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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

Is milk really so well-known, asks UFS’s Prof. Osthoff
2011-03-17

Prof. Garry Osthoff
Photo: Stephen Collett

Prof. Garry Osthoff opened a whole new world of milk to the audience in his inaugural lecture, Milk: the well-known (?) food, in our Department of Microbial, Biochemical and Food Biotechnology of the Faculty of Natural and Agricultural Sciences.

Prof. Osthoff has done his research in protein chemistry, immuno-chemistry and enzymology at the Council for Scientific and Industrial Research (CSIR) in Pretoria and post-doctoral research at the Bowman-Grey School of Medicine, North Carolina, USA. That was instrumental in establishing food chemistry at the university.
 
He is involved in chemical aspects of food, with a focus on dairy science and technology. He is also involved in the research of cheese processing as well as milk evolution and concentrated on milk evolution in his lecture. Knowledge of milk from dairy animals alone does not provide all the explanations of milk as food.
 
Some aspects he highlighted in his lecture were that milk is the first food to be utilised by young mammals and that it is custom-designed for each species. “However, mankind is an opportunist and has found ways of easy access to food by the practice of agriculture, where plants as well as animals were employed or rather exploited,” he said.
 
The cow is the best-known milk producer, but environmental conditions forced man to select other animals. In spite of breeding selection, cattle seem not to have adapted to the most extreme conditions such as high altitudes with sub-freezing temperatures, deserts and marshes.
 
Prof. Osthoff said the consumption of the milk as an adult is not natural; neither is the consumption of milk across species. This practice of mankind may often have consequences, when signs of malnutrition or diseases are noticed. Two common problems are an allergy to milk and lactose intolerance.
 
Allergies are normally the result of an immune response of the consumer to the foreign proteins found in the milk. In some cases it might help to switch from one milk source to another, such as switching from cow’s milk to goat’s milk.
 
Prof. Osthoff said lactose intolerance – the inability of adult humans to digest lactose, the milk sugar – is natural, as adults lose that ability to digest lactose. The symptoms of the condition are stomach cramps and diarrhoea. This problem is mainly found in the warmer climates of the world. This could be an indication of early passive development of dairy technology. In these regions milk could not be stored in its fresh form, but in a fermented form, in which case the lactose was pre-digested by micro-organisms, and the human population never adapted to digesting lactose in adulthood.
 
According to Prof. Osthoff, it is basically the lactose in milk that has spurred dairy technology. Its fermentation has resulted in the development of yoghurts and all the cheeses that we know. In turn, the intolerance to lactose has spurred a further technological solution: lactose-free milk is currently produced by pre-digestion of lactose with enzymes.
 
It was realised that the milks and products from different species differed in quality aspects such as keeping properties and taste. It was also realised that the nutritional properties differed as well as their effects on health. One example is the mentioned allergy against cow’s milk proteins, which may be solved by the consumption of goat’s milk. The nutritional benefits and technological processing of milk aroused an interest in more information, and it was realised that the information gained from human milk and that of the few domesticated species do not provide a complete explanation of the properties of milk as food. Of the 250 species of milk which have been studied, only the milk of humans and a few domesticated dairy animals has been studied in detail.

Media Release
15 March 2011
Issued by: Lacea Loader
Director: Strategic Communication
Tel: 051 401 2584
Cell: 083 645 2454
E-mail: news@ufs.ac.za

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