Midwifery is an old profession, but certainly not a redundant one. These medical professionals are responsible for not just one life, but two.

It takes dedication and passion to be a good midwife. Acting as a medical professional, cheerleader, and trusted advisor, a midwife must advocate for the best and safest birthing method for each one of their patients. Yet, some argue their importance in the health sector is overlooked and the profession is often neglected.

Being part of a miracle

“Many people haven’t a clue what the role of a midwife is,” says Louette Maccallum, a midwife with an estimated 5 000 births under her belt.

She describes the profession she has immersed herself in for the last 34 years with a sense of reverence. “I get to be part of a miracle with every birth I attend. To be able to assist women in their most vulnerable moments… and then to observe the transition from woman to mother and man to father and the joy in the moment of bringing their child into the world is the most beautiful thing to behold. 

“You need to be passionate, caring, compassionate, patient, and be willing to work day or night or both sometimes, with long hours and lots of physical work,” Maccallum says. Regardless of whether they have to conduct their duties in the cheerful daylight hours or in the muted darker hours, midwives play a vital part in the healthcare system. “Midwifery, where care includes proven interventions for maternal and newborn health as well as for family planning could avert over 80% of all maternal deaths, stillbirths and neonatal deaths,” the World Health Organisation (WHO) states in their 2020 campaign to honour nurses and midwives.

The core of maternal health

“Midwifery is the core of maternal health. If you strengthen midwifery in your country, then you are going to see healthy future generations,” says Dr Margreet Wibbelink, a midwife and current general manager at the organisation Sensitive Midwifery.

Midwives have these skills because they have been medically trained to monitor pregnant women and their babies through the entire duration of the pregnancy. According to Wibbelink, midwives are expected to care for expectant mothers from the start. 

“For the first visit, you will do the full examination, and ask all the (necessary) questions about the woman’s health, her medical history, and menstruation,” she says. “You are already screening her to see whether she is a low-risk (pregnancy) or if there are any red flags.” 

They will also conduct the necessary blood tests and confirm how far along the pregnancy is. From this first visit, the midwife begins a journey with the expectant mother. In the public health sector, this journey is likely to take place in a Midwife Obstetric Unit. “During the pregnancy they have regular consultation visits, where you do the blood pressure check, check the growth of the baby, check if the mom is well nourished, and her iron levels are fine,” Wibbelink says. 

“Because there is so much change (happening) in their bodies, they often have lots of questions,” she says. “You will answer them, and in that process, you are making them ready and empowering them for what’s ahead.” According to Colleen Frost, a former midwife, one of the best parts of the job was the relationships she built with patients. “They would then open up about many things. I’m not a counsellor, but I’m able to listen and to be empathetic towards them,” she says.

Power struggles

Midwives also work closely with obstetricians according to Wibbelink, and in the case of a complication or a high-risk pregnancy the doctor will be able to step in and perform a Caesarean-section. However, she cautions that in the private sector, there is currently a power struggle between obstetricians and midwives. 

“The doctors do all the antenatal check-ups, and the birth. The midwives monitor the women but under the doctor’s guidance. They are not independent practitioners. They have given massive territory to the doctors, who are ruling the whole pregnancy sphere,” Wibbelink says. 

Maccallum, who is currently working as an independent midwife, has seen this struggle too. “In the private hospital sector midwives have become carers and assistants. They are not operating in their full capacity. They look after women in labour and monitor the progress but no longer do hands-on births,” she says.

‘Old-fashioned’ vs. ‘modern’ medicine

According to Wibbelink this power struggle comes down to the notion that natural birth is old-fashioned and unnecessary, while modern medicine gives a safer and more convenient alternative in the form of interventions like Caesarean-sections and inducing labour. By extension, midwives could be seen as old-fashioned as well. However, anyone entertaining this notion will quickly be set straight by Wibbelink. “It’s not an old-fashioned thing,” she says emphatically. 

