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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

UFS in partnership with USA ’s Council on Economic Education

2006-02-01

A visit to the campus of the UFS was part of the recent NCEE workshop. Standing from the left are Prof Soehendro (Chairperson: National Education Standardisation Body of Indonesia), Prof Herman van Schalkwyk (Dean: Faculty of Natural and Agricultural Sciences at the UFS), Prof Elena Reshetnyak (Vice-Dean for International Programs, Kharkiv Polytechnic Institute, Kharkiv, Ukraine) and Mrs Annely Minnaar (local coordinator of the NCEE and professional officer of the UFS Department of Agricultural Economics). Seated are from left Prof Sutjipto ( Chairman of the Indonesian Council on Economic Education) and Dr Patty Elder (Vice-President of the NCEE's national programme).
Photo: Stephen Collett

UFS in partnership with USA ’s Council on Economic Education

A group of 50 teachers in Economics, learning facilitators and lecturers from eight countries attended a ‘train the trainers’ workshop this past week in Bloemfontein. The workshop forms part of the outreach programme of the National Council on Economic Education (NCEE) in the United States of America’s (USA) effort to improve the quality of the training in Economics of teachers and lecturers across the world.

The UFS and the Free State Department of Education are the NCEE’s first partners in Africa. “The initiative started in the Free State because of the connection that existed between the UFS and the NCEE,” said Prof Klopper Oosthuizen, from the UFS Department of Agricultural Economics and initiator of the cooperative agreement with the NCEE.

Three faculties at the UFS are involved in the cooperative agreement namely the Faculty of Natural and Agricultural Sciences, the Faculty of the Humanities and the Faculty of Economic and Management Sciences.

A group of 84 teachers and learning facilitators in the Free State attended the ‘train the teacher’ workshop at the UFS in December 2005 in an effort to improve the quality of Economics classes at schools in the Free State. The last national workshop will take place in June 2006 in Bloemfontein. During this workshop a group of 40 teachers and learning facilitators in the Free State will be trained by the NCEE.

“Because of the success with the programme in the Free State Dr Patty Elder, Vice-President of the NCEE’s national programme, announced during last week’s workshop that the initiative will now be extended to the other provinces in the country,” said Prof Oosthuizen. According to Prof Oosthuizen discussions around a strategy to get the other provinces on board of the programme also took place between Dr Elder and Prof Herman van Schalkwyk, Dean of the UFS Faculty of Natural and Agricultural Sciences. Prof van Schalkwyk will take the lead in this regard.

“The presence of Dr Elder and the executive directors of similar education networks in the Ukraine and Indonesia is an indication of the NCEE’s seriousness with the programme in Africa,” said Prof Oosthuizen.

Prof Oosthuizen explained that South Africa is competing to obtain funds from the NCEE to have a total South African representation in the workshops in the following one-year training period.

South Africa has a good chance of establishing the network quickly because of the presentation of the last national workshop in Bloemfontein in June 2006. “We are going to try to have as much South African representation as possible at this workshop,” said Prof Oosthuizen.

Concurrent with the workshop in June 2006, a programme will be developed that will be attended by at least five other provincial education departments and representatives of five other universities. These representatives will then be able to observe on a first-hand basis how this action learning takes place and how the participating countries plan to establish and expand their networks,” said Prof Oosthuizen.

“The NCEE has been working together with international partners since 1992 to strengthen their Economics teaching systems. They have already succeeded in increasing literacy in Economics of schools in the USA and more than 20 East Block countries. More than 1,5 million learners in the East Block countries have already been served by this initiative,” said Prof Oosthuizen.

According to Prof Oosthuizen the focus of the NCEE has since 2004 moved away from the East Block countries to Africa, Asia, Latin America and the Middle East. The representatives that attended last week’s workshop were from South Africa, Egypt, Jordan, Palestine, Indonesia, Mexico, Paraguay and Uruguay. Countries such as Egypt, who was also present at last week’s workshop, are eager to start a similar network.

Media release
Issued by: Lacea Loader
Media Representative
Tel: (051) 401-2584
Cell: 083 645 2454
E-mail: loaderl.stg@mail.uovs.ac.za
31 January 2006

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