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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

DF Malherbe Memorial Lecture
2005-05-19

DF Malherbe Memorial Lecture: Language and language activism in a time of transformation (summary)
Proff Hennie van Coller and Jaap Steyn

Language activism necessary for multilingualism
The awareness is growing that language activism will be needed to bring about a truly democratic multi-lingual society. What is quite clear is that a firm resolve must continuously resist the concentrated pressure on Afrikaans-medium schools (and universities) to allow themselves to be anglicised through becoming first parallel medium, then dual medium, and finally English medium institutions.

Proff Hennie van Coller and Jaap Steyn said this last night (Wednesday night) in the 24th DF Malherbe Memorial Lecture at the University of the Free State. Prof van Coller is head of the Department Afrikaans, Dutch, German and French at the UFS. Both are widely honoured for their contributions to Afrikaans and the promotion of Afrikaans.

They discussed three periods of transformation since 1902, and said about the current phase, which started in 1994:  “Besides all institutions and councils having to be representative of South Africa’s racial composition, places of education were required to open their doors. Quite rapidly this policy has had the result that schools and universities may be solely English medium, but not solely Afrikaans medium. Afrikaans medium institutions — if they claim the right to remain Afrikaans — are quickly branded racist, even though their student body may include all races.

“Education departments are presently exerting great pressure on Afrikaans medium schools to become double or parallel medium schools.  Parallel medium education is an equitable solution provided it can be sustained. Established parallel medium schools, such as Grey College in Bloemfontein, have catered even-handedly for English and Afrikaans speakers for decades. But the situation is different in the parallel medium (and still worse in the double medium) schools that spring up usually at the behest of a department of education.

“Afrikaans schools are converted almost over-night into parallel or dual medium schools without any additional personnel being provided. Depending on the social environment, a parallel medium school becomes reconstituted as a dual medium school on average in five to eight years, and dual medium school becomes an English-only school in two to three years. Some Afrikaans medium schools have become English medium in just three years.

“Though the Constitution recognises mono-lingual schools, officials in the provinces insist that Afrikaans schools become dual or parallel medium; English medium schools are left undisturbed. One must conclude that the tacit aim of the state is English as the sole official language, despite the lip-service paid to multi-lingualism, and the optimistic references to post-apartheid South Africa as a ‘rainbow’ nation.”

They said a recent study has shown that the 1 396 Afrikaans schools in the six provinces in 1993 have dwindled to 844. The fall off in the Free State is from 153 to 97; in the Western Cape from 759 to 564; in Gauteng from 274 to 155; in Mapumalanga from 90 to 3; in the North West from 82 to 13; and in Limpopo Province from 38 to 12.

They said the changes at universities, too, have been severe, as university staffs well know. Ten years ago there were five Afrikaans universities. Today there are none. The government demanded that all universities be open to all, which has meant that all universities have had to become English medium. And no additional funding was forthcoming for the changes. The government policy amounts to a language “tax” imposed on the Afrikaans community for using Afrikaans.

“Only when all schools (and universities) are English will the clamor cease. Academics and educationists are beginning to speak openly of forming pressure groups to save Afrikaans schools, and of using litigation as one of their methods. 59% of Afrikaans parents have said they would support strong action if Afrikaans were no longer a medium of instruction at schools.”

 

 


 

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