According to Wibbelink, the drive towards medicalisation and interventions is slowly being tempered by the realisation “that all these shiny interventions are not good for us”. As recently pointed out on the website AfricaCheck, the WHO previously recommended that caesarean rates should range between 10 and 15% but this recommendation was revised in 2014. Currently the WHO does not recommend an ideal caesarean section rate.

In comparison, South Africa’s rate of caesarean-sections seems relatively high.

According to the District Health Barometer 2015/2016, the national average for Caesarean-sections in the public sector was 26.2%. Rates appear to be even higher in the private sector. A 2012 study published in the British Journal of Midwifery, that focused on delivery methods used in the South African private sector, estimates that the rate is as high as 70%. While a more recent number from a single medical aid scheme, Discovery Health, indicates that the C-section rate among scheme members had risen to 74%, according to The Business Insider.

These high rates do not come without consequences, according to Wibbelink. She says that unnecessary interventions can cause set-backs for the newborn, as some babies are born slightly prematurely, as well as difficulties with bonding between mother and child, breastfeeding and a longer recovery time. According to the WHO report: “Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons…

At population level, Caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates,” the report states. The report further cautions that more research is needed into the exact effect that high C-section rates can have on health, and states that this method of delivery can cause complications. However, it does not specify the exact nature of these complications.

Journey to becoming a midwife

In order to become a midwife in South Africa, a person will need to undergo at least four years of training, according to a 2017 case study by the African Institute of Health & Leadership Development, regarding nursing and midwifery in South Africa. Midwives who were educated in South Africa, like Maccallum, are required to train to become registered nurses first, normally a three-year course, and then study for another year to get a second qualification in midwifery.

While some institutions, according to the case study, teach midwifery as part of a four year nursing degree, Maccallum started out as a general nurse in Neurology at Groote Schuur Hospital in Cape Town. Four years later she started her studies in midwifery at the B.G. Alexander College in Johannesburg. There, she fell in love with midwifery. “I just loved it so much and became so passionate about it that I stayed in midwifery since,” she says. 

According to Senior Manager for Education and Training at the South African Nursing Council (SANC), SJ Nxumalo, the reason South Africa’s path to midwifery is different to that of some other countries like the Netherlands which have a direct qualification for midwifery, is due to the demands of the public health sector.

“A nurse who is allocated in rural areas must be competent in providing comprehensive nursing, including midwifery services, in order to deal with the different needs of patients,” she explains. She adds that “each individual nurse must be comprehensively trained in order to deal with the quadruple burden of disease (that comes with midwifery)”. 

In order to qualify as a midwife, an individual is expected to complete 1 000 clinical hours, according to Nxumalo. She further explains that during this time students will be expected to spend 60 of those hours in an antenatal clinic or department. They will also be expected to work with at least 30 pregnant women, who they will examine under supervision. The aspiring midwives will then witness five births before they are allowed to deliver any babies themselves. 

The first birth

Frost, who obtained her qualification in 2001, still remembers the first birth she witnessed. “I remember that very well,” she laughs when asked to recall this experience.

“You don’t expect to smell those smells or see that amount of blood. Everyone thinks that it is like what you see on the television.” Frost pauses. “It’s definitely not like that. I remember feeling so dizzy,” she adds. “The smells and everything were completely foreign. I wanted to faint!” Once the student midwives have got through the required five births, they start the practical aspect of their training. For this, according to Nxumalo, they need to deliver 15 babies and do 15 internal examinations.

According to Nxumalo, student midwives during this time are also taught “breathing and relaxation techniques, antenatal exercises, post-natal exercises and performing episiotomies” (an incision made in the opening of the vagina during a difficult delivery). She further adds that once qualified the student will be able to “suture or stitch first and second-degree tears of the perineum and of episiotomies and administer local anaesthetic”. Nxumalo says depending on where they are working, a midwife can be expected to fulfil the duties of both nurse and midwife. 

Is the training sufficient?

