NHI IN SOUTH AFRICA

 I have been working in the South African healthcare system for about 9 years. I started as an intern in Thelle Mogoerane Regional Hospital, and did one year of community service at Bara Hospital. I was extremely enthusiastic about my South African medical experience and didn’t mind the overcrowded and short-staffed hospital environment. Every day had a new challenge and new experienceS in clinical medicine.

 Thelle Mogoerane Hospital was recently renovated and had quite a pleasant environment. The government wanted to start the process of making the hospital services paperless in 2015. They started training the staff and distributing laptops, but it was never implemented. We only had access to X-rays over the PAX computer system. This would make hospital record keeping and access to patient’s old files very easy and we also did not have to struggle with various doctor’s handwriting. My Bara maternity experience was different. The department was extremely rundown and old. The post-natal wards were extremely busy, and the hospital did not have warm water and clean toilets. Later on, I had a very pleasant birth experience in one of the private hospitals. The post-natal wards were very clean  with great nursing care. Reflecting back at such a huge discrepancy between the public and the private sector I really feel like something needs to be done in South Africa’s healthcare system.

The NHI is a fund, paid by the taxes from which the government will buy health care services and provide good quality universal health care. This means when we are unwell we can go to our nearest GP or clinic of our choice that has a contract with NHI and not worry about the cost of care. The public sector is providing health care services for 84% of the population and is currently under financial constraint.

The fund will be implemented over phases and over many years. Regulations will be published to address the phased implementation of the NHI Fund and the phased implementation of service benefits as the money is moved to the fund. The business models of the private funders and their business administrators will change over time. Once the NHI covers a benefit, the medical schemes may not cover the same benefits. This means that their membership fees must be reduced and some will be too small to survive so they will consolidate with others to maintain a viable risk pool for the benefits that they will still cover. Administrators of medical schemes no longer manage over 250 options, meaning the complexity of their services will be greatly reduced.

WOMEN IN LEADERSHIP

 As an obstetrician and Gynaecologist we work in a female-dominated environment, however, a lot of the high management posts are held by male doctors. We assume a lot of female doctors compromise on work and research to try and have time to build a family. Even though a lot of the male partners try and be hands-on fathers and help with the raising of kids, the mothers carry most of the burden and they are the organizing and nurturing person who keeps the family together.

 I was very privileged to train in the Wits Obs and Gynae unit under the leadership of Professor Yasmin Adam from 2017. I stepped into community service at Chris Hani Baragwanath Hospital in 2017 and she was the head of the Obs and Gynae Unit. I was extremely overwhelmed to see the high number of registrars and consultants who work at Bara and the high turnover of the patients. Professor Adam was an excellent leader. She could easily manage the clinical aspect of work which involved patient care and academic activities.

She was a great mentor and had a special interest in the screening and treatment of women with cervical cancer in Sub-Saharan Africa. She would personally run the colposcopy clinic on certain days, had numerous publications, and supervised a lot of research projects. We all enjoyed her bedside teachings in the labour ward rounds, and we had lots of teaching episodes when we were preparing for our final FCOG exams. She helped me a lot during my final research corrections, and in that process, I learned a lot from her although I was quite tired and exhausted at that time with the process, now I miss doing research and academic work.

I did not know much about Professor Adam’s personal life, but I know that having a demanding job really takes a great toll on a woman’s personal and family life.  In April the Obs and Gynae department celebrated her retirement and it was a beautiful and emotional night with lots of laughter and tears. She gave us a beautiful speech and highlighted her struggles in the apartheid system as a medical student of Indian ethnicity, and now we are in a place where we have access to education regardless of our race and colour.

 

22 MAY WORLD PRE-ECLAMPSIA DAY

 I am on call and about to leave my house at 6:30, and I get a phone call that a pregnant patient has been admitted to labour ward with eclamptic seizures. The medical officer on call was concerned that despite loading the patient with Magnesium Sulphate the patient had another seizure and was considering other agents such as intravenous Lorazepam and Diazepam. Instantly a lot of things go through my mind, regarding this patient's management. We know that stabilizing the mother takes priority over the baby, and we know once the mother is stable and loaded with Magnesium Sulfate and her blood pressures are controlled we can plan the delivery of the baby which is the ultimate treatment for pregnancy-induced hypertension.

