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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

UV vestig hom afgelope eeu as leier op verskeie terreine

2004-05-11

Michelle O'Connor - Volksblad - 11 Mei 2004

Ondank terugslae nou 'n 'gesonde volwassene'

HOEWEL die Universiteit van die Vrystaat (UV) vanjaar sy eeufees vier en met 23 000 studente die grootste universiteit in die sentrale deel van die land is, was dié instelling se geboorte glad nie maklik nie. MICHELÉ O'CONNOR het met prof. Frederick Fourie, rektor, oor die nederige begin van dié instelling gesels.

DIE behoefte aan 'n eie universiteit in die Vrystaat het reeds in 1855, kort ná die stigting van Grey-kollege, kop uitgesteek.

Grey se manne het hulleself teen 1890 begin voorberei om die intermediêre B.A.-eksamens af te lê. Dié eksamen het hulle toegang gegee tot die tweede jaar van 'n B.A.-graad aan die destydse University of the Cape Good Hope, nou die Universiteit van Kaapstad.

"Presidente F.W. Reitz en M.T. Steyn het destyds albei die stigting van 'n universiteit hier bepleit. Die grootste rede was sodat die seuns van die Vrystaat nie weggestuur word nie.

"Dié twee se droom is op 28 Januarie 1904 bewaarheid toe ses studente hulle onder dr. Johannes Bril, as hoof/rektor van Grey-kollege, vir die graad B.A. ingeskryf het. Dié graad is aanvanklik deur die Kaapse universiteit toegeken.

"Net die klassieke tale soos Latyns en Grieks, die moderne tale, Nederlands, Duits en Engels, filosofie, geskiedenis, wiskunde, fisika, chemie, plant- en dierkunde is aanvanklik aangebied.

"Die UV se geboue het gegroei van 'n klein tweevertrek-geboutjie wat nou naby Huis Abraham Fischer staan, en verblyf in die Grey-kollege se seunskoshuis," sê Fourie.

Volgens hom is die universiteit se eerste raad en senaat tussen 1904 en 1920 saamgestel. Die eerste dosente is aangestel en die eerste geboue opgerig. "Dié tyd was egter baie moeilik.

"Die instelling het teen 1920 net 100 studente gehad en was geldelik in die knyp. Daar was geen vaste rektor nie en geen vooruitgang nie. Vrystaatse kinders is steeds na ander universiteite gestuur.

"Ds. J.D. Kestell, rektor van 1920 tot 1927, het egter dié instelling finaal gevestig.

"Hy het self studente van oor die hele Vrystaat gewerf en geld by onder meer kerke en banke ingesamel. Kestell het selfs Engelse ouers oortuig om hul kinders na die Greyuniversiteitskollege (GUK) te stuur en teen 1927 het dié instelling met 400 studente gespog.

"In die tydperk tussen 1927 en 1950 het die GUK weer verskeie terugslae beleef.

"In dié tyd was dit onder meer die Groot Depressie en die Tweede Wêreldoorlog. Die armblanke-vraagstuk het regstreeks op studente en dosente ingewerk en die politieke onderstrominge van dié tyd het die instelling ontwrig.

"Die GUK het egter oorleef en die Universiteitskollege van die Oranje-Vrystaat (UKOVS) is in 1935 gebore," sê Fourie.

Hy sê in dié tyd is verskeie fakulteite gevestig en teen 1950 het die UKOVS met 1 000 studente gespog.

Teen 1950 het dit 'n onafhanklike universiteit geword en die naam is verander na die Universiteit van die OranjeVrystaat (UOVS).

Dié tydperk is gekenmerk deur Afrikaner- en blanke selfvertroue en heerskappy. Studentegetalle het tot 7 000 in 1975 gegroei en heelwat vooruitgang het in dié tyd plaasgevind.

"Tussen 1976 en 1989 sukkel dieuniversiteit weer met onder meer ekonomiese krisisse, die land se politieke onstabiliteit en word die UOVS geï soleer.

"Een ligpunt in dié tyd is die toelating van die eerste swart studente, die nuwe Sasol-biblioteek en die fakulteit teologie wat die lig sien.

"Tussen 1990 en vanjaar het die UOVS verskeie op- en afdraandes beleef. Die universiteit doen nie net die eerste stappe van transformasie nie, maar begin ook aan 'n beleid van multikulturaliteit werk.

"Die UOVS se naam verander in 1996 na die Universiteit van die Vrystaat/University of the Free State en in 2001 word die Sotho-vertaling bygevoeg.

"Geldelike druk en probleme neem drasties toe en personeel word gerasionaliseer.

"Teen 2000 begin die UV met 'n draaistrategie en studentegetalle neem tot meer as 23 000 toe," sê Fourie.

Hy sê die UV het die afgelope eeu nie net verskeie terugslae oorleef nie, maar homself ook op verskeie gebiede as 'n leier gevestig.

Die universiteit behaal sy eie geldelike mikpunte, neem 'n nuwe taalbeleid van veeltaligheid aan en herbelê in personeel.

Die instelling inkorporeer die kampusse van die Vista- en Qwaqwa-universiteit en groei internasionaal.

Die UV vestig ook fondamente van 'n institusionele kultuur van verdraagsaamheid, geregtigheid en diversiteit.

"Die baba het in die afgelope eeu 'n gesonde volwassene geword."

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