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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

You touch a woman, you strike a rock

2004-11-02

Prof. Engela Pretorius van die Departement Sosiologie in die Fakulteit Geesteswetenskappe by die Universiteit van die Vrystaat het die kwessie omtrent feminisme aangespreek tydens haar intreerede met die onderwerp, You touch a woman, you strike a rock: Feminism(s) and emancipation in South Africa .

Prof. Pretorius het gesê: “Die geskiedenis van feminisme oor die algemeen kan in drie fases verdeel word, waarna verwys word as golwe. Eerste-golf-feminisme (19de eeu) het die fokus geplaas op die beskerming van vroueregte in die openbare terrein, spesifiek die reg om te stem, die reg tot onderrig en die reg om middelklas beroepe en professies te betreë.

Vroeë tweede-golf-feminisme word onthou vir hoe dit moederskap geteoretiseer het as synde ‘n onderdrukkende instelling. Slagspreuke van die 1970s was die persoonlike is polities en susterskap is magtig. Prof. Pretorius sê beide slagspreuke bevestig die idee dat vroue universeel onderdruk en uitgebuit word en slegs deur erkenning van dié situasie kan vroue die strukture wat hul onderdruk verander.

‘n Belangrike aspek van die derde golf van die feminisme-teorie is post-moderne feminisme wat diversiteit en verskille onderstreep. Die poging van hierdie feministe is afgestem op alle vorme van onderdrukking. Vroue van kleur het ook hul ontevredenheid uitgespreek gedurende die derde-golf-feminisme. Die feminisme van vroue van kleur word gekenmerk deur verskeie kwessies en talryke intellektuele standpuntinnames wat neerslaga vind in verskillende terme, soos Afrika feminisme of ‘womanism, sê prof. Pretorius.

Afrika-feminisme dui protes aan teen die wit/westerse geskiedenis en die wit/westerse dominansie binne feminisme. Afrika-vroue het besef dat hul onderdrukking verskillend is van dié van wit vroue en daarom is ‘n ander proses van bevryding nodig. Die Westerse feministiese praktyk om swart vroue by die bestaande feministiese ontologie te voeg, is nie voldoende nie omdat hul unieke ondervindings van slawerny, kolonialisme, onderdrukking deur mans en armoede nie uitgedruk word nie.

‘Womanism’ het tot stand gekom as gevolg van ‘n eksplisiete rassekritiek teen feminisme. Dit is ten gunste van die positiewe uitbeelding van swart mense. Dit word gekenmerk deur kulturele kontekstualisasie, die sentraliteit van die gesin en die belangrikheid daarvan om mans in te sluit.

Die geskiedenis van vroue in Suid-Afrika is verwant aan hul geskiedenis van onderdrukking as gevolg van patriargie. Vroue van verskillende rasse, kulture en klasse het patriargie op verskillende wyses in en variërende mate van erns ervaar. Onder voor-koloniale patriargie het vroue min sê gehad oor huwelikskeuses omdat mans dié besluite gedomineer het.

Die Nederlandse en Britse patriargale erfenis het neerslag gevind in die ideologie van die volksmoeder. Onderwyl dit veral manlike skrywers was wat die beeld van die vrou as versorger en tuisteskepper bevorder het, het vroue self ook hieraan ‘n aandeel gehad, sodat die volksmoeder volwaardig deel geword het van die Afrikaner nasionalistiese mitologie. Alhoewel middel- en werkersklas vroue met dié beeld geïdentifiseer het, het nie alle Afrikaanse vroue die ideologie aanvaar nie.

Onder die Victoriaanse erfenis was Britse vroue beperk to die private eerder as die openbare lewe. Die skeefgetrekte onderrigsisteem wat vroue in huishoudelike loopbane gekanaliseer het, die mag van mans oor hul vroue se eiendom en ‘n tekort aan toegang tot mag en geld het verseker dat vroue by die huis gebly het.

Wit Engelssprekende-vroue het die grootste geleentheid gehad om patriargie uit te daag vanweë hul toegang tot onderwys en die blootstelling aan liberale waardes, sê prof. Pretorius. Liberale vroue soos Helen Joseph en Helen Suzman het ‘n belangrike rol gespeel om in 1930 stemreg vir wit vroue in Suid-Afrika te verseker en het voortgegaan om ‘n rol te speel in die bevryding van swart vroue gedurende die vryheidstryd.

Die feminisme wat onder swart vroue ontwikkel het, was ‘n erkenning van die gemeenskaplike stryd met swart mans om die verwydering van die juk van eksterne onderdrukking en eksploitasie. Swart vroue in aktiewe en onafhanlike politiese rolle het tegelykertyd mans se aannames omtrent hul meerderwaardigheid asook die rassewette van die staat uitgedaag. Daarom kan ons sê dat die feminisme wat hier ontwikkel het, te voorskyn gekom het as gevolg van vroue se betrokkenheid by en toewyding tot nasionale bevryding, sê prof. Pretorius.

Institusionalisering is nie herlei tot magsvoordele nie, want gelykheid is nie in beleidsprogramme geïnkorporeer nie. Die hervestiging van sleutel aktiviste van die vrouebeweging in die regering het die stryd om genderbillikheid verander na ‘n projek wat deur die regering gelei word, sê prof. Pretorius. Ongelukkig word terreine van verandering buite die grense van die regering verwaarloos. Dit kan slegs aangespreek word deur ‘n aktiewe en feministiese stem in die burgerlike samelewing.

“Dit is my oortuiging dat formele instellings vir vroue binne die staat oor die lang termyn slegs effektief kan wees indien daar ‘n effektiewe feministiese vroue-beweging buite die staat in stand gehou word wat die grondslag waarop sosiale beleid gevorm word, kan uitdaag en bevraagteken. Daarom, A luta continua (die stryd duur voort),” sê prof. Pretorius.

Mediaverklaring
Uitgereik deur: Lacea Loader
Mediaverteenwoordiger
Tel: (051) 401-2584
Sel: 083 645 2454
E-pos: loaderl.stg@mail.uovs.ac.za
2 November 2004

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