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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 honours young researchers

2006-02-10

Some of the guests attending the recognition function were from the left: Prof Magda Fourie (Vice-Rector: Academic Planning at the UFS), Mr Joseph Smiles (lecturer at the UFS Department of Political Science and Thuthuka grant holder), Prof Frans Swanepoel (Director: Research Development at the UFS) and Dr Carlien Pohl (lecturer at the UFS Department of Microbial, Biochemical and Food Biotechnology and Thuthuka grant holder).
Photo: Leonie Bolleurs

The guest speaker was Prof Jonathan Jansen, Dean: Faculty of Education at the University of Pretoria (UP). He gave tips to young and promising researchers on how to be an outstanding scholar.
What is a Scholar

UFS honours young researchers

The University of the Free State (UFS) last night honoured 24 young researchers who are taking part in the National Research Fund’s (NRF) Thuthuka programme.

The recognition function is the first of its kind at the UFS. “The renewed focus on research development that was recently announced at the official opening of the UFS by the Rector and Vice-Chancellor, Prof Frederick Fourie, is an indication of the institution’s endeavour to create an environment in which research can be improved and flourish. This can only be obtained when researchers are being valued and that is why it is important to honour our young researchers,” said Mrs Annelize Venter, researcher at the UFS Research Development Directorate and coordinator of the programme.

The focus on research was also touched on recently by President Thabo Mbeki during the opening of Parliament when he said: “We will continue to engage the leadership of our tertiary institutions focused on working with them to meet the nation’s expectations with regard to teaching and research. For its part, the government is determined to increase the resource allocation for research and development and innovation, and increase the pool of young researchers."

According to Mrs Venter, research done in 2004 shows that the majority researchers who publish are white males above the age of 50. “Many students who undertake magister studies choose not to conduct research, but rather to do a thesis and additional subjects. This means that research is not stimulated. Students also find it difficult to obtain financial support for postgraduate studies,” she explained.
“Thutuka is a capacity building programme of the NRF that is aimed to
fund and support the qualifications of women and young black scientists and other researchers who do not have a rating for postgraduate research. It is based on a funding partnership between the UFS and the NRF,” said Mrs Venter.

Last night Prof Frans Swanepoel, Director: Research Development at the UFS, added to his by saying: “With the Thuthuka programme we aim to create and sustain a research culture at the UFS, promote international research and train researchers of a high quality and enhance the research capacity at the UFS by focusing on women, black researchers and other promising researchers.”

The programme was started by the NRF in 2001. At that stage only 17 grants were made countrywide. Last year 370 postgraduate students took part in the programme.

According to Mrs Venter the programme was implemented at the UFS in 2003. “At that stage we only had 5 grant holders. This year there are 24 Ph D and magister students on the programme,” she said.

A couple of young promising researchers, who will be participating in the programme in 2007, also attended last night’s recognition function.

The guest speaker was Prof Jonathan Jansen, Dean: Faculty of Education at the University of Pretoria (UP). He gave tips to young and promising researchers on how to be an outstanding scholar.

Nine professors were also congratulated with their promotion to senior research professor, namely Proff Louise Cilliers (Department of English and Classical Languages), James du Preez (Department of Microbial, Biochemical and Food Biotechnology), Johan Grobbelaar (Department of Plant Sciences), Dingie Janse van Rensburg (Centre for Health Systems Research and Development), Dap Louw (Department of Psychology), Philip Nel (Department of Afro-asiatic Studies and Language Practice and Sign Language), Louis Scott (Department of Plant Sciences), Dirk van den Berg (Department of History of Art) and Andries Raath (Department of Constitutional Law and Philosophy of Law).

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

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