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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

Prof. Letticia Moja a winner in her category

2004-08-17

Prof. Moja a finalist in award
'Every member of staff is important to me'

Michelle Cahill - Bloemnuus

IF you are in need of a dose of inspiration, try and get an appointment with Prof. Letticia Moja, the Dean of the Faculty of Health Science at the University of the Free State. It will not be easy as she has an extremely tight schedule, over and above being a finalist in the 2004 Shoprite/Checkers Woman of the Year competition.

Although not a born and bred Free Stater, this dynamic woman has come to love the Free State. "Once you get past the mindset of a small town and all the negatives surrounding it, it is an absolutely wonderful experience," Moja said.

Moja was born in Pretoria and grew up in Garankuwa as the second eldest of five children. "That was nothing special. I was not the eldest and I wasn't the youngest," she quipped. She had two younger brothers, one of whom died in a car accident and then two sisters.

She went to school in Pretoria and her first contact with the Free State was when she wrote her matric at Moroka High School in Thaba Nchu. "That was one of the best schools for us at that time," she says. After completing matric, she went on to study medicine in KwaZulu-Natal.

In 1982 she returned "home" and completed her internship at the Garankuwa Hospital. Hereafter she specialised in gynaecological obstetrics at Medunsa.

She became the head of the gynaecological obstetrics unit and later opened a branch in Pietersburg.

"This was just about the most heart-rending time of my life. You saw people travelling for up to three days just to see a doctor," she says. "Here we really interacted with the community."

In 2001 she was invited by the University of the Free State to apply for the job of vice-dean of the Faculty of Health Science. "I wasn't too keen," she says, "but they kept on calling to find out if I had applied or not," she says with a smile. "Eventually I gave in and was appointed."

She thought she would work a couple of years under Prof. Kerneels Nel, then the dean of the faculty. "Unfortunately that was not to be. I had hoped that I could learn from him," Moja says.

Prof. Nel died of a heart attack in 2003 after which Moja deputised for him before being appointed as dean.

"This brought along a whole newset of challenges," she says, "Now I have to work out budgets and I need to know what human resources are," she jokes. This has prompted her to take up her studies again and she is currently doing her MBA.

"It has certainly been a challenge to go into management and without my support structure I most certainly wouldn't have been able to do it," Moja says.

Moja is actively involved in her church and serves on various committees including the Health Professional Council where she is acting president of the Medical and Dental Board and the Provincial Aids Council.

To her no job is menial. She recalls when she used to have "high tea" with her staff in Gauteng and Limpopo. "One of the cleaning ladies used to think her job was menial. That is just not so. No hospital can do without even the lowest position. Imagine stepping over rubbish while you're trying to catch a baby. To me everybody is important no matter what you do. "

Moja's eldest daughter is studying for her B.Accounting degree at Wits . Her youngest daughter is in Gr. 9 at Eunice and she has also brought along her niece, who is in Gr. 8 at Eunice. "You see, we need to be three girls in the house."
She feels honoured to have been nominated by the institution especially as it is traditionally male-dominated. "It is not about me, but about the support structure. Nobody can do it on their own. It is a team effort."
BLOEMNUUS - VRYDAG 9 JULIE 2004

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