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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

Nanotechnology breakthrough at UFS

2010-08-19

Ph.D students, Chantel Swart and Ntsoaki Leeuw

Scientists at the University of the Free State (UFS) made an important breakthrough in the use of nanotechnology in medical and biological research. The UFS team’s research has been accepted for publication by the internationally accredited Canadian Journal of Microbiology.

The UFS study dissected yeast cells exposed to over-used cooking oil by peeling microscopically thin layers off the yeast cells through the use of nanotechnology.

The yeast cells were enlarged thousands of times to study what was going on inside the cells, whilst at the same time establishing the chemical elements the cells are composed of. This was done by making microscopically small surgical incisions into the cell walls.

This groundbreaking research opens up a host of new uses for nanotechnology, as it was the first study ever in which biological cells were surgically manipulated and at the same time elemental analysis performed through nanotechnology. According to Prof. Lodewyk Kock, head of the Division Lipid Biotechnology at the UFS, the study has far reaching implications for biological and medical research.

The research was the result of collaboration between the Department of Microbial, Biochemical and Food Biotechnology, the Department of Physics (under the leadership of Prof. Hendrik Swart) and the Centre for Microscopy (under the leadership of Prof.Pieter van Wyk).

Two Ph.D. students, Chantel Swart and Ntsoaki Leeuw, overseen by professors Kock and Van Wyk, managed to successfully prepare yeast that was exposed to over-used cooking oil (used for deep frying of food) for this first ever method of nanotechnological research.

According to Prof. Kock, a single yeast cell is approximately 5 micrometres long. “A micrometre is one millionth of a metre – in laymen’s terms, even less than the diameter of a single hair – and completely invisible to the human eye.”

Through the use of nanotechnology, the chemical composition of the surface of the yeast cells could be established by making a surgical incision into the surface. The cells could be peeled off in layers of approximately three (3) nanometres at a time to establish the effect of the oil on the yeast cell’s composition. A nanometre is one thousandth of a micrometre.

Each cell was enlarged by between 40 000 and 50 000 times. This was done by using the Department of Physics’ PHI700 Scanning Auger Nanoprobe linked to a Scanning Electron Microscope and Argon-etching. Under the guidance of Prof. Swart, Mss. Swart en Leeuw could dissect the surfaces of yeast cells exposed to over-used cooking oil.

The study noted wart like outgrowths - some only a few nanometres in diameter – on the cell surfaces. Research concluded that these outgrowths were caused by the oil. The exposure to the oil also drastically hampered the growth of the yeast cells. (See figure 1)

Researchers worldwide have warned about the over-usage of cooking oil for deep frying of food, as it can be linked to the cause of diseases like cancer. The over-usage of cooking oil in the preparation of food is therefore strictly regulated by laws worldwide.

The UFS-research doesn’t only show that over-used cooking oil is harmful to micro-organisms like yeast, but also suggests how nanotechnology can be used in biological and medical research on, amongst others, cancer cells.

Figure 1. Yeast cells exposed to over-used cooking oil. Wart like protuberances/ outgrowths (WP) is clearly visible on the surfaces of the elongated yeast cells. With the use of nanotechnology, it is possible to peel off the warts – some with a diameter of only a few nanometres – in layers only a few nanometres thick. At the same time, the 3D-structure of the warts as well as its chemical composition can be established.

Media Release
Issued by: Mangaliso Radebe
Assistant Director: Media Liaison
Tel: 051 401 2828
Cell: 078 460 3320
E-mail: radebemt@ufs.ac.za
18 August 2010

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