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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 awards honorary doctorate to global peace ambassador Dr Lakhdar Brahimi

2015-07-07

Professor Heidi Hudson, Director of the Centre for Africa Studies at the UFS and Dr Lakhdar Brahimi.
Photo: Mike Rose from Mike Rose Photography

The Faculty of the Humanities and Centre for Africa Studies rewarded the contributions of Dr Lakhdar Brahimi, a prominent global peace leader, with an honorary doctorate on Thursday 2 July 2015.

The conferment formed one of the highlights of the 2015 Winter Graduations. Dr Brahimi’s work as a United Nations’ (UN) envoy, and African peace leader of note, was deeply respected by the university. Professor Heidi Hudson, Director of the Centre for Africa Studies at the UFS, accepted the PhD on his behalf.

In his acceptance speech, read by Prof Hudson at the Chancellor’s Dinner the same evening, Dr Brahimi expressed his gratitude to the university. “I deeply appreciate your generous recognition, and even now, in the twilight years of my life, I shall try to be worthy of your confidence in everything I say or do.”

“My generation did its share: its successes and its failures are things of the past. We must accept to be judged by you, the graduates. You, the young graduates here at the University of the Free State, and your fellow members of the African intellectual elite, have an exciting opportunity to take on the challenges and fulfil the dreams you have. We must accept to be judged by you.”

Algerian-born Dr Brahimi was first involved with the UN in 1992 as rapporteur to the Earth Summit. Distinctively, he is the most-frequently appointed special envoy of the UN. Amongst many other countries, he has worked as a mediator for South Africa, Haiti, Afghanistan, Iraq, Syria, Democratic Republic of Congo, Cameroon, Burundi, Angola, Liberia, Nigeria, Sudan, and Côte d’Ivoire on behalf of the UN.

Significant peacekeeping efforts in South Africa (1993- 1994)

The ambassador– in his capacity as special representative to South Africa from December 1993 to June 1994 –played a direct role in South Africa’s democratic transition.

Prof Hudson expressed appreciation for the ambassador’s role in facilitating a peaceful transition from South Africa’s Nationalist government into the current democratic dispensation.

“One of the reasons we selected him as recipient of the honorary doctorate, is because of what he did for the African continent,” she said.

In addition, she commented Dr Brahimi for being a living testament of Ubuntu. “He has displayed an ethic of humanism in everything that he has done, in the way that he has mediated in certain conflicts - his main contribution is as a mediator.

According to Hudson, his humility, modesty, and generosity are the epitome of Ubuntu which states that “I am because we are.”

Dr Brahimi as a global peace practitioner

Dr Brahimi served as Undersecretary-General of the Arab League, Arab League Special Envoy for Lebanon, and Foreign Minister of Algeria.

The UN Peace-building Commission was established as a result of recommendations in his2000 Report of the Panel on United Nations Peace Operations (Brahimi Report).

Since 2007, Dr Brahimi has been a member in The Elders - an alliance chaired by Kofi Annan -of peace and human rights advocates including Desmond Tutu, Graça Machel, Mary Robinson, and Jimmy Carter. His passion for justice led to his membership in the Commission on Legal Empowerment of the Poor.

In 2010, he was Laureate of the Special Jury Prize for Conflict Prevention, awarded by the Chirac Foundation (France), which promotes international peace and security.

Dr Brahimi’s influence in Peace Education

The Brahimi Report has had an indelible impact on scholars specialising in the broad field of peace operations. Dr Brahimi’s writings have also contributed to knowledge on post-conflict reconstruction and development (PCRD), a signification part of the African Union’s narrative.

He is a distinguished senior fellow at the Centre for the Study of Global Governance at the London School of Economics. He has taught a postgraduate course on Conflict Resolution at Sciences Po, Paris (2011); is Andrew D. White Professor-at-Large at Cornell University; and is affiliated to the Institute for Advanced Studies at Princeton, where he was a visiting professor from 2006 to 2008.

In addition, Dr Brahimi is a founding member of the French-language Journal of Palestine Studies, and a board member of the Stockholm International Peace Research Institute.

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