Eleven themes were identified from the dialogue relating to perspectives of the proposed model and considerations for transitioning to a new model of care. Some of these themes respond directly to the six key principles proposed in Fig. 1 and others are additional considerations or concerns that emerged from participants. We have summarised the major themes and key points in Table 2. We present these themes in the numeric order of Table 2, supported by verbatim quotes from stakeholders.
Multi-disciplinary team-based approach
The shift to team-based models of maternity care as proposed in the alternative model, represents a major change from the current private sector approach, which predominantly consists of solo obstetrician practices providing the full continuity of antenatal, intrapartum and postnatal care. Midwives are employed by private hospitals to provide support during labour but they do not conduct births. The proposed change in the composition of the care team sparked heated discussions. While stakeholders generally supported the shift, there were differing views on the roles and recognition of team members, respect of team members, team leadership, and concerns regarding availability of necessary skills.
The value of involving cadres such as general practitioners and clinical associates in the maternity care team was supported by several participants with experience in testing small team-based models in the private sector. They argued that having a multi-disciplinary team allows each team-member to work within their full scope of practice and for clinical tasks and decisions to be appropriately matched to different health professionals’ skills and expertise.
The multi-disciplinary team approach where each discipline is working to the top of its scope so what we really did was to take the scope of practice of a midwife, clinical associates and so on and we matched it to the client journey. (Private sector obstetrician)
Our obstetrician only gets to see the patient maybe at 24 weeks. The first 24 weeks can be managed by the medical officer, clinical associate and midwife, so the decisions are primarily taken by the midwives. (Private sector obstetrician)
A representative from a private hospital group and a private obstetrician strongly believed that obstetricians should continue to play a leading role in the team. This sentiment appeared to relate to fears of not being fully apprised in the event of complications which may need to be managed by an obstetrician.
We’re trying to formalise the teams, in a form of terms of reference, so we’re very unequivocal, this is to be an obstetrician led, an obstetrician anchored product, supported by the hospital and the midwives and we’re hoping to bring in the medical officers and the general practitioners. (Private hospital group)
The lead is always the obstetrician because when things go pear-shaped that’s the person who caries responsibility at the end of the day. (Private sector obstetrician)
The lack of trust and the need to restore trust and respect between obstetricians and midwives was raised by both midwives and obstetricians.
I’m standing here in front of you with twelve years of education so please don’t look down on me, on my skills as a midwife and I think that is something we should work on in South Africa. (Public sector academic midwife)
If we don’t mend our relationships so that we can work together better we’re not going to reach far because you can see that there is a feeling that midwives are undermined etc. We need to start there, let’s mend the relationships so that we can move forward and take whatever model that addresses the interests of the patient. (Private sector obstetrician)
The loss of midwifery skills was also a concern, with participants noting that the current model of care in the private sector has contributed to a decline in these skills. They emphasized that this issue should be taken into account when considering any shift to midwife-led care models.
I can quite attest to that, that the current statistic of the caesarean section in South Africa in 2024 terms is actually 85%. Which effectively means out of the 100 admissions that we see here 85% of them will deliver surgically and 15 of them will go normal vaginal delivery. We have actually realised that over time our midwives have lost the skill of managing normal vaginal delivery. They have also lost the skill on managing the CTG (cardiotocograph), which in our view is an early warning system largely because each and every day 85% of our admissions comes to the prenatal ward straight to theatre to be delivered by caesarean section. (Private hospital group)
An independent midwife went further to suggest that addressing the lack of skills and human resources will require consideration of direct-entry midwifery training, a shorter, midwife-specific training. Currently in SA midwifery is part of a four-year general nursing training.
Midwifery skills are being lost. Graduates are going straight into the private labour wards and are not being exposed to true midwifery skills after the training and I think we need to as well look at potentially bringing back direct entry midwifery. (Independent private sector midwife)
Compliance with evidence-based clinical guidelines and accreditation
Stakeholders agreed with the need to address the lack of clinical governance and oversight in the private sector within any alternative model as key to improving quality of care. They called for the adoption of common, agreed-upon protocols, clinical guidelines, regular audit of outcomes and standardized maternity benefits.
Several stakeholders raised concerns about the inconsistent use of guidelines in the private sector.
A presentative from the private health funders noted: “I don’t know, health governance is really nowhere, clinical governance is not in place in many facilities, particularly the morbidity and mortality kind of meetings to review each C-Section.” (Private health funder)
The lack of oversight has resulted in omissions of care in the private sector as one health funder described:
There is huge gaps in the care of patients in the maternity environment in particular omission of care. In the private sector only 30–40% of mothers end up getting an HIV test done. (Health funder association)
To address some of these concerns, stakeholders called for more consistent use of clinical governance processes and guidelines. Participants spoke of the need to follow the example set in the public sector of enforcing clinical guidelines and having regular quality control processes such as audits.
