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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

Multi-disciplinary research approach at UFS

2005-10-25

UFS follows multi-disciplinary research approach with opening of new centre

“A new way of doing business in necessary in the research and teaching of agriculture and natural sciences in South Africa. We must move away from departmentalised research infrastructures and a multi-disciplinary approach to research involving several disciplines must be adapted,” said Prof Herman van Schalkwyk, Dean: Faculty of Natural and Agricultural Sciences at the University of the Free State (UFS).

Prof van Schalkwyk delivered the keynote address during the launch of the Centre for Plant Health Management (CePHMa) at the Main Campus in Bloemfontein today (21 October 2005). CePHMa is an initiative of the UFS Department of Plant Sciences.

According to Prof van Schalkwyk a tertiary institution must practice multi-disciplinary research to be a world-class research institution. “It is difficult for researchers to admit that they do not know a lot about each other’s area of speciality. It is therefore necessary for researchers to make a paradigm shift and to focus on inter-disciplinary co-operation. To do this, we must encourage them to work together and to find a common language to communicate ideas en establish symbiotic relationships,” said Prof Van Schalkwyk.

“We tend to think that research is better and faster if it is specialised. This is not true. The new generation of scientists are young and they are trained to form a concept of the total system and not to focus on a specific area of speciality. At the UFS we encourage this approach to research. This was one of the main reasons for the establishment of CePHMa,” said Prof Van Schalkwyk.
CePHMa is the only centre of its kind in Africa and is established to extend the expertise in plant health management in South Africa and in Africa, to train experts in plant health and to conduct multi-disciplinary research about the health of agricultural crops.

“CePHMa is a virtual centre comprising of ten disciplines applicable to crop production and crop protection,” said Prof Wijnand Swart, Chairperson of CePHMa during the opening ceremony.

“The UFS is the leading institution in Africa in terms of news crop development and manages three research programmes that concentrate on new crops, i.e. the New Crop Pathology Programme, the New Crop Development Programme and the Insects on New Crops Programme. Other applied research programmes that are unique to the UFS are genetic resistance to rust diseases of small grain crops and sustainable integrated disease management of field crops,” said Prof Swart.

“Because the expected growth in population will be 80% in 2020 in sub-Saharan Africa, the future demands of food produce in Africa will be influenced. Therefore research will in future be focused on ways to improve food security by employing agricultural systems that are economically viable and environmentally sound,” said Prof Swart.

“Thorough knowledge of the concept of holistic plant health management is crucial to meet the challenge and it is therefore imperative that innovative crop protection and crop production strategies, with particular emphasis on plant health, be adopted. This is why the Department of Plant Sciences initiated the establishment of CePHMA,” he said.

According to Prof Swart there is a shortage of expertise in plant health management. “The UFS has shown the potential to address the demand of the sub-continent of Africa regarding expertise training and CePHMa is the leader in southern Africa to provide in this need,” he said.

The appropriateness and quality of training in plant health management is reflected in the fact that students from Ethiopia, Eritrea, Malawi, Uganda, Zambia, Ghana, Tanzania, Cameroon, Angola, Mozambique and Lesotho have already been trained or are in the process of being trained in at the UFS.

Scientists from CePHMa have forged partnerships with numerous national and international institutions including the Agricultural Research Council (ARC), various community trusts, seed, pesticide and agricultural chemical companies, in addition to overseas universities.

Media release
Issued by: Lacea Loader
Media Representative
Tel: (051) 401-2584
Cell: 083 645 2454
E-mail: loaderl.stg@mail.uovs.ac.za
21 October 2005

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