Towards developing new private sector maternity care models in South Africa: results from a deliberative stakeholder dialogue

Abstract

Background

Public-private partnerships are a key strategy in many middle-income countries to promote universal access to quality health care and reduce inequities. In maternity care, addressing inappropriate patterns of care within the private sector is essential for these partnerships to succeed. Caesarean rates are rising globally, four of the five countries with the highest caesarean rates are middle-income countries and private hospital care is a strong predictor of caesarean birth. Maternal health care in South Africa faces major challenges in both the public and private sectors. In the public sector, overburdened services and limited skilled staff contribute to poor outcomes. In the private sector, a caesarean birth rate of 77% reflects widespread inappropriate care. Improving equity and outcomes requires leveraging private sector resources, but only if quality issues are addressed. This calls for the development and implementation of new private sector maternity care models. We proposed an alternative model as a starting point for stakeholder engagement. A deliberative dialogue was convened in 2024 to discuss the proposed model. Stakeholders were purposively selected to provide input. The session was audio-recorded and analysed using thematic content analysis. This paper presents a thematic analysis of the issues and responses that emerged from the dialogue.

Results

Key themes that emerged included the need for: a common set of protocols and clinical guidelines for maternity care; a clearly defined benefits package covering antenatal, intrapartum, and postnatal care; a multidisciplinary maternity care team; targeted education to address fears and misperceptions about midwife-led vaginal birth; legislative reforms to allow women-centred team-based birthing units to function as contracting entities. While there was strong support for further development of alternative maternity care models, follow-up discussions revealed the need for a broader coordination process to advance these proposals.

Conclusions

High caesarean birth rates in South Africa’s private sector indicate inappropriate care. The proposed maternity care model emphasizes women-centred, team-based approaches. Stakeholders at the dialogue expressed support for legislative reforms to allow for the creation of multi-disciplinary birthing units. The need for large-scale, innovative behaviour change communication to reduce fears of spontaneous labour and vaginal births, should not be underestimated. Maternity care presents an ideal opportunity to develop public private-partnerships critical towards an integrated, equitable health system in South Africa.

Clinical trial number

Not applicable.

Background

Caesarean birth rates are rising worldwide. Projections estimate that, by 2030, 28% of all newborns will be born surgically. Of the five countries with the highest caesarean birth rates globally, four are middle-income countries and one, Cyprus, is high-income [1]. Receiving care in a private hospital is an important predictor of a caesarean birth. Several middle-income countries have large differences in their caesarean birth rates between public and private health facilities including India [2], Vietnam [3], Brazil [4] and South Africa (SA) [5]. As middle-income countries strive to reduce inequities through universal access to quality health care, public-private partnerships emerge as an important strategy to achieve this [6]. However, addressing inappropriate patterns of care in the private sector, such as inappropriately high caesarean birth rates, is necessary in order for these partnerships to achieve their objectives.

Maternity care in SA faces significant challenges in both the public and private sectors. In the public sector, women with low-risk pregnancies receive midwife-led antenatal care at primary care clinics, community health centres and midwife obstetric units (MoUs). Referrals are made based on risk assessment at each visit and according to agreed upon referral criteria which stipulate which obstetric, medical and neonatal conditions should be managed at each level of care (primary, secondary and tertiary). Care is provided free of charge [7]. Caesarean birth rates (28.8% at the national level) [8] are comparable to the public sector of other middle-income countries [9].

In the private sector, the model of care is predominantly solo obstetric specialist based, with all levels of maternity risk being managed by the obstetrician, on a fee for service basis [5]. Caesarean birth rates of 77% [10] are among the highest in the world. A study exploring modes of delivery amongst members of ten health insurance schemes in SA found that 40% of the caesarean births were classified as elective [11]. When indicated, caesarean birth can play an important role in saving the lives of mothers and children. While it is now recognised that there is no fixed caesarean birth rate which can be considered to be applicable globally and in all situations, evidence gathered by the World Health Organization (WHO) indicates that there is no public health benefit when the rate exceeds 10–15% at a population level [12]. Seen in this light, the high caesarean birth rate in the SA private sector has to be considered to be inappropriate care.