 Pre-eclampsia is a severe complication related to hypertension affecting pregnant women. It can be life-threatening for the mother and the baby. It is still on top of the list of the causes of maternal mortality. In our facility, we had about 3 maternal deaths due to severe pre-eclampsia in 2023. Two patients passed away due to cerebral haemorrhage, one patient changed condition after being intubated with eclamptic fits and demised. Problems with pre-eclampsia can start from week 20 of pregnancy and can last up to 6 weeks after delivery.

It is important to know that pre-eclampsia is a common disease with an incidence between 2-8%, and it affects 4.1 million women per year worldwide. It is responsible for 9% of maternal deaths in Africa and Asia and 26% in Latin America. Things look better in high-income countries however 16% of maternal deaths are seen in African Americans and Latin Americans.

Pre-eclampsia can start with slightly elevated blood pressure and proteinuria, it is a progressive disease that can bring complications such as eclampsia, haemorrhagic stroke, haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, placenta abruption, renal failure, and pulmonary edema. I never forget our patient who was admitted for severe early onset pre-eclampsia at 28 weeks, and we were monitoring her blood pressure and blood tests regularly trying to buy time to deliver the baby later, who ended up with an abruption placenta, massive haemorrhage, pulmonary edema, and ICU admission. We lost the baby, but the mother survived.

The discovery of Magnesium Sulfate as an agent to stop eclamptic seizures and prevent their recurrence has saved a lot of lives over the years. Its use was introduced in the 1900s via an intramuscular injection, however, it wasn’t until the 1920s that major controlled studies demonstrated its superiority over other anticonvulsants.                                                       

We know that a lot of the adverse events in pregnancy tend to repeat in subsequent pregnancies. Another agent that we use very commonly in the ante-natal period is low dose Aspirin to decrease the risk of severe early onset pre-eclampsia. Women who survive pre-eclampsia have long-term consequences such as the risk of stroke, cardiovascular disease, and diabetes, and need to follow up with their healthcare practitioners to keep those risks under control. 

WHY PRECONCEPTION CARE MATTERS

 

Preconception care refers to health measures and planning done before becoming pregnant to ensure a healthy pregnancy and birth outcome. It is best to ensure that reproductive-age women are in optimal health before falling pregnant.

 

o   Women are encouraged to stay fit, and eat a balanced diet rich in essential nutrients such as folic acid, iron, and calcium. Any chronic illnesses such as anemia, diabetes, hypertension, or thyroid disorders are identified and managed accordingly

 

o   Women should be up-to-date with their vaccinations especially Rubella and Varicella, to avoid infection during pregnancy which can affect the fetus and cause severe abnormalities. We also offer screening for various sexually transmitted diseases such as HIV, Hepatitis, and Syphilis to make sure we treat the mothers and their partners and reduce vertical transmission.

 

o   We advise women to avoid harmful habits such as smoking, excessive alcohol consumption, and recreational drugs. They can increase the risks of congenital abnormalities, growth restriction, and intrauterine fetal death.

 

o   Genetic counseling can be done to discuss the family's medical history and the genetic risks. This was very important in my home country where Thalassemia was common and partners had to be screened for Thalassemia minor, and if they were both carriers chances of them having a baby with Thalassemia Major was 25%.

 

o   Women should be screened for mental health issues such as stress, anxiety, and depression. We all know that pregnancy and puerperium can affect a woman’s mental health in various ways. We need to ensure she has mental well-being and good social support to be able to take care of another human.

 

o   Women with previous miscarriages, or other adverse pregnancy outcomes are advised to book early in pregnancy so we have enough time to screen them for high-risk conditions such as pre-eclampsia, preterm labor, etc. By taking these steps individuals can reduce their risk of complications during pregnancy and child care.

 

 

 

ON MOTHERHOOD

 My mother and I have a wonderful relationship together. Since I had a baby myself, I have needed her support even more these days. We are very blessed to stay in the same residential complex. Every morning I drop the baby by her and I know I can focus on work while she is taking good care of her. If I am running late from work or there is an emergency the baby can stay with her longer.

