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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

Power interruptions: Information for internal communication

2008-01-31

As part of the UFS’s commitment to address load shedding, the management would like to communicate the following:

The UFS mainly deals with the power interruptions by way of (a) the possible installation of equipment (e.g. generators) and (b) operational arrangements to ensure the functioning of the UFS in spite of power interruptions.

During the past week progress was made on both fronts. The information that follows resulted from a meeting of a task team of Physical Resources led by Mr Nico Janse van Rensburg, which took place on Monday 28 January (this task team naturally focuses on physical solutions) and a discussion by Exco on Wednesday 30 January 2008. Exco discussed the recommendations of the mentioned task team in respect of physical aspects, as well as the operational arrangements proposed by faculties.

Physical solutions

A Main Campus

1. New emergency power installations already approved:

Last week Exco gave its approval for the design and installation of emergency power equipment in all the large lecture-hall complexes to proceed immediately.

In all these cases

load surveys have been completed and a start has been made with the ordering of equipment and the process of appointing contractors. (Exco approved the adjustment of normal tender procedures in an attempt to expedite completion.)
generators with 20-30% more capacity than required for the current load are being ordered.
provision is being made for the connection of lights and at least one wall plug to the emergency power.
the expected construction time is 16 weeks (except in the case of the Flippie Groenewoud Building where it is 6 weeks).

The above-mentioned concerns lecture halls/ venues in the following buildings: Examination Centre, Flippie Groenewoud Building, Stabilis, Genmin and the Agriculture Building.

As far as the Agriculture Building is concerned, a larger generator (larger than required for lecture venues only) is being ordered in view of simultaneously providing essential research equipment (refrigerators, ovens, glasshouses) with emergency power within 16 weeks.

2. Investigation into the optimal utilisation of present emergency power installations

All the emergency power systems are being investigated on the basis of a list compiled in 2006 to determine whether excess capacity is available and whether it is possible to connect additional essential equipment or lights to it.

The electrical engineer warns as follows:
“Staff members must under no circumstances overload present emergency power points.

A typical example of this is a laboratory with 10 power points of which 2 points are emergency power outlets. Normally a fridge and freezer would, for example, be plugged into the two emergency power points, but now, with long load-shedding interruptions, a considerably larger number of appliances are being plugged into the power point by means of multi-sockets and extension cords. In the end the effect of such connections will accumulate at the emergency generator, which will then create a greater danger of it being overloaded and tripping, in other words, no emergency power will then be available.”

3. Requests and needs addressed directly to Physical Resources or reported to Exco via the line managers.

All the physical needs and requests addressed directly to Physical Resources or submitted to Exco via the line managers are being listed, classified and considered technically in view of their being discussed by the task team on Monday 11 February.
The information will (a) lead to recommendations to Exco regarding possible additional urgent emergency power installations, and (b) be used in the comprehensive investigation into the UFS’s preparedness for and management of long power interruptions.

Requests that can easily be complied with immediately and that fit into the general strategy will indeed be dealt with as soon as possible.

4. Purchase of loose-standing equipment: light, small, loose-standing generators, UPSs as solutions to/ aids during power interruptions

Exco approved that

a) faculties and support services accept responsibility themselves for the funding and purchase of loose equipment such as, for example battery lights, should they regard these as essential.
b) UPSs (uninterruptible power supplies) that faculties and support services wish to purchase to combat the detrimental effect of unexpected power interruptions on computer equipment) can (as at present) be purchased from own funds via Computer Services.
c) UPSs (uninterruptible power supplies) that faculties and support services wish to purchase to combat the detrimental effect of unexpected power interruptions on other types of equipment can normally be purchased from own funds with the consent of the line manager concerned.
Note: Please just make sure of the appropriateness of the equipment for a specific situation: it is not a power supply that can bridge a two-hour power interruption.)
d) small, loose-standing generators can be purchased from own funds via Physical Resources and installed under their supervision.
e) laptop computers can , where necessary, be purchased from own budgets. The availability of second-hand laptop computers must be taken into account.

B Vista

No major problems have been reported to date. The situation is being monitored and will be managed according to need. The same guidelines that apply to the Main Campus will naturally also apply to the Vista Campus.

C Qwaqwa

The situation is receiving attentions and solutions have already been found for most problems.

D General

1. All-inclusive project
A comprehensive investigation into the UFS’s preparedness for and management of long power interruptions will be launched as soon as possible. Available capacity will be utilised first to alleviate the immediate need. The needs assessment to which all faculties and support services have already contributed is already an important building block of the larger project.

2. Building and construction projects currently in the planning and implementation phase
The need for emergency power for projects such as the new Computer Laboratory is being investigated proactively and will be addressed in a suitable manner.

3. Liaison with Centlec
Attempts at direct and continuous liaison are continuing in an attempt to accommodate the unique needs of the UFS.

4. HESA meeting and liaison with other universities
A representative of the UFS will attend a meeting of all higher education institutions on 11 February. The meeting is being arranged by HESA (Higher Education South Africa) to discuss the implications for the sector, the management of risks and the sector’s response to government.

5. Internal communication
It is the intention to communicate internally after every meeting of the task team, which will take place on Mondays. Strategic Communication will assist in this regard.

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