Further research is needed to confirm this, but several factors may contribute to high caesarean birth rates in the private sector in SA. These include individual specialist-driven care models, fee-for-service remuneration, medico-legal frameworks, and a lack of clinical governance [5]. A research brief of the Council for Medical Schemes, the regulatory body for private health insurances in SA, concluded that “urgent steps must be taken to reduce what is likely to be high levels of medically unnecessary caesarean births in the medical schemes population” [10]. A key challenge for policy makers is how to address the inappropriate patterns of obstetric care in the private sector and how to mobilise private sector resources to serve the broader population dependent on the public sector, without replicating those patterns of inappropriate care.

There is global recognition of the need to shift towards person-centred, respectful, integrated and high-quality maternity care, provided and coordinated by midwives working within collaborative interdisciplinary teams. In 2024 the WHO published a global position paper, and in 2025 implementation guidance on transitioning to midwifery models of care [13, 14] with the justification that transitioning to midwifery models of care represents a cost-effective strategy to optimize outcomes for women and newborns with minimal use of unnecessary interventions. The model of maternity care in the public health sector in SA is midwife-led yet is under-resourced both in terms of human and financial resources, lacks continuity of care and does not always ensure a positive experience of care as recommended by the WHO [15, 16]. Developing and implementing new maternity care models in the private sector which lend themselves to Public Private Engagements (PPEs) with the public sector could play a vital role in relieving some of the burden on the public sector and improve equitable access to high quality and safe maternity care.

Drawing on insights from our research on care and contracting models in five rural district hospitals in the Western Cape, where private general practitioners (GPs) were contracted to provide caesarean delivery services [17–19], we proposed an alternative model for delivering maternity care in the private sector. This proposed model was developed as a starting point to initiate stakeholder dialogue on new models of private sector maternity care [20]. As a first step, we convened a deliberative stakeholder dialogue to discuss and refine the proposed model. This paper presents a thematic analysis of that dialogue.

Methods

We utilised the deliberative dialogue health systems research method [21] to document stakeholder inputs and discussion content from a one-day dialogue on a proposed model of maternity care for the private sector. Deliberative dialogues are a group process that can help to integrate and interpret scientific and contextual data for the purpose of informing policy development and are increasingly being used, particularly on the African continent to bridge health research with action [22]. These dialogues “allow research evidence to be considered together with the views, experiences and tacit knowledge of those who will be involved in, or affected by, future decisions about a high-priority issue” [23].

Data collection and analysis

A one-day deliberative dialogue was held in September 2024 at the University of Pretoria hosted by the Health Systems Research Unit, South African Medical Research Council (MRC) in partnership with the Clinton Health Access Initiative (CHAI).

Key stakeholders involved in maternity care oversight or delivery were invited. The list was jointly curated by MRC and CHAI to ensure fair representation among policymakers and other stakeholders. Slightly more obstetricians (7) participated than midwives (5) since we sought to invite representatives from all relevant stakeholder groups and there were more stakeholder groups involving obstetricians. The invited participants were provided with the proposed model [20] and a summary of it, in order to provide background to the policy issue for discussion. The key principles of the model are summarized in Fig. 1. These principles were: (1) the model of care should be multi-disciplinary and team-based; (2) professional indemnity should be covered by a hospital birthing centre on a group basis rather than the current individual liability model; (3) hospital birthing centres should be required to be compliant with evidence-based clinical guidelines and protocols with regular structured audit and feedback processes in order to receive and maintain accreditation; (4) there should be a risk-based antenatal, intrapartum and postnatal care pathway based on evidence-based guidelines; (5) the hospital birthing centres should be remunerated through a risk-based global fee for the full period of maternity care; (6) health care providers working at a birthing centre should be remunerated through a fixed fee (per session or month), not on a per case or type of delivery basis. The level of remuneration should be commensurate with the level of skill and expertise of the provider.

Fig. 1.

Principles for a proposed alternative model of maternity care. (adapted from Solanki et al. [20])

The dialogue was held in-person to maximize engagement and discussion. Two stakeholder groups (WHO and a professional indemnity provider) were based in Europe and unable to travel to the event so they submitted pre-recorded video inputs and did not participate in the dialogue. The main medical indemnity provider for health professionals in private practice in SA is an international insurance company with medical advisors based in Europe.

