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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

Sites of memory. Sites of trauma. Sites of healing.
2015-04-01

Judge Albie Sachs – human rights activist and co-creator of South Africa’s constitution – presented the first Vice Chancellor’s Lecture on Trauma, Memory, and Representations of the Past on 26 March 2015 on the Bloemfontein Campus.

His lecture, ‘Sites of memory, sites of conscience’, forms part of a series of lectures that will focus on how the creative arts represent trauma and memory – and how these representations may ultimately pave the way to healing historical wounds. This series is incorporated into the five-year research project, led by Prof Pumla Gobodo-Madikizela, and funded by the Mellon Foundation.

Sites of memory and conscience – and healing

“Deep in solitary confinement, I read in the Bible: ‘the lion lay down with the lamb … swords will be beaten into ploughshares.’” And with these opening words, Judge Sachs took the audience on a wistful journey to the places in our country that ache from the past but are reaching for a better future at the same time.

Some of the sites of memory and conscience Judge Sachs discussed included the Apartheid Museum, Liliesleaf, District Six Museum, and the Red Location Museum. But perhaps most powerful of them all is Robben Island.

Robben Island

“The strength of Robben Island,” Judge Sachs said, “comes from its isolation. Its quietness speaks”. Former prisoners of the island now accompany visitors on their tours of the site, retelling their personal experiences. It was found that, the quieter the ex-prisoners imparted their stories, “the gentler and softer their memories; the more powerful the impact,” Judge Sachs remarked. Instead of anger and denouncement, this reverence provides a space for visitors’ own emotions to emerge. This intense and powerful site has become a living memory elevated into a place of healing.

After Judge Sachs visited the National Women’s Memorial in Bloemfontein some years ago, he came to an acute realisation as he read the stories, experienced the grief, and saw the small relics that imprisoned commandoes from Ceylon and St Helena sculpted. “It’s so like us,” he thought, “our people on Robben Island making a saxophone out of seaweed, our people carving little things. It was so like us. It was another form of inhumanity to human beings in another period.”

The Constitutional Court

The Constitutional Court next to the Old Fort Prison is also a profound site of trauma and healing. Bricks from the awaiting trial lock-up were built into the court chambers. “We don’t suppress it, we don’t say let’s move on. We acknowledge the pain of the past. We live in it, but we are not trapped in it. We South Africans are capable of transcending, of getting beyond it,” Judge Sachs said.

Transforming swords into ploughshares

Judge Sachs had great praise for Prof Gobodo-Madikizela’s research project on Trauma, Memory, and Representations of the Past. “You convert and transform the very swords, the very instruments, the very metal in our country. In a sense, you almost transform the very people and thoughts and dreams and fears and terrors into the ploughshares; into positivity.”

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