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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

Researcher finds ways to serve justice efficiently

2016-01-07

Prof Monwabisi Ralarala tackled the serving of justice from a linguistic viewpoint.
Photo: Supplied

In 2012, local and international media was saturated with reports of the Eugène Terre’Blanche murder trial. At the judgment, Judge John Horn read a lengthy extensive document, of which three pages were dedicated to voicing his concern about how police officers distort statements in the process of translation. Considering the fact that statements are the entry points to the criminal justice system, Prof Monwabisi Ralarala’s attention was drawn to the negative impact such distortion had insofar as the administration of justice was concerned. Of the three PhD degrees conferred by the University of the Free State (UFS) Faculty of Humanities at the 2015 Summer Graduation, one was in Language Practice with Prof Ralarala’s name on it.

Prof Ralarala’s research interests in language rights, forensic linguistics, and translation studies led him to use the Terre’Blanche trial as the basis for his second PhD case study titled: Implications and explications of police translation of complainants' sworn statements: evidence lost in translation. The doctoral dissertation focused on police stations in the Xhosa-speaking community of Khayelitsha in Cape Town.

Language and the law

When the victim of a crime approaches the South African Police Services (SAPS), the requirements are that a sworn statement be taken. However, as a prerequisite, the narration needs to be translated into English. “The process unfolds in this manner: the complainant or the person laying the charges speaks in a language that they understand, and then the police officers translate that information into English because English is still the de facto language of record,” explained Prof Ralarala.

In the process of translation, the original narrative is lost, and so is some of the evidence. “They [the statements] have to be packaged in a certain way, in the form of a summary. As a police officer, you have to discard all the original narrative and create another narrative which is in English,” added the Associate Professor and Institutional Language Coordinator at the Cape Peninsula University of Technology.

Evidence is the basis of any court case and, when it is translated by police officers who do not hold the credentials of professional translators, a problem inevitably arises.

Because police officers are not trained in translation, “Some of the statements are filled with distortions, changing of information all together. In some cases, one would come across a case which was initially an assault but then - through the change and transformation, re-narration, retelling of the story by someone else - it becomes a case of attempted murder.”

Considering that a statement determines a suspect’s fate, it becomes all the more important to ensure that accuracy is upheld.

His internal and external supervisors, Prof Kobus Marais and Prof Russel Kaschula from the UFS and Rhodes University respectively stated that his PhD work has been hailed as a gem by international scholars. “According to one international assessor, he has made an exceptional contribution to the humanities and social sciences in general and to the fields of linguistics and translation studies in particular.”

Reshaping the landscape

According to Prof Ralarala, there are huge gaps in the translated versions of statements which create a problem when a ruling is made. Some of the recommendations put forward in his dissertation to bridge that gap are:

• to review the language policy insofar as the criminal justice system is concerned. The languages we speak are official and constitutionally embraced, and they hold the same status as English, hence they need to be used in criminal justice processes;
• to revisit the constitution and review if the provisions made for the Nguni languages are implemented;
• to supplement paper and pen with technology such as tape recorders. Statements can be revisited in cases where a controversy arises;
• to deploy professional translators and interpreters at police stations;
• to design a manual for police officers which contains all the techniques on how a statement should be taken.
• to enforce constitutional provisions in order to reinforce the language implementation plan in as far as African languages are concerned .

These recommendations serve to undo or eliminate any perceived injustices perpetuated and institutionalised by current linguistic and formal practices in South Africa's criminal justice system.

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