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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 Council unanimously reappoints Dr Khotso Mokhele as Chancellor

2015-04-02

Dr Khotso Mokhele, Chancellor of the University of the Free State

The Council of the University of the Free State (UFS) unanimously reappointed Dr Khotso Mokhele as Chancellor during its quarterly meeting held on 13 March 2015. He was first appointed in this portfolio by the Council on 4 June 2010.

“It is an honour for the Council to reappoint someone of this stature as Chancellor of the UFS. With his solid academic background and high profile in the business world, Dr Mokhele has been a great asset to the UFS. On behalf of the Council and the university community, I extend a word of appreciation for the work he has done during his first term as Chancellor of the UFS. He is an exceptional leader, and the university community is looking forward to have him as Chancellor for a second term,” said Judge Ian van der Merwe, Chairperson of the UFS Council.

Dr Mokhele was awarded a BSc Agriculture from Fort Hare University, and continued his studies at the University of California Davis (USA) on the Fulbright-Hays Scholarship Programme, completing his MSc (Food Science) and PhD (Microbiology). He was subsequently a postdoctoral fellow at Johns Hopkins University School of Medicine (USA) and the University of Pennsylvania School of Medicine (USA). Dr Mokhele is the recipient of honorary doctorates from nine South African universities including the UFS, and from Rutgers University in the USA.

He was Chairman of the Rhodes Scholarship Selection Committee for Botswana, Malawi, Namibia, Lesotho and Swaziland (2007-2011), and served on the South Africa at Large Rhodes Scholarship Selection Committee for more than 10 years. As President and Chief Executive Officer (CEO) of the Foundation for Research Development (1996-1999) and the NRF from 1999 to 2006, Dr Mokhele played a central role in providing visionary and strategic direction to the South African science system. He was the Founder President of the Academy of Science of South Africa (ASSAf), Founder President and CEO of the National Research Foundation (NRF), Chairperson of the Economic Advisory Council to the Premier of the Free State (2001-2004), and a member of the Advisory Council on Innovation to the Minister of Science and Technology (2003-2007). His role in securing government and international support for the Southern African Large Telescope Project (SALT) is evidence of his dedication to science in South Africa. The success of this project laid the basis for South Africa being selected to host more than 70% of the Square Kilometre Array, an international mega telescope for radio astronomy.

In recognition of his contribution to the development of science, he was the recipient of the Technology Top 100 Lifetime Achievers Award in 2009 and the National Science and Technology Forum Award in 2005. His role in science is recognised internationally. He was an elected Vice-President: Scientific Planning and Review of the International Council for Science and Chairperson of its Committee for Scientific Planning and Review (2005-2008) as well as a member of the Committee on Developing and Transition Economy Countries of the International Social Science Council (2008-2010). He also represented South Africa on the executive board of UNESCO, and was awarded the Member Legion of Honour of the Republic of France for his work in strengthening scientific ties between South Africa and France.

Dr Mokhele currently serves as Special Advisor to the Minister of Science and Technology, the Honourable Naledi Pandor. His current corporate positions include: Non-Executive Chairman: Board of Directors, Impala Platinum Holdings Ltd (Implats); Lead Independent Non-Executive Director: African Oxygen Ltd (Afrox); Non-Executive Director of Zimbabwe Platinum Holdings Ltd (Zimplats); Hans Merensky Holdings Ltd; and Tiger Brands Ltd. He is the President of the Hans Merensky Foundation (South Africa) and a Trustee of SciDev.Net (a web-based scientific magazine based in London, UK) and Start International Inc (USA).

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