During the morning session, key stakeholder groups were invited to give a 10-minute response to the proposed model. No specific template was provided for these presentations however, the invitation letter requested speakers to consider their level of support for the proposed model, the key barriers to implementation and suggestions for dealing with them, refinements suggested to the proposed model or proposals for alternative models. This formed the first half of the dialogue lasting three hours. In the afternoon session all attendees had the opportunity to provide their inputs during a facilitated discussion of two hours duration. The facilitator invited participants from each stakeholder group to provide inputs focusing especially on stakeholders who had not presented in the morning session. No specific questions were posed, and participants were free to comment on any aspects of the proposed model or to describe their own experiences of alternative models of care. The list of stakeholder groups that were invited and the number of presenters and total attendees are listed in Table 1. All participants were present for the full duration of the dialogue including the morning and afternoon sessions.

Table 1.

Dialogue participants

Stakeholder Group	Number of presenting attendees in the morning session	Number of non-presenting attendees	Total number of attendees
National Department of Health, National Health Insurance section	1	1	2
Obstetricians: including members of SASOG, private and public sector obstetricians representing the NCCEMD	3	4	7
South African Society of Anesthesiologists	0	1	1
Midwives: including independent private midwives and midwives in the public sector/academia representing SOMSA	2	3	5
Private hospital association and individual private hospital groups	1	2	3
Civil society groups: including People’s health movement, Embrace, Section 27	0	4	4
Private health care consultants	1	2	3
Health funders association and individual medical insurance companies	2	3	5
Regulators including the CMS and SAMA	0	2	2
Global Health Funders	0	1	1
Global Health Agency: CHAI	1	1	2
Total attendees present at the dialogue	35
Additional pre-recorded video inputs
Professional medical indemnity provider	Based in the UK and sent a pre-recorded video input
Multi-lateral UN agency – WHO	Based in Geneva and sent a pre-recorded video input

SASOG: South African Society of Obstetricians and Gynaecologists; NCCEMD: National Committee on Confidential Enquiries into Maternal Deaths; SOMSA: Society of Midwives of South Africa; CMS: Council for Medical Schemes; SAMA: South African Medical Association; WHO: World Health Organization; CHAI: Clinton Health Access Initiative

The dialogue was audio-recorded and transcribed. We also collated all PowerPoint presentations given by invited stakeholders. The transcript from the dialogue and PowerPoint presentations were analysed using deductive thematic content analysis [24, 25]. The data were analysed by sector or profession (e.g. public sector, regulators, obstetrician, midwife etc.).

The team met on several occasions to reflect upon, discuss and come to mutual agreement on major categories and themes. We focused throughout on ensuring credibility and that our findings represented the deliberative dialogue. For example, we used triangulation to compare findings from across data sources such as stakeholder presentations and discussion comments in order to strengthen interpretations and create a more meaningful description of the policy implications of the proposed model [24].

Results

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.

Table 2.

Summary of major themes and key points

Themes related to the six key principles of the proposed model of care (Figure 1)		Additional themes that emerged from participants at the dialogue
Major theme	Key points raised in the dialogue	Major theme	Key points raised in the dialogue
1. Multi-disciplinary team-based approach	Involving cadres such as general practitioners and clinical associates in maternity care teams	7. The desired outcomes of a change in the current maternity care model	Improving quality of maternity care
	Team members should be enabled to practice within their full scope e.g. midwives conducting vaginal births		Women-centred models of care
	Clarifying roles and team leadership		Improve efficiency and equity
	Restoring trust and respect between midwives and obstetricians		Public-private engagement
	Loss of midwifery skills in managing labour and conducting vaginal births	8. Operating model and ownership of a birthing unit	Concerns about situated a birthing unit within a hospital environment since pregnancy and birth is not an illness event
2. Compliance with evidence-based clinical guidelines and accreditation	Inconsistent use and lack of enforceability of clinical guidelines in the private sector		Obstetricians favoured ownership by clinicians not hospital groups
	Instituting regular audit processes	9. Legislative and regulatory changes	Current restrictions on group practices have implications for global fees
	Accreditation cycle to allow for change management		Partnerships between health professionals under different regulatory bodies.
	Lack of capacity of regulatory bodies	10. Targeted education to address fears and misperceptions about midwife-led vaginal birth	Restoring confidence and trust in midwife-led care
3. Risk-based care pathways	Care plan matched to risk-stratification		Need for behaviour change communication to counter misperceptions and fears
	Health care provider assigned based on risk-stratification	11. Opportunities for public-private engagement	Improving equity in access to quality maternity care for the whole population.
4. Risk-based global fee per maternity care episode	Need to define risk and what is included in a benefit package		Continuity of care is a major difference between the public and private sector maternity care models.
	Risk-based remuneration relies on accurate data collection
5. Fixed-fee remuneration for providers	Fixed-fee remuneration not currently possible by insurance providers
	Fixed-fee may be inadequate for midwives spending long hours with birthing women
6. Group indemnity cover	Support for group-based indemnity cover due to currently high individual cost
	Indemnity linked to risk management, patient safety and need for protocols

