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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

Applications for the Vice-Chancellor's Prestige Programme for 2013/2014 now open

2012-12-06

This highly prestigious programme, led by the Vice-Chancellor of the University of the Free State, seeks to identify, develop and promote the next cohort of the most promising and talented UFS academic members of staff who obtained a doctoral degree within the last five years. These are young scholars who have chosen academic careers and who are focused and determined to become senior academics in their respective disciplines.

Once identified, these scholars will be put through an intensive programme of academic and scholarship support that includes an advanced residential programme, exposure to leading scholars, intensive reading and writing programmes, high-level seminar participation and presentation, nuanced publication schedules and personal mentoring and advice.

The selection process is highly competitive, and aimed at those young scholars with the potential to obtain upper-level ratings (Y1 and P). The selection criteria include the following:(1)

1. Recently obtained a PhD degree.

2. Evidence of an active publication record.
3. Early recognition of scholarly work, e.g. successful funding/grant applications and academic awards.
4. The early development of a post-doctoral intellectual project that shows evidence of scholarly “potential” (defined by the NRF Y-category).
5. Indication of the young scholar’s understanding of what their envisaged postdoctoral endeavours will contribute to the body of knowledge.

This period of support will run over a cycle of two years after which a new intake of next generation professors will be selected.

While this cohort will be selected for an intensive programme, ongoing development and support of all young scholars will continue. The selected scholars will reflect a balance of young academics from the humanities (broadly defined, including education, law, theology and the social sciences) and the natural sciences (broadly defined, including the agricultural and health sciences).

Call for Applications

This is a call for applications for the Vice-Chancellor’s Prestige Programme for 2013/2014. Candidates are invited to submit applications. No nomination is required, but deans and heads of department will also be asked to invite young scholars to apply. Complete applications are due by Monday 21 January 2013. A full application will include the following documentation:

1. A complete curriculum vitae of the candidate.
2. A complete exercise of intent comprising the following:
2.1   Select two journal articles (copies of which to accompany the application) in the area you have identified for your intellectual focus post PhD. These articles have to be selected from journals of international standing in your field.
2.2   The articles need to be summarised (250 words each), and
2.3   Two questions have to be identified that you would want to pursue in relation to your intended project.
2.4   This is followed by a brief, critical summary of a hundred lines maximum to indicate how these articles inform, integrate or provoke your planned future research.

Submission and contact address

A paper copy of the application must be submitted to the Vice-Chancellor’s secretary, Ms Melissa Coetzee, in the Main Building by 16:00 on Monday 21 January 2013 and an electronic copy of your entire application to the administrative assistant, Mr Albert Nell:nella@ufs.ac.za. You will be contacted to acknowledge receipt. Candidates will be informed of the outcome in February. Further information on the Vice-Chancellor’s Prestige Scholar Programme can be directed at any of the following co-directors (in alphabetical order):

Prof Jackie du Toit, Prof Neil Roos, Prof Aldo Stroebel or Prof Corli Witthuhn.

[1] The VC reserves the right to nominate young scholars to the programme and also to invite scholars to a panel interview to evaluate personal qualities, professional commitment and academic ambition.

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