When we make recommendations that we aim to translate into guidelines and protocols, we assume that every site conducts morbidity and mortality review meetings where minutes are kept, actions are assigned to individuals and there is follow up to hold individuals to account and such systems are very weak to non-existent in the Private Sector. (Public sector obstetrician)
The proposed alternative model recommended annual accreditation of a birthing unit based on compliance with evidence-based guidelines, enforced through a structured reporting and monitoring framework. However, stakeholders raised several concerns regarding the accreditation period, enforceability of guidelines, the effectiveness of monitoring systems, and weaknesses in current regulatory oversight.
Some stakeholders questioned whether an annual accreditation cycle was too short to allow for meaningful change and quality improvement.
Annual accreditation, while we agree with the accreditation, I think the period is too short. Yearly accreditation does not allow the change management interventions to happen, you shut a lot of these units before they even get started. (Private sector obstetrician)
Concerns were raised regarding the enforceability of clinical guidelines and the lack of mechanisms to ensure provider compliance. Even when guidelines exist, a member of the SA Society of Obstetricians and Gynaecologists (SASOG) stated that there is no monitoring of their impact:
SASOG has produced a couple of guidelines which are held under the Better Obs program, I don’t think we have yet seen anyone have a look, what is the impact of the better Obs within private.” (Public sector obstetrician)
Stakeholders expressed concerns about the limited capacity of regulatory bodies, such as the Health Professions Council of South Africa (HPCSA), to ensure quality and enforce accountability.
But once again you have poor HPCSA oversight, the mandate is to protect the public by regulating the providers, but they’ve got no mechanism to assess quality out there, they’ve got no mechanism to assess outcomes out there, so effectively they’re very reactive in the way they do their stuff and from my perspective there’s a lot of work that needs to come up. (Private health funder)
Risk-based care pathways
Stakeholders highlighted the importance of clear risk stratification with team-based models of care to ensure that women receive care from the most appropriate team member depending on their level of risk. One private obstetrician who had implemented a team-based care model described how this approach replicates the model of care in the public sector:
We stratify you according to a very standard stratification process through a multi-disciplinary team process, you’re allocated to a risk band and your care plan is then carried back and forth between the obstetrician and the midwives and the rest of the team, so essentially that is how it is organised and that is a public sector model, we didn’t recreate this we just borrowed it from where it was already well developed. (Private sector obstetrician)
A public sector obstetrician described the experience of applying risk-based guidelines to determine appropriate care pathways:
From working in the public sector I would say one third of the patients could possibly be managed under purely midwife care and be cared for throughout and delivered by midwives without the involvement of a doctor. Probably about a third have got risk factors or complications that would require at least co-management with the doctor but still deliver vaginally but maybe about a third will maybe end up having a Caesar. (Public sector obstetrician)
Risk-based global fee per maternity care episode
The proposed remuneration model consisted of two key components: (1) A value-based risk-adjusted global fee for maternity care, covering the full period from antenatal to postnatal services at a birthing centre; (2) time-based remuneration for providers working at a birthing centre.
While the shift to a value-based, global fee model was broadly supported, stakeholders raised several key considerations, including the need to define “value-based” care, manage risk-sharing mechanisms, agreeing on the structuring of global fees, and navigating regulatory constraints.
Stakeholders highlighted concerns regarding how risk and value would be measured and shared within a value based, global fee model. One private obstetrician shared an example of a risk-based approach to costing that differs from the current private sector fee for service approach:
Once we have stratified them then you allocate resources so that the least complicated use some resources but your most complicated people are using most resources so your obstetrician will spend more time with the complicated cases rather than the approach which is now agnostic to complexity to a large extent. We also believe that this should form the bottom-up pricing approach or costing approach. Once we accept that most complex people require most time and most skills, then you accept the notation that we must risk grade the global fees. (Private sector obstetrician)
A key issue raised was the need for accurate, standardized data collection to support risk-adjusted remuneration models.
When we talk about risk-based renumeration for example, risk adjusted renumeration you can only do that if you have the data and the mechanism of collecting the data and ensuring that it is accurate is something that I think needs emphasis. (Private health funder)
Concerns were raised regarding what benefits and services should be included in the global fee to ensure transparency for funders, providers, and patients.
