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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

Legal elite tackle thorny issue of corruption

2013-01-24

Our Faculty of Law brought together top experts and judges for a Symposium on Corruption, to investigate one of the most pressing concerns of South Africans.
Photo: Stephen Collett
24 January 2013

YouTube Video

Chief Justice Mogoeng Mogoeng yesterday (24 January 2013) concluded the proceedings of the first day of the International Symposium on Corruption, hosted by the Faculty of Law of the University of the Free State (UFS). In his address Justice Mogoeng made no excuses as to the magnitude of the threat corruption presents to South African citizens.

“Urgent action and efficient measures are called for to arrest this scourge, for the sake of our constitutional democracy,” he warned. “Our vibrant constitutional democracy will not and cannot survive in the face of rampant corruption.”

Justice Mogoeng said the spate of civil and labour unrest erupting throughout the country can be attributed to corruption. According to him the scope and far-reaching implications of corruption drives South Africans to “boiling point” and evokes “anger, frustration and a don’t-care-attitude that often manifests in widespread protest actions” and disrespect for the rule of law.

“South Africans, irrespective of race or creed, must identify and focus on their common enemies and find a conciliatory and unifying way of dealing with what divides them, including the lingering prejudices of the past,” Justice Mogoeng urged.

Despite the threat corruption poses, he stressed that all South Africans have a role to play in the fight against corruption and that there are different role players that can become involved in the process. Especially important is the media and faith-based agencies which, according to Justice Mogoeng, can regenerate morals and secure a “national moral code.” The State must further ensure enforcement of anti-corruption measures and preside over the selection of individuals of “solid character” to reside in agencies meant to fight corruption.

He highlighted the need for an unbiased and independent judiciary, one immune to outside influences controlled by powerful forces, as well as personal agendas.

Although Justice Mogoeng believes that the private sector is most guilty of transgressions based on corruption, he stated that a “well-coordinated war” against it must be waged in all sectors in order to stamp it out.

Justice Mogoeng presided over the unveiling of the redesigned foyer of the CR Swart Building and praised the Faculty of Law for its innovation with regard to the symposium.

“I look forward with great optimism to more well-organised symposiums that strike at the nerve-centre of the well-being of our constitutional democracy,” he concluded.

Symposium seeks answers and solutions

The Faculty of Law at the University of the Free State (UFS) concluded its International Symposium on Corruption on Friday 25 January 2013. The event featured a stellar cast of speakers, including the Chief Justice of South Africa, three current Supreme Court of Appeal judges, high-court judges, advocates, prosecutors, journalists, as well as local and international legal academics.

Throughout the two-day symposium, corruption was dissected as a severe problem in the South African socio-economic landscape and solutions were sought to alleviate the pressing concern.

The main attractions of the symposium were undoubtedly the attendance and presentations delivered by Chief Justice Mogoeng Mogoeng, as well as Prof. Leon Wessels. Prof. Wessels was described as “one of the founding fathers of the constitution of South Africa” by Judge Fritz Brand, a current Appeal Court judge and the third-longest serving judge in the country.

“Corruption is stealing the constitutional dream of this country. Corrupt leaders are fearless, those who expose corruption, are fearful,” Prof. Wessels warned.

Judge Brand closely trails the second longest serving judge in the country in former Kovsie, as well as former UFS Council Chairman, Judge Faan Hancke. Both judges addressed the symposium and chaired sessions, along with Prof. Johan Henning, Dean of the Faculty of Law, and Judge Ian van der Merwe, Chairman of the UFS Council.

It was, however, not all doom and gloom, as several of the speakers offered tangible ideas in what was often termed the “war on corruption”. Celebrated Sunday Times journalist Mzilikazi wa Afrika who has been arrested following the police leasing scandal which he exposed, urged South Africans to stand together in their fight against corruption, before it is too late.

People on the front lines in the day to day fight against corruption also spoke at the symposium, giving the audience a better understanding of the intricacies and challenges involved in the process. The Head of the National Prosecuting Authority’s Asset Forfeiture Unit, Mr Willie Hofmeyer, as well as Advocate Xolisile Khanyile, who is the Director of Public Prosecutions in the Free State, elucidated this struggle.

The symposium also hosted Prof. Chizu Makajima, a celebrated academic from the United Kingdom.

The two-day symposium ended in style as the delegates gathered in the Centenary Hall on the Bloemfontein Campus for lunch, with a further address by Prof. Leon Wessels

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