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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

Moshoeshoe film screened at UFS as part of transformation programme

2004-10-14

A ground-breaking documentary film on the life and legacy of King Moshoeshoe I, the founder of the Basotho nation, will be screened at the University of the Free State (UFS) tonight (Wednesday 13 October 2004) at 19:00.

Rector and Vice-Chancellor of the UFS, prof. Frederick Fourie, said the UFS commissioned the documentary as a practical demonstration of the university’s commitment to the continued transformation of the campus and the creation of a new inclusive institutional culture for all staff and students.

It is part of a larger UFS project to honour the Moshoeshoe legacy of nation-building and reconciliation and to explore his role as a model of African leadership.

The documentary tells the life story of the legendary king, with emphasis on his remarkable leadership skills, his extraordinary talent for diplomacy and conflict resolution and his visionary commitment to creating a new nation from a fragmented society.

Almost all the filming was done on or around Moshoeshoe’s mountain stronghold, Thaba Bosiu.

The last part of the documentary explores the lessons for African leadership to be learnt from Moshoeshoe. The hour-long documentary film was produced by the well-known journalist Mr Max du Preez and was commissioned by the UFS as part of its centenary celebrations.

“Through this documentary film about King Moshoeshoe, the UFS commits itself to developing a shared appreciation of the history of this country,” said prof. Fourie.

“King Moshoeshoe was a great African statesman and leader. He was born in this region of the country, but his influence and legacy extends way beyond the borders of the Free State, Lesotho and even way beyond the borders of South Africa,” said prof. Fourie.

As part of the larger project, the UFS is investigating a possible annual Moshoeshoe memorial lecture that will focus on African leadership, nation-building and reconciliation, possible PhD-level research into the life and legacy of King Moshoeshoe and a literary anthology including prose and poetry.

“We must gain a deeper understanding of what really happened during his reign as king. Therefore the University of the Free State will encourage and support further research into the history, politics and sociology of the Moshoeshoe period, including his leadership style,” said prof. Fourie.

According to prof. Fourie the Moshoeshoe project will enable the UFS to give real meaning to respect for the diversity of our languages and cultures, and the unity South Africans seek to build as a democratic nation through such diversity.

According to the producer of the documentary, journalist Mr Max du Preez, the UFS deserves credit for recognising this extraordinary man and for financing this important documentary.

Du Preez said: “It was about time that South Africa rediscovered Moshoeshoe. Colonialist and Afrikaner Nationalist historians have painted him as a sly, untrustworthy and weak leader. Most historians have preferred to glorify leaders in South Africa’s past who were aggressors and conquerors. In the process most present-day South Africans came to regard Moshoeshoe as a minor tribal figure.”

“Yet this was the man who broke the cycle of violence, famine and suffering during the traumatic time in central South Africa in the early 1800s. During the entire 19th century, Moshoeshoe was virtually the only leader in South Africa who did not answer violence with violence, who did not set forth to conquer other groups and expand his land,” said Mr du Preez.

“I have no doubt that the stability that the Free State region has enjoyed over more than a century was largely due to Moshoeshoe’s leadership and vision. He can quite rightly be called “The Nelson Mandela of the 19th Century,” Mr du Preez added.

Explaining the title of the documentary film, Mr du Preez said: “We decided to call the documentary “The Reniassance King” because whichever way one looks at it, Moshoeshoe symbolised everything behind the concept of an African Renaissance.”

“He was progressive, just and fair; he deeply respected human life and dignity (we would nowadays call it human rights); he embraced modernity and technology without ever undermining his own people’s culture or natural wisdom; he never allowed European or Western influence to overwhelm him, make him insecure or take away his pride as an African,” said Mr du Preez.

“Moshoeshoe was the best of Africa. If only contemporary African leaders would follow his example of what African leadership should be,” Mr du Preez said.

Among the interviewees in the film were Lesotho’s most prominent historian, Dr LBBJ Machobane, the head of the UFS’s Department of History, prof. Leo Barnard, Moshoeshoe expert and Gauteng educationist Dr Peter Seboni, Lesotho author and historian Martin Lelimo and Chief Seeiso Bereng Seeiso, Principal Chief of Matsieng and direct descendant of the first King of the Basotho.

The documentary film on King Moshoeshoe will be screened on SABC 2 on Thursday 4 November 2004.

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