Although 1 000 clinical hours and 15 deliveries may seem like a lot, Wibbelink doesn’t think that this is sufficient to train midwives properly. “International standard says you need to have done at least 40 births,” she says. 

Wibbelink has been conducting research for her PhD about the perceptions of midwives in the public sector. Within this research she claims to have encountered a similar concern among these midwives who state that “the new midwives are not skilled, not competent and lack practical training”. In addition, they also have to cope with the challenges in the public health sector. “There is a massive shortage of staff, and a lack of motivated midwives… There are things like the lack of resources, especially in rural areas. They battle with bad roads, ambulances that come too late, blood products that are not arriving. They’ve really got the worst end (of the bargain). Moms are dying unnecessarily under their hands.”

Very traumatising

Losing a patient, whether it is the mother or the baby, can haunt a midwife long after the death occurred. According to Frost, the patients that she remembers most are the ones who lost their babies. “I can still see some of their faces,” she says lowering her voice. “When they lose their babies in the form of a stillbirth, they still have to go through the normal birth process. There’s no joy in that. That I remember quite vividly.” Frost explains: “We then have to wrap that (stillborn) baby for the undertaker to collect the body… It’s very traumatizing.” 

According to Maccallum, conditions in the public health sector are horrific, and have led to traumatised and drained midwives. “These midwives are exhausted and in need of emotional support themselves. They are heroes,” she adds.

This article was produced by Spotlight – health journalism in the public interest.

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Elri Voigt

The coronavirus should have everyone’s attention by now, health experts say. And people with heart disease have extra reasons to be alert.

Covid-19, which was first reported in the Chinese city of Wuhan in December, has sickened tens of thousands of people and killed hundreds around the globe.

On Tuesday, Dr Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, said its spread in the United States seemed certain.

“It’s not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness,” she told reporters during a news conference.

For people with underlying heart issues, the concerns are serious enough that the American College of Cardiology issued a bulletin this month to warn patients about the potential increased risk and to encourage “additional, reasonable precautions.”

Based on early reports, 40% of hospitalised Covid-19 patients had cardiovascular disease or cerebrovascular disease (which refers to blood flow in the brain, such as stroke), according to the bulletin.

“That statistic doesn’t mean people with heart disease are more likely to contract the coronavirus,” said Orly Vardeny, associate professor of medicine at the Minneapolis VA Health Care System and University of Minnesota. “It just means that those folks are more likely to have complications once they do get it.”

Vardeny, an adviser on the ACC bulletin, said the virus could affect heart disease patients in several ways.

The virus’s main target is the lungs. But that could affect the heart, especially a diseased heart, which has to work harder to get oxygenated blood throughout the body, she said. “In general, you can think of it as something that is taxing the system as a whole.”

That could exacerbate problems for someone with heart failure, where the heart is already having problems pumping efficiently.

Someone with an underlying heart issue also might have a less robust immune system. People’s immune systems weaken as they age, Vardeny said. And “in those with chronic medical conditions, the body’s immune response is not as strong a response when exposed to viruses”

If such a person catches a virus, she said it’s likely to stick around and cause complications.

A virus also may pose a special risk for people who have the fatty buildup known as plaque in their arteries, Vardeny said. Evidence indicates similar viral illnesses can destabilize these plaques, potentially resulting in the blockage of an artery feeding blood to the heart, putting patients at risk of heart attack.

Stay at home if you’re sick

Vardeny emphasised that information about Covid-19 is changing almost hourly. But previous coronaviruses, such as SARS and MERS, offer insight. They were linked to problems such as inflammation of the heart muscle, heart attack and rapid-onset heart failure, the ACC bulletin said.

Covid-19 also has similarities to influenza, Vardeny said. At the moment, she said, “We don’t think the actual risk is any higher per se. It’s just that the spread is quicker.” And unlike the flu, there’s no vaccine.

Covid-19 numbers change rapidly. The World Health Organization reported the fatality rate from the illness was between 2% and 4% in Wuhan, and 0.7% outside Wuhan.

