says, the doctors and midwives at Sebokeng Hospital near Johannesburg told her she was behaving like an arrogant white “madam” by asking too many questions and refusing to have a caesarean section because they wouldn’t let her read the consent form.

Moleboheng, who is black, alleges that she was left to handle a difficult breech delivery without help. She says her baby boy was born blue, and that she had to be resuscitated after being left sitting in a pool of blood unattended by doctors for three hours.

“I gave birth like an animal,” Moleboheng said. “Their attitude to patients is very bad. But not many people have the guts to come out and say what happened to them.”

Despite boasting sub-Saharan Africa’s wealthiest economy and some of the world’s richest mineral resources, South Africa has an abysmal record on maternal and infant health. About 4,500 women die giving birth each year. The rate of such deaths has quadrupled since1998, to 625 per 100,000 live births, leaving South Africa worse off than much poorer African countries such as Swaziland, Uganda, Ghana, Cameroon, Togo, Burkina Faso and Mauritania.

Part of the increase is the result of South Africa’s high incidence of AIDS, according to a recent report by Human Rights Watch. But countries such as Botswana and Swaziland, with similar HIV infection rates, have much lower maternal and infant mortality.

Nearly 90% of South African women give birth at medical facilities, one of the best rates on the continent. Yet much of the maternal mortality problem is caused by poor healthcare: untrained and corrupt hospital staff members, some of whom demand bribes before they will attend women in labor; doctor shortages; and lack of accountability, the Human Rights Watch report says.

Women were pinched, slapped and accused of lying and in one case stabbed in the thigh with scissors while in labor, according to the report. It documented many cases in which staff members failed to attend to women giving birth or demanded bribes before they would offer care.

Birthing staff members interviewed by Human Rights Watch explained the slaps and pinches and other assaults as ways to make women open their legs during birth.

“There’s no excuse for abusing patients,” said Liesl Gerntholtz of the rights group’s Johannesburg office. “Poor training is not an excuse for slapping patients or abusing patients or leaving women unattended for hours and hours.”

Moleboheng is suing Sebokeng Hospital for negligence. About 1,600 doctors in the public health system are being sued, and in Gauteng, which includes Johannesburg and is the most populous state, the Health Department paid out $88 million last year because of medical malpractice suits, putting a strain on the health budget.

“You wonder, because so many black people were fighting for empowerment,” said Moleboheng, referring to the black struggle against the repressive apartheid system of white-minority rule. “Now we’ve got it, we’re abusing each other.”

Another reason for South Africa’s poor performance on maternal health is the legacy of apartheid, in particular its corrosive effect on education, impairing both the quantity of trained midwives and their quality and attitude, said Robert Pattinson of the South African Medical Research Council. In Gauteng, the number of midwives is 50% lower than the World Health Organization standard.

“Undoubtedly, there’s a very severe health staff shortage,” he said. “There’s a problem with the caring attitude. A lot of that will be explained by burnout of people just having too much work to do.”

The hospital has conducted an internal inquiry on Moleboheng’s claims, but a hospital spokesman said there was no comment on the allegations.

A spokesman for the Gauteng health department, Simon Zwane, didn’t confirm the details of the case, but said the incident was “really regrettable.”

“It’s not representative. That kind of thing is not really widespread,” he said. “There are isolated incidents that happen here and there from time to time.” But he announced in early August that the health department was setting up a team to ensure improvements in service to patients.

Moleboheng says that when she arrived at the hospital entrance at 11 a.m., a doctor was yelling at a weeping female patient, and Moleboheng’s husband and sister were barred from coming in.

She says she waited seven hours to see a doctor. At 6 p.m., he examined her and prescribed pills but explained nothing.

“Nobody explained anything,” she said. “They don’t explain and they get upset if you ask. It’s like you know too much.”

When she questioned the need for a caesarean, the nurse demanded that she sign a consent form. She says she asked to read the form and the nurse refused to let her. Because hospital officials or staff members declined to give specifics of the case, this claim and others made by Moleboheng cannot be substantiated. But the Human Rights Watch report says patients commonly are not informed about procedures or the reasons for them.

Moleboheng refused to sign, terrified because her mother died of complications after a caesarean in 1997.

“The nurse said, ‘These ones in the fancy nighties, they’re the ones we struggle with every time.’ The midwife said, ‘You know what? This one doesn’t want to listen. She talks too much.’

“That’s when they started calling me Madam — Madam this, Madam that. When you call someone Madam, it’s like the old days when white women were called Madam because they didn’t do anything. It’s an insulting word for a spoiled woman full of herself.”

At 10:45 p.m., as she tried to deliver, she felt that the baby was obstructed in the birth canal.

“I started screaming for help:’Please sister, come!’ ” She says a nurse came, leaned against the door, folded her arms and told her to push.

When the baby was born, 10 minutes later, he didn’t cry and was purplish blue. But she said that was just the beginning of her nightmare. After a nurse broke the umbilical cord, trying to remove the placenta, she says she was left bleeding for several hours.

About 2 a.m., three hours after the bleeding started, she was wheeled into an operating room. When she awoke, she asked about her baby. Her infant, who was supposed to be in the hospital’s nursery while she was being operated on, was in a crib at her bedside. But he was alive.

The nurse in the operating room had waited for hours after her shift ended, to see whether Moleboheng had survived. “She said, ‘You must live, for your baby.’”

That one kind nurse almost made up for her pain. But not quite.

“I feel angry,” she said, “and it’s an anger that won’t go away.”

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