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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

Research contributes to improving quality of life for cancer patients

2016-11-21

Description: Inorganic Chemistry supervisors Tags: Inorganic Chemistry supervisors

Inorganic Chemistry supervisors in the Radiopharmacy
Laboratory during the preparation of a typical complex
mixture to see how fast it reacts. Here are, from the left,
front: Dr Marietjie Schutte-Smith, Dr Alice Brink
(both scholars from the UFS Prestige
Scholar Programme), and Dr Truidie Venter (all three
are Thuthuka-funded researchers).
Back: Prof André Roodt and Dr Johan Venter.
Photo: Supplied

Imagine that you have been diagnosed with bone cancer and only have six months to live. You are in a wheelchair because the pain in your legs is so immense that you can’t walk anymore – similar to a mechanism eating your bones from the inside.

You are lucky though, since you could be injected with a drug to control the pain so effective that you will be able to get out of the wheelchair within a day-and-a-half and be able to walk again. Real-life incidents like these provide intense job satisfaction to Prof André Roodt, Head of Inorganic Chemistry at the University of the Free State (UFS). The research, which is conducted by the Inorganic Group at the UFS, contributes greatly to the availability of pain therapy that does not involve drugs, but improves the quality of life for cancer patients.

The research conducted by the Inorganic Group under the leadership of Prof Roodt, plays a major role in the clever design of model medicines to better detect and treat cancer.

The Department of Chemistry is one of approximately 10 institutions worldwide that conducts research on chemical mechanisms to identify and control cancer. “The fact that we are able to cooperate with the Departments of Nuclear Medicine and Medical Physics at the UFS, the Animal Research Centre, and other collaborators in South Africa and abroad, but especially the methodology we utilise to conduct research (studying the chemical manner in which drugs are absorbed in cancer as well as the time involved), enhances the possibility of making a contribution to cancer research,” says Prof Roodt.

Technique to detect cancer spots on bone
According to the professor, there are various ways of detecting cancer in the body. Cancer can, inter alia, be identified by analysing blood, X-rays (external) or through an internal technique where the patient is injected with a radioactive isotope.

Prof Roodt explains: “The doctor suspects that the patient has bone cancer and injects the person with a drug consisting of an isotope (only emits X-rays and does no damage to tissue) that is connected to a phosphonate (similar to those used for osteoporosis). Once the drug is injected, the isotope (Technetium-99m) moves to the spot on the bone where the cancer is located. The gamma rays in the isotope illuminate the area and the doctor can see exactly where treatment should be applied. The Technetium-99m has the same intensity gamma rays as normal X-rays and therefore operates the same as an internal X-ray supply.” With this technique, the doctor can see where the cancer spots are within a few hours.

The same technique can be used to identify inactive parts of the brain in Alzheimer patients, as well as areas of the heart where there is no blood supply or where the heart muscle is dead.

Therapeutic irradiation of cancer
For the treatment of pain connected with cancer, the isotope Rhenium-186 is injected. Similar to the manner in which the Technetium-99m phosphonate compound is ingested into the body, the Rhenium-186 phosphonate travels to the cancer spots. Patients thus receive therapeutic irradiation – a technique known as palliative therapy, which is excellent for treating pain. A dosage of this therapy usually lasts for about two months.

The therapy is, however, patient specific. The dosages should correspond with the occurrence and size of cancer spots in the patient’s body. First, the location of the cancer will be determined by means of a technetium scan. After that, the size of the area where the cancer occurs has to be determined. The dosage for addressing total pain distribution will be calculated according to these results.

Technique to detect cancer spots on soft tissue
Another technique to detect cancer as spots on bone or in soft tissue and organs throughout the body is by utilising a different type of irradiation, a so-called PET isotope. The Fluor-18 isotope is currently used widely, and in Pretoria a machine called a cyclotron was produced by Dr Gerdus Kemp, who is a former PhD graduate from the Inorganic Research Group. The F-18 is then hidden within a glucose molecule and a patient will be injected with the drug after being tranquillised and after the metabolism has been lowered considerably. The glucose, which is the ‘food' that cancer needs to grow, will then travel directly to the cancer area and the specific area where the cancer is located will thus be traced and ‘illuminated’ by the Fluor-18, which emits its own 'X-rays'.

In the late 80s, Prof Roodt did his own postdoctoral study on this research in the US. He started collaborating with the Department of Nuclear Medicine at the UFS in the early 90s, when he initiated testing for this research.

Through their research of more than 15 years, the Inorganic Group in the Department of Chemistry has made a major contribution to cancer research. Research on mechanisms for the detection of cancer, by designing new clever chemical agents, and the chemical ways in which these agents are taken up in the body, especially contributes to the development in terms of cancer therapy and imaging, and has been used by a number of hospitals in South Africa.

The future holds great promise
Prof Roodt and his team are already working on a bilateral study between the UFS and Kenya. It involves the linking of radio isotopes, as mentioned above, to known natural products (such as rooibos tea), which possess anti-cancer qualities.

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