By comparison, as of mid-February, the CDC estimated there had been at least 29 million flu illnesses, 280 000 hospitalisations and 16 000 deaths from it in the United States this season.

Many of the same precautions that work against the flu should be helpful against Covid-19, Vardeny said, because it appears to spread the same way – through droplets in the air when someone coughs or sneezes.

For now, she suggests people defend themselves by hand-washing, keeping surfaces clean and avoiding travel to areas with outbreaks.

The ACC bulletin recommends people with cardiovascular disease stay up to date with vaccinations, including for pneumonia. The ACC also supports getting a flu shot to prevent another source of fever, which could potentially be confused with the coronavirus infection.

In the news conference, Messonnier summed up her advice as, “Stay home if you’re sick; cover your cough; wash your hands.”

She also warned that people need to prepare for the possibility of closures of work, school and more.

“I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe,” she said. “But these are things that people need to start thinking about now.”

– American Heart Association News

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Zakiyah Ebrahim

Amid the carnage of the First World War, a flu epidemic took hold in the front-line trenches and subsequently spread around the world, infecting one-quarter of the world’s total population and ultimately killing more people than the war itself.

Before it was over, somewhere between 50 million and 100 million people died from what became known as “the Spanish flu.” The currently accepted mortality rate for the Spanish flu is between one and three per cent, and its total mortality numbers are shocking in part because of its widespread reach, proliferating throughout country after country around the globe.

A familiar name

The Spanish flu pandemic was triggered by a virus that is now a household name: H1N1. H1N1 resurfaced in 2009, again spreading to the far reaches of the planet, but with only a small fraction of the death toll of its first emergence.

Although it was not an identical virus, it could have been equally deadly in theory, in part because of its potential to kill people who were younger in age and not otherwise considered vulnerable to flu-related mortality. The absolute mortality rate of the 2009 H1N1 pandemic was 0.001-0.007 per cent. The total number of dead in this case was in the hundreds of thousands around the globe, with a disproportionate number believed to be affected in southeast Asia and Africa.

Why the vast differences in mortality? These two versions of H1N1 did not have the same origin, and there is also an evolutionary push for subsequent versions of the same virus to be less deadly. So the two versions of H1N1 would have been different in these respects.

But, importantly, the world was different too. The conditions under which the Spanish flu overtook the world were abhorrent. The First World War had been raging for several years, and the front lines where the illness emerged were places where young soldiers lived among corpses, rats and contaminated water, and had limited opportunities for personal hygiene.

In 2009, even the most poor nations of the world had better living conditions than those experienced by the average soldier in the trenches of First World War. Despite this, the nations that had the least ability to provide clean environments for their populations were hit the hardest by the H1N1 infections, with large numbers infected and many fatalities.

The spread of COVID-19 in China – and recent cases appearing closer to home – has people worried about another Spanish flu scenario. This will not be another Spanish flu, but we have an important opportunity to control the proliferation of the virus within our own populations.

Behaviour and herd immunity

Herd immunity is a concept that comes from the field of zoology. It refers to the ability of a population of animals to resist infection by a pathogen – such as a virus – because a sufficiently large number of individuals within the population have humoural immunity on an individual level. Humoural immunity is the ability of the immune system to form antibodies against a specific infectious agent.

With herd immunity, transmissibility in a population is dramatically reduced via immunological mechanisms. This is the theory behind vaccines, which boost specific immunity within (ideally) a very large proportion of the population, such that a transmissible disease never gains a foothold.

Notice the term “immunological mechanism,” and consider whether the same principle could apply on a behavioural level.

As the body’s humoural immune responses deflect infection, so do behaviours that block routes into the body for an infectious agent. With a very large proportion of the population consistently implementing behaviours that reduce transmissibility, epidemics can be prevented or vastly limited, without the reactionary measure of quarantine.

Just as humoural immunity does not convey perfect protection to the individual, the same is true for behavioural immunity; it is simply important that a very high proportion of the population is performing precautionary behaviours consistently. Protection is on the level of the herd, more so than on the level of the individual.

