During the COVID-19 pandemic, pregnancy has become an even more emotional experience. Women place all their hopes and trust in midwives and doctors to assist them during labour. Incidents of mistreatment or sub-standard care reach social media and news outlets quickly, and the community at large condemns health workers for no-care actions. Women want a positive birthing experience, even in an overloaded and under-resourced health system. 

It is no secret that women are more vulnerable during pregnancy. They are also looking forward to the birth of their babies. Communities expect respectful quality maternity care from health centres and hospitals. 

Generally, health care providers are compassionate and caring. They want to learn more and practice quality obstetric care that will reduce stillbirths and new-born deaths. CLEVER Maternity Care is a programme created by the University of Pretoria’s Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies to improve respectful care during childbirth in district hospitals and midwife obstetric units in community health centres. It addresses gaps in the health system and clinical governance and focuses on teamwork and improving health professionals’ knowledge and skills. Champions model respectful quality birthing care to the rest of the team and encourage midwives and doctors to do better every day. 

CLEVER is the acronym for Clinical care, Labour ward organisation, Elimination of care barriers, Verification and measurements to improve care, Emergency obstetric care drills, and Respectful care. Clinical practices can only improve once a health facility’s functioning is enhanced by strengthening the basic infrastructure. The environment must be clean and cared for; essential equipment must be available and maintained; medicines and other supplies should be at hand and continuously replenished. 

The CLEVER programme supports managers, midwife teams, doctors and other clinical staff with weekly support sessions to help create a safe environment. The sessions model behaviour change, reinforce collaboration and teamwork and build clinical capacity. Each session starts with a bedside hand-over round during the change of shift of day and night staff. The rest of the session is embedded in mentoring and coaching around respectful and safe childbirth care, including a simulated drill to improve emergency deliveries skills. The team discusses guidelines and other educational materials selected for that week. 

Why does the implementation of CLEVER Maternity Care work? At the core is the change of habits through repetitive activities until new care habits become automatic. Staff find it satisfying because they observe the improvements in their care. 

The process of behaviour change begins with awareness of own and team behaviour. The centre looked at occupational safety insights to inform actions to improve staff’s levels of competence and respectful care. Pointing-and-calling is a method to reduce negligence and human error, leading to the coordination between one’s mind and hands. It makes team members aware of the accuracy and helps them to concentrate better. 

The daily celebration of small gains and simple rules improve habits and skills. For example, the ‘NO shouting!’ practice reminds the team to avoid disrespect and mistreatment. Team members are also encouraged to offer assistance and support to colleagues struggling with a difficult birth or an anxious client. Small acts of kindness can make a difference on a bad day.

The University of Pretoria’s Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria and at the Maternal and Infant Health Care Strategies Unit, implemented the CLEVER Maternity Care in Tshwane District. There was an overall improvement in women’s satisfaction with their childbirth experience. They appreciated having a voice. The skills and knowledge of the birth attendants improved, and there was a reduction in stillbirths and new-born deaths. Respectful care, appropriate communication and improvement in maternity services made the difference. 

The pandemic has overwhelmed our health system, thus putting a strain on maternity health workers’ physical and mental health needs. District health management and their teams should reflect on how to improve all the time, one step at a time, despite the adverse circumstances.

About the Author: Dr Sarie Oosthuizen is a Family Physician at the University of Pretoria’s Research Centre for Maternal, Fetal, New-born and Child Health Care Strategies, University of Pretoria and at the Maternal and Infant Health Care Strategies Unit, SA MRC. She holds an honorary appointment at Tshwane District Health Services, where she was the District Clinical Specialist Team leader until May 2020. 

Dr Oosthuizen assists with quality improvement projects and further implementation of CLEVER Maternity Care in district healthcare facilities.