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)

Discussion

This deliberative dialogue was the first attempt to bring together stakeholders to initiate discussions about an alternative model of maternity care for the private sector at a critical time in SA’s preparatory period for implementing a national health insurance scheme. The dialogue was deliberately structured to encourage open discussion rather than framing the model as something to be supported or opposed. While participants raised questions and concerns, there was broad consensus on the need for alternative models. Thus, it provided a forum for sharing of views and perspectives but was not able, given the limited time, to arrive at a mutually agreed upon maternity care plan for the private sector, or how PPEs might operate to benefit women in the public sector. The dialogue revealed recognition of the shortcomings of current maternity care and the urgent need for alternative care models. Team-based midwife-led care models, as proposed in the dialogue, have been found in a Cochrane review to result in higher rates of vaginal births, safer outcomes, more positive birth experiences [26] and lower costs [27].

Major health system reforms challenge vested interests and require strong political will and coherent strategies to succeed. The dialogue participants identified several key challenges that would need to be addressed in developing alternative maternity care models.

From a political perspective, the dialogue highlighted the broad range of stakeholders that would be affected by the potential reforms. Key political challenges identified included: Managing power relations and vested interests of different groups, aligning reforms with the country’s broader health policies and convincing policymakers and regulators to support the proposed changes. Shifting to a team-based model of maternity care represents a major change from the current solo obstetric practice model in the private sector. This would require systems of risk assessment to ensure that low risk women can be managed by midwives with medical doctor oversight, and obstetric specialists manage complex cases with joint management with other medical disciplines e.g. cardiologists as required.

The viewpoints of participants on team-based models of care revealed the critical need to clarify roles, responsibilities and scope of practice between midwives and obstetricians to address the currently large differentials in power, leadership and independence. Participants also emphasised the need to restore trust and respect between midwives and obstetricians to ensure the success of team-based models. A study undertaken in Germany to explore power and complexity in obstetric teamwork found that the issue of power and hierarchy emerged as a decisive factor in the social dynamics of the maternity care team [28].

From a content perspective, the dialogue emphasized the significant work required to develop alternative models. Essential components to address include: determining the most appropriate ownership model for birthing units, agreement on a common set of protocols and clinical guidelines for maternity care, development of audit and monitoring processes, development of a clearly defined benefit package covering antenatal, intrapartum, and postnatal care, determining the optimal multi-disciplinary maternity care team, creation of targeted education programs to address fears and misconceptions about midwife-led vaginal births and legislative reforms to establish women-centred, team-based birthing units as contracting entities.

The need to re-prioritise care towards being woman-centred was raised by several participants particularly representatives from civil society. An evaluation of a team-based maternity care model for women of low obstetric risk in Australia found that 91% were very satisfied with their overall pregnancy experience. In this private health care model, care was provided by general practitioners with obstetric training and midwives [29]. Aspects of care that were associated with high satisfaction included the supportive interpersonal relationships developed across the team, longer clinic appointments that allowed for a full discussion of concerns, and the convenience of having a range of maternity care services available in one location [29]. Another study from Australia compared cost and outcomes for low risk primigravida women in midwifery group practice with standard hospital care and private obstetric care. The study found that women who received care from a midwife group practice were significantly less likely to have an elective caesarean birth and a significantly lower total cost of care compared to both standard hospital care and private obstetric care [30].

A descriptive case study on midwife-led birthing centres in four low-and-middle income countries (SA, Bangladesh, Pakistan and Uganda) found four universal enabling factors influencing success of such centres: (i) an effective financing model; (ii) quality midwifery care that is recognized by the community; (iii) interdisciplinary and interfacility collaboration, coordination and functional referral systems; and (iv) supportive and enabling leadership and governance at all levels [31].

The need for large scale, innovative behaviour change communication at a societal level has been recognised as an important component of shifts to midwife-led care [32]. A scoping review of women’s mode of birth preferences found that perceptions of safety and fear of pain were major reasons for mode of birth preferences [33].