The big question is what are the specified benefits included and excluded? I’m highlighting this because if I look at the medical scheme environment at this point in time, there has been a lot of these alternative reimbursement in the last 2 decades but the main failure of this is because this is not specified properly. So, when you’re talking about this global fee, does it include hysterectomy after perhaps haemorrhaging or even sepsis type of thing, you need to specify exactly what is included in the global fee, what is excluded so the provider, patient and the funder there is complete transparency as to who is going to be doing what and what needs to be paid. (Private health funder)
Fixed-fee remuneration for providers
The proposal to remunerate providers at birthing centres on a fixed fee, time-based model sparked some concerns. One health funder commented that the current remuneration model used by health insurers does not allow for specialists to claim for time, only for procedures (fee for service). A midwife in the public sector raised concerns that time-based remuneration may be inadequate for midwives who spend long periods with birthing women.
It’s mentioned about paying time-based costs. Coding currently doesn’t allow that for obstetricians. There are no time-based codes. You cannot pay for time in obstetrics. Okay, so you have to look at it from a coding perspective. And also, how do we actually prevent that time-based is not going to lead to a situation where quality is compromised by pursuing a time-based model, so there is a lot of things that need to be built into a funding model. (Private health funder)
Time-based I cannot see independent midwifes going to work in hospitals for a salary. Again, it is not like they earn a high salary, it’s just sometimes you can look after a patient for 24 hours and I think that that is going to be very difficult to orchestrate. (Public sector academic midwife)
Group indemnity cover
Indemnity cover is a critical issue affecting maternity care in both the public and private sectors in SA. Any alternative maternity care model would need to address the challenges of indemnity coverage to ensure financial sustainability and patient safety. The proposed model recommended shifting from individual indemnity cover to a group-based indemnity model.
Stakeholders from the private hospital sector expressed strong support for transitioning to group-based indemnity cover rather than individual liability which comes at a large personal cost to private specialists.
We fully support transition from individual indemnity to the group one. (Private hospital)
A speaker from one of the leading indemnity insurers in the country emphasized that indemnity challenges are not just legal or financial issues but closely linked to patient safety and systemic risk management.
The real threat to obstetric care is around patient safety or maybe as administrators will understand that it is around liability. So, if it is around patient safety or liability, you really want to solve patient safety issues and it is very important as well to solve indemnity issues. You really have to solve the patients’ safety liability issues and it is beyond an individual, it is a systematic issue, it is about managing the labour ward, it is about using guidelines, it is about using protocols and probably having risk managers ensure that those guidelines and protocols are adhered to. (Indemnity cover provider)
The desired outcomes of a change in the current maternity care model
This theme relates to the participants overall perspectives on what they considered to be the desired outcomes of a new model of maternity care. Improving overall quality of care, shifting to more women-centred models, enhancing resource efficiency, addressing inequities, and fostering better public-private collaborations emerged as the key desired outcomes of an alternative model of care.
A representative from a civil society organisation shared the need to ensure a high quality of care in a new model:
It is not just about reducing caesarean section, but it is also about ensuring that all women have quality health care and I don’t think we should lose sight of that. (Civil society)
Sentiments were also expressed of the need to shift to more women-centred models of care as this representative from civil society shared:
Our starting point should really be women-centred care because everything else follows, you know if we’re able to get that right then everything else will work itself out. (Civil society)
Participants also discussed the need for a new model to provide a platform for more efficient use of resources, both human and financial as one obstetrician in the private sector shared:
There are low productivity models, so solo practice either in midwifery or in obstetrics are not scalable; an obstetrician delivers one baby every two days or so, this is the kind of productivity but in a country with 800 gynecologists for 60 000 000 people, that’s bad productivity. (Private sector obstetrician)
A representative from a private hospital group echoed these sentiments:
I think there is extra capacity in the private sector this is irrefutable so, uhm I can talk for (name of hospital group). We have 33 units, our busiest unit, which is (name of hospital), they deliver 7 babies a day, of which 3 is likely to be NVD (normal vaginal delivery). Collectively as a business we deliver 100 babies a day which is the equivalent of (name of large academic public hospital) as a single hospital, per day. (Private hospital group)
The final desire for a change in the private sector model was related to addressing inequity and developing a model that would lend itself to public-private engagement so that the resources from the private sector could be used to the benefit of the entire population as these two participants described:
One of the critical success factors to any approach would be to take along the greater and the broader majority of people that access our health care and that is something that I think needs to be looked into. (Health regulator)
Coming from the public sector perspective, there should be some way in which the excess doctors’ resources in the private sector helps the public sector, so I think the thing we haven’t been able to explore enough but it is necessary for the way forward is, how can the public sector be able to make use of the HBBCs (hospital-based birthing centres). I think that could happen in the urban areas. (Public sector obstetrician)
The following themes relate to issues raised by participants as important considerations that would need to be taken into account when shifting to an alternative maternity care model for the private sector.