Are we talking about the wrong things?

In the context of this concept of “behavioural herd immunity,” current discussions about COVID-19 in conventional and social media may be focused on the wrong things. Rather than talking about fear-inducing counterfactual scenarios (what ifs), we need to focus on crowdsourcing strategies that limit the ability of the infection to get a foothold in our population.

A vaccine would be nice and will eventually arrive. But in the meantime, epidemics like COVID-19 can be prevented by increasing the prevalence of precautionary behaviours in the general population that impede its spread.

These measures include a few familiar maxims, none of which are implemented consistently enough, and a few unfamiliar ones, which very much need to be taken up individually en masse. And soon.

The familiar ones:

• wash your hands frequently and properly;
• cover your mouth (with your arm) when coughing or sneezing;
• avoid close contact with those who are already infected.

Before brushing off the above as obvious, we should ask ourselves: do we do these with complete consistency? Can we do better? Consider also the following less obvious but equally important behaviours:

1. Disinfect your mobile device screen twice per day – it is a portable petri dish, accumulating bacteria and, yes, viruses. Antibacterial wipes are necessary here, as they generally kill viruses as well. Clean your device at least twice daily, once at lunch and once at dinner time (or linked to another daily routine). A recently published study estimates that viruses like COVID-19 may be able to persist for up to nine days on smooth glass and plastic surfaces, like a mobile phone screen.

2. Avoid touching your face. Your mouth, nose, eyes and ears are all routes into your body for viruses, and your fingers are constantly in touch with surfaces that may contain viruses. This simple measure is very hard to maintain consistently, but is essential for infection control.

3. Use masks only if you are yourself ill and give social kudos to people who are responsible enough to use them when sick.

4. Self-quarantine if you are ill and have a fever.

5. Engage your social network to brainstorm other simple behavioural changes.

Preventing spread

Strengthening herd immunity through behaviour is critical to preventing COVID-19 spread. We need to be talking about it more, and doing it more. In the sea of fear-provoking uncertainties, this is something that we are in control of individually and en masse.

Let’s do better about implementing the above precautionary behaviours with high consistency, and over the long-term.

And here’s a side benefit: we will be preventing many other infectious illnesses from spreading, including seasonal influenza, which kills more people in an average month than COVID-19 did last month.

Peter Hall, Professor, School of Public Health and Health Systems, University of Waterloo

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Peter Hall, University of Waterloo

Chicago’s brief and now-defunct soda tax did cut the consumption of sugar-sweetened drinks, a new study finds, along with raising funds for public health initiatives.

From August to November 2017, when the tax was in effect, the volume of soda sold in Cook County dropped 21% and the tax raised nearly $62 million, nearly $17 million of which went to a county health fund.

“The evidence suggests that taxes on sweetened beverages may be an effective policy tool for reducing sweetened beverage consumption,” said lead researcher Lisa Powell. She’s director of health policy and administration at the University of Illinois at Chicago’s School of Public Health.

“The evidence also shows that households will undertake tax avoidance strategies, such as cross-border shopping, which will dampen the impact of the tax,” Powell said.

No nutritional value

The Cook County levy was one cent per ounce on sodas and other sugar-sweetened drinks. After two months, pressure from the public and extensive lobbying by the American Beverage Association forced the Cook County Board of Commissioners to rescind the tax, the Washington Post reported.

Samantha Heller, a senior clinical nutritionist at New York University Medical Center in New York City, said research has found a strong association between the consumption of sugar-sweetened beverages and type 2 diabetes, obesity, heart disease, kidney disease, tooth decay and gout.

“These beverages taste good but are loaded with calories and have virtually no nutritional value,” she said. “Do we really want our kids, family members or ourselves suffering from preventable chronic illnesses when we can easily drink other beverages?”

The jury, however, is still out on whether cutting back on these drinks will have an impact on the obesity epidemic and its consequences.

