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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

Prof Frederick Fourie to step down as UFS rector

2008-09-08

“It is with sadness that I hereby announce my intention to step down as rector and vice-chancellor of the University of the Free State (UFS) in the 4th quarter of this year.

Obviously this decision has not been taken lightly. After careful consideration I am, however, convinced that this is as far as I can take the UFS as vice-chancellor and rector. This flows primarily from the exhausting times that I have experienced during the past nine years, first as vice-rector (since 1999) and then as rector (since 2003), in managing and implementing several complex strategic projects.

The challenges and complexities of continuous change management at a higher education institution, and specifically the demands of further dynamic development and transformation at the UFS, demand enormous amounts of emotional energy and drive. For me the stress due to, especially, the political divisions and tensions in the UFS Council and the broader university community during the past year has been extremely draining. The broader institution and its people also show signs of trauma.

I think it is time for new and fresh leadership, especially in the light of the transformation challenges of the UFS.

I have thus decided to step down in the interest of transformation and the further dynamic development of the UFS.

Having been on sabbatical leave since May, I will not return to take up my post. I will remain on leave until my official date of retirement from office. (The exact date must still be determined.)

I am grateful for the opportunity to have been at the helm of the UFS and to help the institution cross several bridges. During the past nine years I have been privileged to lead large strategic projects together with many dedicated and talented UFS colleagues. It has been a wonderful experience of thinking and working together in order to elevate the functioning of the University to new levels in several key areas.

One of the most important projects was the financial turnaround strategy of 2000-2005, which took the UFS from a financial crisis to a situation where currently it annually has almost R100 million of discretionary funding available to spend on strategic projects, and where staff remuneration and promotion opportunities have increased dramatically since 2000. In this period the UFS has also grown from approximately 10 000 students to more than 27 000 in 2008.

A second was the strategy to invest strongly in the academic core and notably research, research capacity and research apparatus. Since 2003 research outputs have increased by approximately 50% - a significant accomplishment of our researchers and faculties. In conjunction with this, the launch of the six strategic academic clusters (focus areas) should create the basis for the continued growth in the national and international stature of the UFS in future. The development of the national leadership role of the UFS with regard to community service also was a special and successful project.

A third large strategic project was the progress with regard to diversity, the balanced multilingualism policy in the academe as well as the administration, the employment equity plan, the UFS transformation plan and especially the institutional charter – which could lay the foundation for a university where one and all can experience a true sense of belonging amidst diversity. These have been important steps that we can feel proud of (although much work obviously remains with regard to non-racialism and also non-sexism).

As far as residences are concerned, it was historically significant that this time, in contrast to 1997/8, the UFS succeeded in crossing the bridge of diversity and integration in residences – with due regard to the difficulties we faced. Hopefully this will considerably ease the task of my successor and her/his management team in managing diversity and in pursuing best practice transformation.

A fourth large project was the large-scale upgrading and development of infrastructure, academic buildings and facilities as well as support service facilities, student facilities and pedestrian walkways. The objective was a campus of the highest quality and aesthetics to effect a lasting improvement in their work- and living environment for staff and students. Indeed, the UFS Main Campus today is seen as an example of sensitive and high quality campus planning.

Other initiatives which haven’t borne fruit yet are, for example, those with regard to entrepreneurial activities, sport development and sport business development, and the possible establishment of an engineering programme or faculty at the UFS.

On the whole the most important thing for me has been the progress in establishing a deep commitment to quality and equity/fairness and in boosting the national and international profile of the UFS as a high quality progressive university. Of course, justice, equity and quality intrinsically are challenges which require daily dedication to make it an ingrained habit.

I wish to thank all those people with whom I could work during the past years in tackling large and complex challenges with mutual loyalty, shared wisdom and effort – from the Financial Turnaround Team to the Exco, the Executive Management, the Faculties, the Senate, support service divisions, the University Council and several committees and task teams”.

Frederick C.v.N. Fourie
Rector and Vice-Chancellor
University of the Free State

Prof Frederick Fourie has been with the UFS since 1976. After obtaining a PhD in Economics from Harvard he was appointed professor at the age of 29 in 1982, head of the Department of Economics in 1992, Distinguished Professor in 1998, Dean of the Faculty of Economic and Management Sciences in 1997, Vice-rector: Academic in 1999 and vice-chancellor in 2003.

Media Release
Issued by: Lacea Loader
Assistant Director: Media Liaison
Tel: 051 401 2584
Cell: 083 645 2454
E-mail: loaderl.stg@ufs.ac.za
8 September 2008

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