Operating model and ownership of a birthing unit
The birthing unit model proposed was a hospital-based model, however, midwives raised concerns about situating a birthing unit within a hospital since pregnant and birthing women are not sick and the hospital environment can be fearful for women as one midwife described:
We need an environment that is welcoming for people that they’re not fearful, and therefore I would be reluctant for this to be embedded in a hospital building. An environment that reeks of power, control, illness, because it’s not an illness, pregnancy is not an illness it’s a health event. We do need to make sure that that is part of the understanding of such a service in my opinion. (Public sector academic midwife)
The proposed model assumed that ownership of birthing units would be by private-hospital groups, however, private obstetricians were vocal about the need for a birthing unit to be owned by the clinicians. This view related to the need to ensure remuneration for specialists for their clinical oversight role in a unit that would have predominantly midwife-led births.
Private hospitals must never own these HBBCs, that’s a big no for us. In that model all these disciplines would co-own the company so that even when you’re not turning up for the caesarean, you’re compensated as part of the team because you own the entity and your expertise is not only coming into play at the point of care, its coming to play in the backend when you’re doing the quality assurance and everything else that’s required. (Private sector obstetrician)
Legislative and regulatory changes
While there was broad support for a team-based, multi-disciplinary practice approach, concerns were raised about potential regulatory hurdles, particularly within the medical insurance environment. Stakeholders emphasized that legislative and regulatory reforms would be essential for the successful implementation of the proposed alternative maternity care model.
Overall, the team-based care is good. The multi-disciplinary practice approach is good. You might be facing a regulatory hurdle in terms of the implementation of this multi- disciplinary group practice to address the problem that you’ve got currently within the medical scheme environment because of regulation 5 of the medical scheme Act. Regulation 5 says, for all invoices of these group practices you have to list the practitioner of service; who the person was, what service was rendered, and then obviously the reimbursement amount that goes with them, so if you’re going to go with the whole- risk adjusted global fees you might have a little bit of problems and a little bit of issues to overcome, but it’s not insurmountable I think it can be done. (Private health funder)
A midwife raised the need to consider how to create effective group practices that are inter-disciplinary with different regulatory oversight:
I don’t think the changes have embraced the issue of being able to go into partnership with health professionals that are registered with a different regulatory body and if that’s the case that means that the midwifes will always be salaried staff under the power of doctors, and I don’t think that that is a partnership. I think that it is continuing the dominance of the medical model, which I don’t think is appropriate in caring for women who are essentially healthy in most cases. (Public sector academic midwife)
Targeted education to address fears and misperceptions about midwife-led vaginal birth
This theme emerged as a critical aspect that should be addressed in order to shift to an alternative model of care. Participants agreed that the drivers of the high caesarean birth rate in the private sector are multi-factorial and that any shift to an alternative model of care would require restoring confidence and trust in midwife-led care and women’s confidence in their ability to give birth through innovative large-scale behaviour change communication.
It is very important that we work on our community, there is a perception that all women need to see an obstetrician and that is not really necessary, we need to build that being with a woman midwife led care where there is trust, skill and also choices for the clients. (Public sector academic midwife)
When you speak face to face with the patients, their choices are driven by TikTok, by google, by what the next door neighbour said, so the educational component which was spoken to by WHO colleagues at the beginning of it is patient education. (Private sector obstetrician)
We’re made to believe that these teams can’t work together, we’re made to believe that midwifery-led care for low-risk women is potentially inferior when actually its vaginal birth that is feared. (Independent private midwife)
Opportunities for public-private engagement
The proposed alternative maternity care model aimed to address high levels of inappropriate care in the private sector while also creating opportunities for PPEs to mobilize private sector resources in support of the public sector. Given SA’s ongoing health reforms to implement National Health Insurance (NHI), ensuring that the proposed model aligns with NHI strategies and objectives is a key consideration.
Stakeholders highlighted several issues that would need to be addressed to achieve seamless integration with NHI.
There is no framework to mobilise private sector to serve the broader population without transferring some of the problems in private sector. (Private sector obstetrician)
Another challenge identified was how the proposed model would integrate with public sector maternity care services, since antenatal and postnatal services are provided in primary care clinics and deliveries in hospitals and these services will be reimbursed using different mechanisms under NHI.
The NHI fund will pay for primary health care services via capitation mechanism, essentially a fixed per user payment for looking after a patient for a period of time. Hospitals will be reimbursed via an episode-based system called diagnosis related groups and global budgets. It is the initial thinking that that package will include antenatal care. Not births, not deliveries but antenatal and postnatal maternal and child health care will be included in that package, and this is something that we will need to think about. (National Department of Health)