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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

Premiere of the documentary on King Moshoeshoe - Address by the Rector

2004-10-14

Address by the rector and vice-chancellor of the University of the Free State, prof Frederick Fourie, at the premiere of the documentary on King Moshoeshoe, Wednesday 13 October 2004

It is indeed a privilege to welcome you at this key event in the Centenary celebrations of the University of the Free State.

We are simultaneously celebrating 100 years of scholarship with 10 years of democracy

Today is a very important day with great significance for the University. This Centenary is not merely a celebration of an institution of a certain age. It is a key event in this particular phase of our history, in our transformation as an institution of higher learning, in taking the creation of a high-quality, equitable, non-racial, non-sexist, multicultural and multilingual university seriously.

This is about building something new out of the old, of creating new institutional cultures and values from diverse traditions.

It is about learning together - as an higher education institution - about who we are where we come from – to decide where we are going.

It is about merging the age-old tradition of the university, of the academic gown, with the Basotho blanket, the symbol of community engagement.

Then why is it important that we remember Moshoeshoe, where does he fit into our history?

In the Free State province, where large numbers of Basotho and Afrikaners (and others) now live together, a new post-apartheid society is being built in the 21st century.

The challenge is similar to that faced by Moshoeshoe 150 years ago. As you will see tonight, he did a remarkable thing in forging a new nation out of a fragmented society. He also created a remarkable spirit of reconciliation and a remarkable style of leadership.

Not all people in South Africa know the history of Moshoeshoe. Many Basotho – but not all – are well versed in the history of Moshoeshoe, and his name is honoured in many a street, town and township. Many white people know very little of him, or have a very constrained or even biased view of his role and legacy. In Africa and the world, he his much less known than, for instance, Shaka. (In Lesotho, obviously, he is widely recognised and praised.)

We already benefit from his legacy: the people of the Free State share a tradition of moderation and reconciliation rather than one of aggression and domination.

With Moshoeshoe, together with Afrikaner leaders and reconciliators such as President MT Steyn and Christiaan de Wet, we have much to be thankful for.

Our challenge is take this legacy further: to forge a new society in which different cultural, language and racial groups – Basotho, Afrikaners and others – will all feel truly at home.

Bit by bit, on school grounds, on university campuses, in each town and city, people must shape the values and principles that will mould this new non-racial, multicultural and multilingual society.

A shared sense of history, shared stories and shared heroes are important elements in such a process.

Through this documentary film about King Moshoeshoe, the UFS commits itself to developing a shared appreciation of the history of this country and to the establishment of the Free State Province as a model of reconciliation and nation-building.

Moshoeshoe is also a strong common element, and binding factor, in the relationship between South Africa / the Free State, and its neighbour, Lesotho.

For the University of the Free State this also is an integral part of real transformation – of creating a new unity amidst our diversity.

Transformation has so many aspects: whilst the composition of our student and staff populations have been changing, many other things change at the same time: new curricula, new research, new community service learning projects.

In also includes creation of new values, new (shared) histories, new (shared) heroes.

It includes the incorporation of the Qwaqwa campus, which serves a region where so many of the children of Moshoeshoe live, including her majesty Queen Mopeli.

We see in Moshoeshoe a model of African leadership – of reconciliation and nation-building – that can have a significant impact in South Africa and Africa as a whole.

We also find in the legacy of King Moshoeshoe the possibility of an “founding philosophy”, or “defining philosophy”, for the African renaissance.

To develop this philosophy, we must gain a deeper understanding of what really happened there, of his role, of his leadership.

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.

We hope to do this in partnership with National University of Lesotho.

The Moshoeshoe documentary is one element of a long-term project of the UFS. The other elements of the project that we are investigating are possible PhD-level research; a possible annual Moshoeshoe memorial lecture on African leadership; and then possible schools projects and other ways and symbols of honouring him.

It is my sincere wish that all communities of the Free State and of South Africa will be able to identify with the central themes of this documentary, and develop a shared appreciation for leaders such as King Moshoeshoe and the legacy of peace, reconciliation and nation-building that they have left us.

Prof. Frederick Fourie
Rector and Vice-Chancellor
University of the Free State
13 October 2004.

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