Substantial work remains in developing the structure and content of value-based contracting including: defining value-based care metrics, designing fair risk-sharing mechanisms, clarifying covered services, ensuring regulatory compliance and determining feasible provider remuneration structures. Work is also needed to establish reporting, monitoring, and accreditation standards and mechanisms to ensure compliance across the model. Indemnity and indemnity cover emerged as a critical concern. Effective risk management strategies, such as adherence to clinical guidelines and standardized protocols are seen as essential in reducing liability risks. Strong mechanisms for monitoring health establishments against core norms and standards exist in the public sector under the Office of Health Standards Compliance, an independent body established to ensure quality and safety in healthcare by monitoring health establishments. However, monitoring of private health facilities only began in 2022 and only 21% of private health facilities have been inspected compared to 65% of public health facilities [34].

While the dialogue primarily focused on reforming the private sector maternity care model, participants stressed the importance of aligning the proposed model with broader healthcare reforms in SA; and the need for improvements in public sector maternity care. A key consideration for alignment with broader health reforms includes considering how to improve continuity of care for women in the public sector where antenatal and postnatal services are commonly provided at different health facilities (primary care clinics) to intrapartum care (community health centres and hospitals) which is different from the private sector model where all care is provided by a specialist obstetrician at a private hospital. Addressing these policy and structural challenges will be essential to enable PPEs.

Participants at the dialogue acknowledged that while the proposed model served as a useful catalyst for discussion, there is no “one-size-fits-all” model. The complexity of dealing with multiple stakeholders and the range of issues that need to be addressed makes a centrally co-ordinated process difficult. A more feasible approach may be for policy makers and regulators to create a more flexible regulatory framework which allows the different stakeholders (or groups of stakeholders) to develop and pilot alternative models more actively and with greater leeway.

The study highlights the urgent need for alternative maternity care models in SA’s private sector. With a maternal mortality ratio of 111.7, in 2023 [35], SA is far from reaching the SDG of 70 by 2030. Two thirds of maternal deaths are deemed to have been preventable within the health system, so the urgency of reform is clear. Utilisation of private sector resources to assist the public sector with quality improvement and access; and reducing inappropriate patterns of care in the private sector are both very important.

Strengths and limitations

A strength of the deliberative dialogue approach was having a wide range of stakeholders together in person to provide inputs on the model. Limitations include that two stakeholder groups were based in Europe and due to the decision to have an in-person only event, these stakeholders could only provide pre-recorded input and were not able to participate in the discussion. They may have had important insights to share in the discussion that are not captured in the findings. The participating stakeholders all had vested interests that would be challenged in an alternative model. Participants may not have felt free to share what could be considered controversial thoughts. Both private and public sector stakeholders participated and these sectors have different goals and agendas (shareholder profit versus universal health coverage). One day may not have been enough time to establish trust to share freely. The proposed model focused primarily on private sector reform; neither the model nor the dialogue explicitly explored quality improvement of public maternity sector health systems (community health centres, midwife obstetric units, district hospitals, regional and tertiary hospitals), which would also be essential to improve maternal health outcomes in SA.

Conclusions

Models of maternity care globally are evolving towards a greater focus on woman-centred care, accompanied by evidence that increasing interventions raise costs but do not improve outcomes. SA is at a critical point in the journey towards universal access to high quality maternity care for all women which requires shifting the model of care in the private sector towards a team-based midwife-led model that offers the potential for public-private engagement.

However, altering care models within health systems is complex, requiring coordination among multiple stakeholders and addressing diverse challenges. The inputs received at this first dialogue pave the way for further discussion, legislative and regulatory changes and opportunities to test new models within a more flexible regulatory framework.

Author contributions

TD: Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. SF: Conceptualization, Writing – review & editing. VB: Conceptualization, Writing – review & editing. GS: Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. All authors read and approved the final manuscript.

Funding

The research was funded by the Clinton Health Access Initiative and the South African Medical Research Council.

Data availability

The anonymised transcript of the dialogue is available from the corresponding author on reasonable request.

Declarations

Human ethics and consent to participate

Ethics approval for the dialogue was obtained from the Human Research Ethics Committee of the South African Medical Research Council (Protocol ID: EC002-3/2024). Participants were provided with an information sheet and consent form which all participants signed either prior to or on the day of the dialogue.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.