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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

UFS forms a strategic partnership with Yale University

2010-03-16

At the official inauguration of the Jonathan Edwards Center Africa was, from the left, front: Prof. Harry Stout, Chair of the Department of American Religious History at Yale University; Prof. Jonathan Jansen, Rector and Vice-Chancellor of the UFS; back: Prof. Dolf Britz, Director of the Jonathan Edwards Center Africa at the UFS; Prof. Kenneth Minkema, Executive Director of the Jonathan Edwards Center at Yale University; Prof. Adriaan Neele of Yale University, now also Professor Extraordinary in the Faculty of Theology at the UFS; and Prof. Francois Tolmie, Dean of the Faculty of Theology at the UFS.
Photo: Stephen Collett

The University of the Free State (UFS) officially inaugurated the Jonathan Edwards Centre Africa in its Faculty of Theology last week. This centre, affiliated with the Jonathan Edwards Centre Yale University in New Haven in the United States of America, was established at the UFS last year.

The strategic partnership between the UFS and Yale University exemplifies the vision of the Faculty of Theology to be an internationally renowned theological and training faculty.

Leading scholars from Yale University, Prof. Harry Stout, Chair of the Department of American Religious History, and Prof. Kenneth Minkema, Executive Director of the Jonathan Edwards Center at Yale participated in the inauguration of the Jonathan Edwards Center Africa.

The Dean of the Faculty of Theology, Prof. Francois Tolmie said, “This visit underscores the strategic relationship between Yale University and the Faculty of Theology and will assist in us continuing to foster high aspiring scholarship, student and faculty support.”

This is an exciting development between universities renowned for excellence in learning, and innovation in scholarship. Prof. Minkema added, “The establishment of this renowned center for research, education and publication, at the UFS is a significant expansion of Edwards scholarship and will serve widely both academia and the church,” Said Prof. Stout.

The Faculty of Theology also announced the appointment of Prof. Adriaan Neele of Yale University as Professor Extraordinary. The appointment follows the vast growth of the Jonathan Edwards Centre Africa. “I welcome this appointment with much anticipation as the strategic relationship between Yale University and the Faculty of Theology develops in unprecedented ways, attracting doctoral students from Southern Africa, South Korea and America,” said Prof. Tolmie.

Jonathan Edwards (1703-1758), pastor, revivalist, Christian philosopher, missionary, and president of Princeton University, is widely regarded as North America’s greatest theologian. He is the subject of intense scholarly interest throughout the world, because of his significance as a historical figure and the profound legacy he left on America’s religious, political and intellectual landscapes.

“The centre and appointment of Prof. Neele will provide sustainable scholarship of primary sources in new and promising ways, said Prof. Dolf Britz, Director of the Jonathan Edwards Africa at the UFS.

“My appointment at this prestige university of Southern Africa is both an honour and humbling. I look forward to a beneficial and academic engagement with students, as well as to serve the academy and the church,” said Prof. Neele.

Prof. Neele’s inaugural address entitled A Transitional Moment in Theology argued for the classicality and catholicity of Edwards’ theology.

The interest in Edwards globally has in part been fuelled by the work of the Jonathan Edwards Centre at Yale University, whose sole mission is to support inquiry into the life, writings, and legacy of Jonathan Edwards by providing resources that encourage critical appraisal of the historical importance and contemporary relevance of America’s premier theologian.

The primary means to achieve this are with the Works of Jonathan Edwards Online, a digital learning environment for research, education and publication that presents all of Edwards’s writings, along with helpful editorial materials that allow the reader to examine Edwards's thought in incredibly powerful, useful ways.

Media Release
Issued by: Lacea Loader
Director: Strategic Communication (actg)
Tel: 051 401 2584
Cell: 083 645 2454
E-mail: loaderl@ufs.ac.za
15 March 2010

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