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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

Enhancement of social justice focus at research colloquium

2010-10-07

At the third Education for Social Justice Research Colloquium the publication Praxis towards sustainable empowering learning environments in South were handed to Prof. Ezekiel Moraka, Vice-Rector: External Relations at the UFS. At this occasion were, from the left: Prof. Dennis Francis, Dean of the UFS Faculty of Education; Prof. Sechaba Mahlomaholo, Research Professor in the Faculty of Education Sciences at the North-West University; Prof. Moraka; and Dr Milton Nkoane, Senior Lecturer in the UFS Faculty of Education.
Photo: Leonie Bolleurs

This year, the University of the Free State (UFS) was the host for the Research Colloquium: Education for Social Justice for the very first time. It is the third time that this colloquium has been presented.

Prof. Ezekiel Moraka, Vice-Rector: External Relations at the UFS, opened the colloquium, stating that academics, through their research, are ultimately in a good standing to advise government on important issues such as social justice for them to address these issues accordingly.

Prof. Sechaba Mahlomaholo, Research Professor in the Faculty of Education Sciences at the North-West University, delivered the opening address on the theme: Validating community cultural wealth towards sustainable empowering learning environments for social justice. He said that the legacy of our recent past as South Africa still continues to haunt us, especially as exemplified in the dysfunctionalities that are rife in our education.

“With the colloquium we manage to bring together the ideas, thoughts, resources and efforts of educators and/or educationists concerned with the creation of a more equitable, equal, free, hopeful, peaceful and socially just society. Through our teaching, our community engagement and research activities we strive towards a more humane, caring, respecting and respectful South Africa and the world,” he said.

According to Prof. Mahlomaholo, education and its research are some of the most potent mechanisms at the very centre of social transformation. The papers at the colloquium focused on investigating, understanding and responding to issues of amongst others:

The medium of teaching and learning which continues to be a barrier to many learners to perform to the best of their abilities in the majority of the education institutions in South Africa;
Health, sexuality, HIV/Aids, stigmatisation and other deseases plaguing our communities currently;
Self-fulfilling prophecies and stereotypes about some learners not being as intelligent as the rest and this finally being reflected and confirmed in their poor academic achievements;
Differentiated levels of parental involvement in the activities of their children’s learning due to long absences from their families as they have to work in far-off places of employment;

Papers delivered at the colloquium moved beyond merely identifying the problems; they also suggested possible and plausible research-based solutions to these, such as integrating HIV/Aids education in curricula, listening to the aspirations of significant stakeholders such as mothers and parents generally in teaching and facilitating more rigorous community engagement practices.

At the colloquium gala dinner the book Praxis towards sustainable empowering learning environments in South Africa by authors Dr Milton Nkoane, Senior Lecturer in the UFS Faculty of Education, Prof. Mahlomaholo and Prof. Dennis Francis, Dean of the Faculty of Education at the UFS, was launched. The publication consists of a collection of the best peer-reviewed papers from a conference with the theme Creating sustainable empowering learning environments through scholarship of engagement. The main criterion for inclusion was that the paper should contribute to the theme by means of an original, tight, theoretical and empirical study conducted with the aim of informing the practice of creating sustainable empowering learning environments. The concrete cases examined in many of the chapters are very useful to helping readers understand the specific, on-the-ground concerns related to higher education and schools.

Media Release
Issued by: Leonie Bolleurs
Strategic Communication
Tel: 051 401 2707
Sel: 0836455853
Email: bolleursl@ufs.ac.za
30 September 2010

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