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Why midwifery should be in the hands of trained midwives

20 December 2021 | Story Elsabé Brits

Dr Elgonda Bekker, from the University of the Free State (UFS), completed her doctoral degree in nursing in 2020, with a practical, transformative thesis to improve the education of midwives in the country.

Midwives who are properly trained and acknowledged for their skill and experience do not only save lives but make a huge contribution to maternal health in South Africa. However, there is a dire need for professional midwives and competent educators.

Dr Elgonda Bekker, from the University of the Free State (UFS), completed her doctoral degree in nursing in 2020, with the title: Competencies of South African midwifery educators: a transformative framework. It is a practical, transformative thesis to improve the education of midwives in the country. Sadly, just months after she received her degree she passed away. Yet, her colleagues at the School of Nursing at the UFS continue to build on the foundation she laid.

Too much too soon, too little too late

The World Health Organisation (WHO) states that 10-15% of births may need intervention through caesarean section. A recent analysis, however, found that private hospitals had a caesarean section rate of 73.6%, compared to 26% in the public sector.

Although the public sector rate is higher than the WHO target, the private sector rate is not justifiable, Bekker writes. The case fatality rate for mothers who died after a caesarean section had been performed showed an increase. That is one of the statements indicating that not all medical interventions are of benefit to mothers.

A focus on too much too soon or too little too late in the Lancet series on midwifery of 2014 indicated the need for better-quality care. In South Africa both manifest because of the disparity between private and public healthcare. According to Bekker’s research, the high caesarean section rate in the private sector is a classic example of over-medicalisation of obstetric care, whereas the public healthcare system follows a midwifery-led model of care.

“Midwives are a vital solution to correct this disparity. Competent midwives, educated to standards, can prevent interventions without indication, provide service in rural settings and advocate for the rights of the childbearing family,” she wrote.

Midwifery is a disempowered profession

Winnie Moroa Motlolometsi, a midwifery educator, explains that professional nurses in the country have a dual registration with the South African Nursing Council as a nurse-midwife. This leads to many qualified midwives not necessarily practising as midwives. It is therefore very difficult to calculate the number of practising midwives.

Furthermore, the conflation of nursing and midwifery requires training as a generalist practitioner. Depending on the institution where they are trained, professional nurses may or may not comply with the International Confederation of Midwives’ Global Standards for education and regulation of the midwifery profession.

Nevertheless, according to Dr Bekker’s research, midwifery is a disempowered profession, because the global guiding documents are neither considered by the regulatory authority nor the National Department of Health. There is a triple gap for competencies, coverage, and access:

Insufficient numbers of competent midwives
.. who can cover maternal health services

…who render services that address the needs of women

There is a dire need for competent midwives in the country, but the predicament is that whilst midwifery educators are qualified, they are not necessarily clinical specialists, which ultimately jeopardises the quality of maternal healthcare.

What was also clear from Bekker’s research is that although South Africa has a progressive constitution, gender equality has not materialised on grassroots level. Violence is ever present. Women are viewed as weaker, vulnerable, and less suited for the workplace. Nonconformity to sexual gender norms, based on cultural or religious bias, creates conflict for some women.

Dr Deidre van Jaarsveldt, senior lecturer in the School of Nursing at the UFS, said Bekker’s study highlighted that feminism is a strengthening agency for women. In this study it was important to frame the context of midwifery as a disempowered, woman-led profession, caring for women who are still finding themselves in a society where there is gender inequality.

The research indicated that there were many challenges:

Lack of autonomy for midwives
Non-compliance with the global midwifery standards
Conflation of nursing and midwifery
Midwifery regulated by non-midwives
Lack of direct entry into midwifery education in the country

High litigation in maternal and child healthcare – there is fearfulness among practitioners and reluctance to work within the midwifery profession

In practice it is difficult to distinguish midwifery specialists from nurses who are practising as generalists and are expected to offer maternal healthcare services. If something goes wrong, the midwifery profession is held accountable, but practising midwives were not necessarily involved.

Reproductive, Maternal, Newborn and Child Health Hub

There is a dire need for midwifery to become an autonomous profession guided by global standards. Membership should be based on advanced qualifications, which strengthen midwifery as a speciality. This can only be attained through education and maintained by a regulatory body, as well as the de-conflation of midwifery from nursing. When this happens, midwives will know who the actual midwives are and be able to hold one another accountable, Motlolometsi adds.

Dr Bekker advocated for the “decolonising” of midwifery, which means restoring the knowledge to the profession. To allow midwives to receive quality education, midwifery should become an independent profession that is guided by global standards and regulated by midwives.

Van Jaarsveldt says the School of Nursing at the UFS endeavours to offer quality midwifery education. Students learn in a high-tech simulated learning environment where they can become competent before working with actual mothers and babies. The educators are clinical experts, supported by a team of midwifery practitioners who act as preceptors for the students.

Before her untimely death, Dr Bekker started establishing a Reproductive, Maternal, Newborn and Child Health Hub in the Faculty of Health Sciences, which is continuing under the leadership of Dr Cynthia Spies, supported by a team of interprofessional experts.

“Through research and continuous improvement of education and practice, this group of professionals envisions optimising and strengthening reproductive, maternal, newborn, and child health competencies so that current maternal and child morbidity and mortality trends can improve resulting in surviving and thriving childrearing families.

