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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 keeps the power on

2015-06-24

At a recent Emergency Power Indaba held on the Bloemfontein Campus, support structures at the university met to discuss the Business Continuity Intervention Plan to manage load shedding on the three campuses of the UFS.

Currently, 35 generators serving 55 of the buildings have already been installed as a back-up power supply on the three campuses of the university. According to Anton Calitz, Electrical Engineer at the UFS, the running cost to produce a kWh of electricity with a diesel generator amounts to approximately three times the cost at which the UFS buys electricity from Centlec.

Planned additional generators will attract in excess of R4 million in operating costs per year. For 2015, the UFS senior leadership approved R11 million, spread over the three campuses. Remaining requirements will be spread out over the next three years. University Estates is also looking at renewable energy sources.

On the Bloemfontein Campus, 26 generators serving forty-one buildings are in operation. On South Campus, two generators were installed at the new Education Building and at the ICT Server Room. Lecture halls, the Arena, the Administration Building, and the library will be added later in 2015. Eight generators serving 12 buildings are in operation on the Qwaqwa Campus. In 2015, the Humanities Building, Lecture Halls and the heat pump room will also be equipped with generators.

Most buildings will be supplied only with partial emergency power. In rare cases, entire buildings will be supplied because the cost of connecting is lower than re-wiring for partial demand. According to Nico Janse van Rensburg, Senior Director at University Estates, emergency power will be limited to lighting and power points only. No allowances will be made for air-conditioning.

“Most area lighting will also be connected to emergency power,” he said.

Where spare capacity is available on existing emergency power generators, requests received for additional connections will be added, where possible, within the guidelines. The following spaces will receive preference:
- Lecture halls with the lights, data projectors, and computers running
- Laboratories for practical academic work and sensitive research projects
- Academic research equipment that is sensitive to interruptions
- Buildings hosting regular events

According to Janse van Rensburg, all further needs will be investigated. Staff can forward all emergency power supply needs to Anton Calitz at calitzja@ufs.ac.za

Staff and students can also manage load shedding in the following ways:

1. Carry a small torch with you at all times, in case you are on a stairwell or other dark area when the lights go out. You can also use the flashlight app on your phone. Download it before any load shedding occurs. This can come in handy if the lights go out suddenly, and you cannot find a flashlight. Load-shedding after dark imposes even more pressure on our Campus Security staff. We can assist them with our vigilance and preparedness by carrying portable lights with us at all times and by assisting colleagues.
2. Candles pose a serious safety risk. Rather use battery- or solar-powered lights during load shedding.
3. Ensure that your vehicle always has fuel in the tank, because petrol stations cannot pump fuel during power outages.
4. Ensure that you have enough cash, because ATMs cannot operate without electricity.
5. The UFS Sasol Library has study venues available which students can use during load shedding.
6. When arranging events which are highly dependent on power supply, especially at night, organisers should consult the load-shedding schedule before determining dates and preferably also make back-up arrangements. If generators are a necessity, the financial impact should be taken into consideration.

The senior leadership also approved a list of buildings to be equipped with emergency power supplies.

More about load shedding at the UFS:
Getting out of the dark
More information, guidelines and contact information

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