My first memories of my mom, were probably when I was about 5 years old. My favourite bedtime story was the ugly duckling, and every single night I used to cry to that story even though it had a happy ending! The other memories are from the time my little brother was born. Back then we did not have disposable nappies and washing and drying the special cloths used as nappes was a process. I remember my little brother’s nappy time, bath time, and feeding times. The best memories of me and mom in my adult life is our little trip to Mauritius.

Another prominent part of my childhood was grandma. She was lovely. Always kind and patient.  We used to stay in the same house. She always had lots of stories to tell from how she met Grandpa, her teaching career and challenges, and how mom and uncle were raised and married. I always felt great around her. She even organized someone to sort out my sewing and knitting school projects in grade 6. Later on, I developed an interest in crochet when I was an intern, it used to help me relax from work stress. 20 years ago there were no YouTube tutorials, so I had to sit next to granny’s friend and follow her crochet steps!

Motherhood has really humbled me and there are several things I wish I had known before:

I always looked at my mom and felt like I would do better one day, but now I understand that all mothers are doing their best for their children, no matter what they go through in life.  Things I want to do differently from my mom is to be more fun and playful with my daughter and be her best friend.

It really takes a village to raise a child. We all need support from our partners, family, friends, and community to look after the children. I am blessed to have my parents around after I immigrated to South Africa.

We tend to lose our old identity after we become mothers, and it is difficult to be fully functional in our careers. Women often choose to work part-time or stay at home to be able to give the care the children need, and it is an extreme honor to raise small humans into adults.

Motherhood in the modern age is a complex topic. A lot of things need to be addressed such as the challenges of work and family life, the impact of social media on motherhood and parenting, and the importance of self-care and mental health for mothers.

 

The photos are of my mother and me,  then and now!

TRYING TO CONCEIVE

 There is a lot of pressure on women who are trying to conceive. Usually, there is a flicker of hope when they miss their period for a few days, and the hopes and dreams shatter when the period comes. This means the uterine lining gets thickened and becomes secretary with all the Estrogen and Progesterone, but the egg and the sperm do not get together to fertilize, therefor the endometrial lining sheds and menstruation occurs.

To work out the best time to fall pregnant we need to know how the menstrual cycle works. This starts from the first day of the last menstrual period (LMP) until the first day of your next period. On average this cycle takes 28-32 days. Based on a 28-day cycle, and counting from the first day of your LMP, the date of ovulation can be anywhere between days 11-21. This is when women are most fertile. There is usually an increase in cervical mucous, which is the perfect medium as it helps to protect and nourish the sperm as it proceeds towards the egg.

The egg only lives for a short time (12-48) after leaving the ovary, but the sperm can survive between 3-5 days in the female reproductive system. Millions of sperm are ejaculated by the male partner during sexual intercourse, but only a few reach the fallopian tubes. There needs to be at least one healthy and vigorous sperm already waiting in the fallopian tube when the egg is released during ovulation.

The best chance of conception occurring is when intercourse takes place during the 5 days before ovulation, there is a 33% chance of falling pregnant if the intercourse takes place on the day of ovulation. We are not the most fertile species but approximately 99% of humans do fall pregnant after having intercourse with no contraception for 12 months.

 

 

 That is me, heavily pregnant on the last day of work, before my maternity leave. 

 

 

 

 

 

ADOLESCENT'S FIRST GYNAE VISIT

 A teenager’s first gynaecology visit can be quite daunting. The most common reason for their check-up is usually dysmenorrhea or heavy menstrual bleeding. Some girls even get admitted to the hospital with severe anemia to receive a blood transfusion. Some mothers bring along their young daughters to familiarize them with gynae visits, while others come for birth control counseling. We rarely get consults for early or delayed puberty.   

Puberty typically begins between the ages of 10-14 and lasts around 2-3 years. During this time the girls experience physical and emotional changes as their bodies develop and prepare for reproductive maturity. The breasts begin to grow and develop, and there is hair growth in the pubic and axillary regions. Hormonal changes lead to acne on the face and the body. Girls experience a growth spurt, gaining weight and height. The final step in the girl’s puberty is the onset of menses.

