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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

UFS alumnus receives PhD in Statistics from the University of Oxford
2016-06-03

Description: DW Bester  Tags: DW Bester

In May of this year, DW Bester obtained
a DPhil in Statistics at the University of
Oxford.
Photo: Supplied

On 14 May this year, Dr DW Bester received a DPhil in Statistics from the University of Oxford. The entire ceremony, which was held in the Sheldonian Theatre in Oxford, was conducted in Latin, as has been the case for the past 800 years.

Dr Bester completed his undergraduate studies and his honours degree at the University of the Free State (UFS). “At first, I was only planning to study for a master’s degree, but was privileged to get an opportunity to do a PhD as well. I didn’t think twice!” he says.

Studies at the University of Oxford


Universities in England do not require a master’s degree for PhD studies. With the help of Prof Max Finkelstein from the UFS Department of Mathematical Statistics and Actuarial Science, Dr Bester registered for the DPhil programme in Statistics directly after his honours studies.

“The title of my thesis was: Joint survival models: A Bayesian investigation of longitudinal volatility. It dealt with a problem in the medical field to determine the cause of stroke risk: is it the absolute level of blood pressure, or the volatility thereof? The analysis of this question led to interesting models which needed advanced application techniques. I had to study these techniques and write programmes for their application.

Although Dr Bester is working currently as the technical head of a company that calculates insurance for power stations, satellites, rockets, and cyber risks, he would like to continue working with his Oxford supervisor in future to make the techniques they have developed more accessible for researchers outside of the field of statistics.
 
“Studying at Oxford requires hard work, perseverance, and a lot of luck. Luck plays a big role, since there are no guarantees that hard work will ensure you a spot in one of the top universities.

Regarding his studies at Oxford, Dr Bester thinks back on his exposure to the GNU/Linux operating system, and free software. “I have seen how valuable this is for analyses in practice. I also had the privilege of meeting the father of free software, Richard Stallman,” Dr Bester says.

2011 Rhodes Scholar

He was elected as Rhodes Scholar in 2011. According to Dr Bester, who has been interested in Mathematics since high school, the Rhodes scholarship was something of a fluke. He applied for the Rhodes scholarship on the recommendation of Prof Robert Schall of the Department of Mathematical Statistics and Actuarial Science.

Role of the UFS in his successes


In addition to the continued support from the team of passionate professors and lecturers at the UFS, the actuarial degree at the UFS is fraught with statistics. Emphasis is also placed on Bayesian statistics. This was crucial to his studies at Oxford. According to Dr Bester, this topic is emphasised strongly in the international statistics community.

Dr Bester regards the work done by two of his lecturers, Michael von Maltitz and Sean van der Merwe, among his highlights at the UFS. Since our first year, they have created an atmosphere of camaraderie among the students. “I think this contributed to the success of everybody. They also make an effort to present topics outside of the syllabus regularly,” says Bester.

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