“The goal is to develop partnerships and opportunities for collaboration and research with colleagues in healthcare disciplines and to extend beyond healthcare to include innovative interdisciplinary partnerships,” says Spies. The objectives include:

Practice development with implementation of evidence-based practice and positive experience of the childbirth and child health continuum;
Clinical competency development through training and the development of short learning programmes;
Clinical research that addresses the current reproductive, maternal, neonatal and child health mortality, morbidity and health issues in central South Africa.

News Archive

Graduates challenged to fulfil their leadership obligations

2017-12-08

Photo: Johan Roux

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6 December: Morning
6 December: Afternoon
7 December: Morning
7 December: Afternoon

A total number of 1 226 qualifications, including diplomas, certificates, and degrees, were conferred during the two days of the 2017 End-of-Year Graduation Ceremony which took place on the Bloemfontein Campus of the University of the Free State (UFS). Forty doctorates and 109 master’s degrees were awarded. Most doctorates (19) were awarded in the Faculty of Natural and Agricultural Sciences which also conferred the biggest number of master’s degrees (27).

Celebrating excellence
Some of the highlights at this year’s graduation ceremonies were when the university honoured Prof Paul Holloway and Marius Botha with honorary doctorates and Joyene Isaacs with the Chancellor’s Medal.

Isaacs, Head of the Department of Agriculture in the Western Cape, who was nominated by the Centre for Sustainable Agriculture in the Faculty of Natural and Agricultural Sciences for the Chancellor’s Medal, said: “Agriculture is one of those areas people take for granted. With this medal, agriculture can come to the fore. Agriculture is placed in the spotlight and it is important for this country, but also globally, because we look after the food supply. For me agriculture has been a sustainable livelihood but also a career. Everything about agriculture excites me! I hope that through this award I can take agriculture to the next level.”

Prof Holloway, internationally acclaimed expert in the science and technology of surfaces, thin films, and nanoparticles, who received the Honorary Doctorate in Science degree, said: “This award recognises the efforts we (the UFS and the University of Florida in the US) have jointly developed. We introduced the UFS to phosphors and today it (the UFS) has world-wide recognition expertise in this field. We also learnt from them. They brought us technology we did not have before. It was a mutual growth technique and we all benefit from that. If you work together you can achieve remarkable things.”

“It is the greatest honour of my life. I’ve been associated with the UFS for 17 years in the capacity of moderator, examiner and sometimes lecturer.” These were the words of Botha, author and expert in the financial planning circles of South Africa who was nominated for an honorary degree by the School of Financial Planning Law.

Botha told graduates that a qualification in the financial planning field would give you many opportunities. “If you enter almost any financial services organisation in South Africa, you will find senior people there that completed the postgraduate diploma in Financial Planning Law at the UFS,” he said.

During a luncheon that was hosted by Prof Francis Petersen, the UFS Rector and Vice-Chancellor, in honour of these esteemed graduates, he thanked them for the contribution they had made, not only for the UFS, but for advancing science, technology, and the better of society. “The Honorary degrees and Chancellor’s Medal are the highest accolades and recognition that the university can bestow on individuals who have excelled in science or scholarship or have contributed to service to this country. You are exemplary individuals and you make the UFS, our country and the world proud,” he said.

Photo: Johan Roux

Inspiration for the future
Likeleli Monyamane, a UFS Council member, addressed graduates during the morning ceremony on 6 December 2017. She motivated graduates to walk tall and learn to serve our country. “Finding your voice comes with a responsibility to speak for those who do not have a voice,” Monyamane said.

Leah Molatseli, who launched South Africa’s first legal e-commerce website, Lenoma Legal, was the guest speaker at the afternoon session on 6 December 2017. “You are going to start afresh. It is going to feel like you know absolutely nothing and it’s ok. You need to make peace with that in order for you to learn.

“A lot of young people expect instant success when they enter a job. I am 29 and have had three jobs, two side jobs and numerous certificates. But I decided to create my own future. That is what I did with Lenoma Legal. Some people are meant to be ordinary and some extraordinary,” said this young entrepreneur and Kovsie Alumnus.

On the second day of the graduation ceremonies Dr Imtiaz Sooliman, founder and Director of the Gift of the Givers Foundation, challenged the newly graduated alumni to be carriers of hope for Africa. “We need people of skill, spirituality and heart,” he said.

“How do you want others to believe in you if you don’t believe in yourself? We South Africans, we can make things happen. Believe in yourself,” he said.

“The best science you can do is for others. The moment you achieve that, you mean something to someone,” he said.

Prior to dissolving the congregations, Dr Khotso Mokhele, the Chancellor of the UFS, said: “It has taken hard work, commitment, dedication, to walk across the stage. You deserve all of that.”

Interesting facts of the graduation
Among the graduates at these ceremonies was former Miss World 2014, Rolene Strauss. She received a Bachelor of Medicine and Bachelor of Surgery Degree.

The Faculty of Natural and Agricultural Sciences is also very proud of the first group of BAgric students who graduated on the Agricultural College Programme. The eight agriculture students all received the Bachelor of Agriculture degree, majoring in Agricultural Management.

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