It is important that every girl develops at her own pace, and some may start puberty earlier or later than others. Due to an ovulatory cycle, the periods may be irregular and the girls might miss a period and bleed for weeks the following month. It is important to obtain a good history from the girls and ask them to keep a diary and track their menstruation. It might seem difficult but it is important to ask the girls if they are sexually active and what they use for birth control. It is important to ask if they have missed any school days due to severe pain or bleeding.

A few baseline investigations can help rule out anemia, bleeding disorders or thyroid dysfunction. If all these appear normal we can offer these girls several options such as conservative management along with iron supplements and medication that reduce the menstrual blood flow, or if the teenager is keen we can start some sort of combined contraceptive such as the pill or patch. It can help regulate the menses, reduce acne, and prevent the progression of endometriosis if they have a bit of it lastly it is a reliable contraceptive agent.

 

That is me, being the bookworm teenager in grade 8. Always busy with my books. I wasn't into sports or anything else. 

That is me in the first year of medical school continuing what I love the most. 

BURNOUT

 Burnout is often related to prolonged stress and exhaustion related to work or caregiving responsibilities. It can lead to mental and physical exhaustion, reduced performance, irritability, and withdrawal from social interactions. With time the person’s work performance decreases and feels dissatisfied with work and personal life.

It took me a while to understand my symptoms are related to exhaustion and burnout. It is very profound, and it can’t be fixed with a good night's sleep or a relaxed weekend. This happened to me at the end of my registrar training. From the previous year, I had started preparing for the fellowship exams. This is when time was divided between work and night shifts and studying. The exams passed and I realized I had to re-write my research document. Another year went by with me sacrificing all my free time writing and doing corrections. On top of this, as my training time was coming to an end, I had to start struggling to find a job. It wasn’t a consultant job as my paperwork wasn’t done/ I ended up working in a level one hospital as a medical officer. I did not even have interns. I had no job satisfaction. I was there to pass the time and pass my master of medicine and get a salary. I was heavily pregnant at that time.

Maternity leave was also overwhelming. After a month I started assisting in theatre and doing locums to make ends meet. I finally started working as a consultant. I still felt overwhelmed with the new responsibilities and the workload. I hardly took 10 days of annual leave that year. This is the second year of working in the new hospital. I feel more relaxed. I have more job satisfaction.

The baby is about 17 months, she sleeps through and is more manageable to look after. I joined the local gym again. I took leave the first two weeks of January to recharge and relax. I have resumed the activities I enjoy such as reading, painting, going for walks, and little crochet projects. It took me a while to feel like myself and recover from work and study exhaustion.

Work-life balance is extremely important to reduce the risk of burnout. It is important to prioritize self–care, set boundaries to seek social support, and address any underlying issues leading to stress.

This is our obstetric unit, and we are all exhausted after our busy shift in Bara Hospital. 

 

 

INTERNATIONAL SIBLING'S DAY

 The 10^th of April is International Siblings Day. It is meant to celebrate the bond between siblings and honour the special relationship they share. It is time to recognize the support, love, and connection that siblings bring to each other’s lives. Whether you have a brother, a sister, or multiple siblings, it is an opportunity to show appreciation for their presence and the unique memories and experiences you have shared together.

I have a younger brother, and we have a five-year age gap. I wasn’t really happy back then when he was born.  Even though my mom was a housewife, she was not coping with looking after me and my brother. By the time I was 7 and going to grade 1; Grandma who used to live with us was taking care of me most of the time. I found it difficult to connect with my little brother then. We started enjoying each other’s company when I was in grade 5 and by then he was about 5 years old. He happened to be a more social and happy child than me.

In 2006, he moved to SA and I stayed back home to finish studying in medical school. We were very disconnected and I felt very lonely. Even when I reunited with the whole family back in 2013, I was struggling with the new culture and the family’s lifestyle. He was studying software engineering and got his first job while I was busy sorting out my paperwork with the Health Profession Council of South Africa. He still has a fun and outgoing nature, and I am the quiet and introverted one. 

He helped me a lot in adjusting to the South African lifestyle. He used to show me around, teach me how to drive, and help with all my smartphone, computer, and technology-related problems.

