Maternity services in the private sector are in crisis, with many obstetricians leaving active practice and fewer medical graduates opting to specialise in the field. Malpractice insurance has increased 10-fold in the past decade, making the demands on lone obstetric practices increasingly heavy.
Dr Howard Manyonga, head of The Birthing Team
A key driver of these high malpractice premiums is scant documentation of treatment decisions and poor compliance with standard care protocols.
Insurance providers will not risk court when doctors are sued, choosing rather to settle in the face of inadequate documentation of the care provided.
This is a consequence of doctors working in isolation at what should be a team sport. An individual practitioner cannot follow protocol designed for medical teams, nor can they manage the detailed records of the high number of patients required to make their practice profitable.
At the start of 2017, the future looked bleak – but, integrated team models are making the retention of obstetricians possible. When maternity care is delivered by teams, the risk of poor outcomes is reduced, full documentation is routine, and because of that, insurers are willing to discount indemnity premiums for the healthcare professionals in the team. In light of this, I predict that in 2018 we will see the following trends in maternity care:
Obstetricians to team up with midwives
Healthcare is best delivered by teams with various skill sets and expertise. Maternity care is no different. Currently, specialists and independent midwives are paid separately and must compete over patient care, rather than collaborate. This can result in delays in the transfer of patients who develop complications, creating risk for both the midwife and the accepting obstetrician, as well as a higher chance of poor outcomes for the patient. A set-up in which obstetricians and midwives work together for a team fee prevents this, delivers more holistic care and promotes record-keeping. Such teams, of 12 midwives and three or four obstetricians, can together deliver 300 babies per month – a huge untapped capacity. To date, two clinician owned teams are actively practising this way in South Africa – one in Berea, Johannesburg and another in Central Durban – both under the brand name The Birthing Team.
Task-shifting will become the norm
A midwife is trained to carry out routine assessments, tests, patient care and education. A specialist is best utilised in their role as a consultant, providing clinical guidance and reacting to women with complex problems and crises. Both should be involved in treatment decisions, but need not both be present at each consultation. In well-designed systems with good management and well-established systems for communication, the right professionals do the jobs best suited to them. This reduces cost to patients, improves their satisfaction with care and delivers better outcomes. Note, a known factor in the decision to litigate is a lack of adequate communication from clinicians with their patients and their families following adverse outcomes. But in a team model, communication and management of patient relationships is prioritised, with the support and participation of the specialist and auxiliary health professionals as needed.
Obstetricians working in teams will be better able to achieve work-life balance
Working within a team provides obstetricians with much-needed time off. Although involved in the birth of many more babies, having colleagues with whom payment is shared means doctors do not need to be on call 24 hours a day. The support, the lifestyle and professional benefits of working in a team, beyond the financial ones, have proved very meaningful to participating members of these integrated teams. Job satisfaction grows with the constructive peer review and the emotional support of teamwork. Crises often drive innovation, and the private maternity care sector in South Africa is a dire need of it. I strongly believe that teamwork is the solution, capable of delivering the high value of care that allows for lower malpractice insurance costs and better health outcomes for patients.
Dr Howard Manyonga is an obstetrician and gynaecologist with an MBA and special interest in health systems management. He led the effort to develop task shifting models in maternity and cervical cancer screening at the Wits Reproductive Health and HIV Institute and was COO at Marie Stopes South Africa before joining PPO Serve and driving the development of The Birthing Team.
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