“We do not have enough data yet to say for sure that soda tax reduces the risk of chronic diseases,” Heller said.

One can hope that fewer purchases result in less consumption, which could ultimately help reduce the rates of obesity and chronic diseases like type 2 diabetes, she said. “But these conditions take years to develop, and thus it may take years to assess the effects of a soda tax,” Heller said.

More responsive to price increases

For the study, Powell’s team used data from supermarkets, grocery, convenience stores and other outlets in Cook County, Illinois, comparing that data with St. Louis City and County, Missouri, where there was no tax.

The researchers also found no significant increase in purchases of untaxed drinks.

Objections to taxing sugar-sweetened drinks include that the tax is regressive and affects poorer consumers most, and also that it’s an example of the “nanny state” trying to limit choices.

Powell said, “Lower-income individuals are more frequent consumers of sugary beverages and therefore disproportionately bear more of the harms associated with consuming sugary beverages.”

Lower-income consumers also tend to be more responsive to price increases and will reduce their consumption of sugary drinks to a greater extent than higher-income people and, in turn, will benefit more from the associated health benefits of reduced consumption. “Thus, while the tax may be economically regressive – from a health perspective it is progressive,” she said.

Negative health consequences

It is not the government’s business to determine what people drink, Powell said. “But governments do play a role in helping to correct what economists call ‘market failures’ that may lead consumers to over-consume certain products, such as sugary drinks or tobacco,” she noted.

The goal of the tax is to help offset the negative health consequences that are associated with these drinks, which end up being paid for in part by other tax revenue, Powell said. “We have seen this same policy used as a means to help reduce smoking,” she added.

No states have a tax on sugar-sweetened drinks. But the cities of Boulder, Colorado; Philadelphia; Seattle; and four California cities: Albany, Berkeley, Oakland, and San Francisco, do tax these drinks.

If you like bubbly drinks choose seltzer, Heller said. “Choose plain or flavoured seltzers or add a few tablespoons of 100% juice or an herbal tea for flavour. Water, tea and unsweetened plant-based milks are also good options,” she advised.

The report was published online in the Annals of Internal Medicine.

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Grandparents can be a bad influence on kids’ weight, researchers say.

That’s the upshot of an analysis of 23 studies conducted in the United States and eight other countries by a team from the Brown School at Washington University in St. Louis.

The study found that kids who were cared for by grandparents had nearly 30% higher odds for being overweight or obese.

While grandma and grandpa may mean well, they can affect their grandchildren’s weight in various ways, including eating habits, physical activity and perceptions of what represents a healthy lifestyle, according to the researchers.

Negative influences

“Through offering wisdom, teaching traditions, providing guidance and making memories, grandparents are often able to leave behind a legacy that their grandchildren will cherish and benefit lifelong,” said lead author Ruopeng An, an assistant professor.

“However, some negative influences from grandparental care may also be present and cannot be overlooked,” he added in a university news release.

One of those negative influences affects a child’s diet and exercise habits.

“The notion of ‘the bigger the healthier’ is still relevant,” An said.

Some grandparents may urge their grandkids to eat bigger and more frequent meals, and will offer sweets and fried foods as a way to show love, he pointed out.

Similar trends across cultures

“In fact, in some cultures, grandparents may also be more likely to excuse children from doing household chores, a key form of physical activity,” An added.

He said he was surprised that the studies – from the United States, the United Kingdom, China, Japan and five other nations – showed similar trends across cultures.

“Affluence and being well fed is valued and desirable to many grandparents as they had experienced hunger and poverty in their youth, which they may pass on to their grandchildren, who, to the opposite, are fighting against a world of food swamps and ever-expanding portion sizes,” An said.

The findings were recently published online in the journal Childhood Obesity.

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The levels for this week were modelled on 10 years of archived data and current weather patterns. Grasses were low, tree pollen was low and included the types; eucalyptus, white stinkwood and olive. Weeds included goosefoot, the daisy family and dandelion. Mould levels were low.