We both enjoy eating out, staying fit, traveling, and having Turkish coffee. We mostly meet at my parent’s place on Sundays for lunch and coffee. We have our disagreements, but we have been getting along pretty well over the years! He certainly has a more exciting social life than I do and has traveled to more countries. Having siblings is definitely a blessing in our lives.

One of my favorite photos of us, when he was about 6 months.

He is about 2 and we are both playing in our great-grandmother’s house in the summer. 

 

CERVICAL CANCER IN SUB-SAHARAN AFRICA

 Cervical cancer poses a significant burden in Sub-Saharan Africa, due to limited access to preventive measures, early detection, and treatment services. At our facility, we usually diagnose three to four new patients with gynaecological cancer and mainly cervical cancer every month. They are often quite young and have concomitant HIV infection. Women often present with severe anaemia, pain, foul-smelling vaginal discharge, or even kidney failure.

 Last month I had to counsel the family of a young patient in her 30s who was very sick and delirious with end-stage cervical cancer and her biopsy results were still pending. The family members were her aunt and her sister. They were devastated to hear the news and they were not coping looking after her and her 3 young children, the youngest who was 18 months old.

 According to the World Health Organization (WHO), approximately 25% of all cervical cancer cases worldwide occur in Sub-Saharan Africa, even though this region represents only about 14% of the world’s female population. Many women do not have access to regular cervical cancer screening programs, such as pap smears or HPV testing. Poverty, limited education, and cultural beliefs all limit women’s access to cancer prevention and treatments. HIV infection is prevalent in this region and this also increases the risk of cervical cancer.  Vaccination programs are limited in many countries in this region which contributes to the high burden of the disease.

 The healthcare infrastructure has numerous challenges such as shortages of trained healthcare professionals, limited diagnostic facilities, and insufficient treatment centers. The biopsies taken take four to six weeks to be reported by the pathologists and the waiting list to start treatment is six to twelve months for the patients to get chemotherapy or radiation.

 We all hope for a better future for our women in this region of the world. There needs to be more public awareness to educate communities on the importance of cervical cancer prevention, early detection, and treatment.

Below is Charlotte Maxeke Johannesburg Academic Hospital which is one of the referral oncology centers. 

 

 

 

 

 

 

 

 

HOW I BECAME A GYNAECOLOGIST

 Medicine is a long and confusing journey. Going to medical school in my hometown, I had no idea what I was stepping into. One of my family friends who was a qualified dentist tried to convince me to do dentistry because the training is easier and there are no internship night shifts. My university marks were borderline for the medical school near home and I could be accepted in another province. My family suggested I choose pharmacology as a second option so I managed to stay close. I had made up my mind and I wanted to become a doctor.

Medical school and the difficult exams went smoothly, we were slowly introduced to bedside teaching and the hospitals and I found it very fascinating. Some of my friends didn’t enjoy dealing with patients and they had already made up their minds to exit clinical medicine or do radiology or pathology. Community service was in the rural areas. I was doing family medicine in a rural clinic. Dealing mostly with outpatients, prescribing paracetamol or chronic meds for diabetes and hypertension. I remember how the community service dentist used to suffer and sweat with loads of locals coming for tooth extractions every day!

I had made up my mind about emigrating to South Africa after my community service. The first two years of immigration were spent dealing with the registration process to get into the south African internship program. It was a difficult time waking up every morning feeling bored with no purpose. When there is no work there is no money and no fun! I learned a lot in my two years of internship and now I understand the reason South African doctors get a lot of respect internationally. In Medical school, I went through a phase where I wanted to become a cardiologist. The books and the theory were nice, but the internal medicine rotation, dealing with chronically ill patients, seeing the cardiac echo, and the cath lab weren’t what I wanted to do for the rest of my life. Stepping into a busy labour ward was love at first sight!

I always wanted to do my SA internship at Chris Hani Baragwanath Hospital, but I did not get it. I made it to Bara for community service and spent 12 months in maternity rotation and grew very quickly. I saw it all. Getting through the primary exams of obstetrics in Bara gave me the opportunity to get into the specializing program the following year. It was a four-year program with the COVID pandemic, a wedding, and a pregnancy on top of the crazy night shifts, exams, and a research project.

 

Myself and the facility midwife in Community service back home in 2012, and a Christmas shift at Bara Hospital in 2018 with our nursing staff.