Discussion platform between midwifery educators and health professionals in the Free State province.
Subject: Maternal health services (Conferences, meetings and seminars)
Maternal health services (Standards)
Child health services (Conferences, meetings and seminars)
Child health services (Standards)
Nurses (Psychological aspects)
Nurses (Practice)
Nurses (Vocational guidance)
Midwives (Training)
Midwives (Practice)
Midwives (Vocational guidance)
Practice guidelines (Medicine)
Author: Schoon, M.G.
Pub Date: 05/01/2011
Publication: Name: South African Journal of Obstetrics and Gynaecology Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0038-2329
Issue: Date: May, 2011 Source Volume: 17 Source Issue: 2
Topic: Event Code: 350 Product standards, safety, & recalls; 200 Management dynamics; 280 Personnel administration
Product: Product Code: 8000187 Maternal & Child Health Care; 9105264 Maternal & Child Health Programs; 8043100 Nurses; 8043500 Midwives NAICS Code: 621999 All Other Miscellaneous Ambulatory Health Care Services; 92312 Administration of Public Health Programs; 621399 Offices of All Other Miscellaneous Health Practitioners SIC Code: 8099 Health and allied services, not elsewhere classified; 8049 Offices of health practitioners, not elsewhere classified
Geographic: Geographic Scope: South Africa Geographic Name: Free State, South Africa Geographic Code: 6SOUT South Africa
Accession Number: 257675219
Full Text: With the establishment of a maternal and child health task team in the Free State province, problems relating to knowledge and skills of professionals in maternity sections were identified. This concern was also expressed in the Saving Mothers report. In view of these concerns, a platform was established where professionals from various training schools and the midwifery workforce at institutions supporting students in health could discuss concerns relating to maternal services.

A two-day workshop in August 2010 was held including representatives from the Free State University School of Nursing (maternity division) and the departments of Obstetrics and Family Medicine in the School of Medicine, as well as members from various campuses of the Free State School of Nursing (Department of Health) and hospitals providing training to health care students.

The workshop was funded with the assistance of the Midwives AIDS Alliance and was attended by 43 health professionals, including midwives, professional nurses, specialists and medical practitioners. Heads of all the schools were present to show their support.

After four introductory presentations, structured discussions took place in a group context with the aim of identifying the most pressing problems with maternal services and making some recommendations to solve the problems.

General remarks on issues identified by the various groups

The core themes identified were:

Workforce image

Lack of self-respect of practitioners working in maternal services was identified as problematic because of a general lack of appropriate role models and leadership that could promote quality of care in maternal services.

The following factors were suggested as contributing to an inferior image:

* All nurses are regarded as midwives irrespective of their interest.

* Nurses are often sent to labour units as part of a disciplinary process.

* Many nursing professionals working in labour wards do not do so by choice.

* It was suggested that a process of value clarification should be undertaken to allow midwives to reclaim their profession, to clarify the core values needed to render quality midwifery care and to determine the dedication and willingness of staff to work in maternal services. Direct-entry midwifery programmes and focused specialisation could open pathways to attract staff with the right attitude and dedication.


All groups identified gaps in the training of midwives. The current methods are not promoting quality, and huge differences in the approaches between various schools (and professions) indicate a lack of standardisation in training. Educators felt that the end product of their training is good, but not appropriately utilised by the service delivery platforms. In contrast, the service delivery units highlighted a sub-optimal link between educators and the service delivery workforce. The fact that educators are not involved in service delivery, and the lack of clinical facilitators assisting midwifery students and staff in the work environment, contribute to problems in the training of midwives. If the link between the service delivery platform and the educators can be improved, inappropriate training could be removed from the curriculum. Initiatives from the national Department of Health to close the skills gaps should be included in the training curriculum of new health workers.

Clinical competencies

Skills and competencies are lacking in maternity sections. Good competencies are usually found in those professionals who have a passion for the subject. There are currently no mechanisms to enforce activities to retain competencies, and a strong motivation was made to introduce continuing professional development (CPD) processes for midwives to ensure that competencies are improved and retained. The focus on generalist training of nurses/midwives was highlighted as a problem. Collapsing family planning services was highlighted as an example of removal of focused specialisation. Restoring dedicated skilled staff with a desire to work in the maternity services is required to improve practical skills.

Management and leadership

Lack of good management and leadership is contributing to the poor quality of services. Too many managers turn a blind eye to corruption and lack of discipline. Sub-optimal care allowed to continue without consequences adds to a general lack of discipline in the delivery area. Frequent rotation of skilled staff out of the maternity services was highlighted as a general problem resulting in staff rendering service without the appropriate competencies. Furthermore, inappropriate staff members are sent to conferences and workshops and these staff do not provide feedback to the rest of the team, resulting in loss of opportunities to improve knowledge of the team.

Lack of teamwork, not only among midwives but also between medical professionals and midwives, contributes to poor-quality service. Many institutions do not have perinatal review meetings, and the multidisciplinary ward rounds have been discontinued.

There was also a strong plea for occupational health support to staff working in maternity services. This would include various ways of ensuring a healthy workforce, including HIV prevention and industrial psychological support.


Roles of the various players in midwifery are poorly defined. No scope of practice for advanced midwives is in place, and there is disagreement countrywide as to what their role and function should be. Staff returning from advanced training courses are expected to provide the same service as they did before the additional training, negating its point. Decisions by experienced midwives are often overruled by junior and inexperienced medical practitioners, leading to further dissatisfaction.

The majority of the delegates wanted to reintroduce the 'green epaulette' midwife of the past.

A modular approach to training of 'skilled birth attendants' based on competencies required in labour wards was suggested as a solution, and this training would be irrespective of professional group. This highlighted the multi-professional dynamics in midwifery skills and the need for active multi-professional involvement in delivery of maternity services. This approach would address the often poor skills training of medical practitioners in normal delivery techniques.

The way forward

The delegates at the workshop listed 14 priorities that should be considered for action, and these are set out in Table I. Five priority actions that should receive urgent attention were selected through a voting process.

1. Introduce mechanisms to strengthen competencies

Lack of professionals with the required competencies was highlighted as a critical issue affecting maternity sections.

Mechanisms need to be developed to ensure that competent staff are working in delivery units. It was suggested that 'privileging' of staff needs to be introduced based on proven competencies.

Teaching of health professionals with respect to delivery techniques and complications should be standardised. Outputs should be the same irrespective of the professional group that works in a labour ward setting.

Constructive discussions between nursing and medical training facilities would be required to establish a unified single-output training initiative for all professionals with respect to skills required for childbirth and maintenance of such skills and competencies.

2. Facilitate value clarification in the midwifery profession

A systematic approach using a technique of appreciative enquiry should be used to examine how professionals in maternity units view themselves as professional midwives. This value clarification will assist in determining how many staff working in maternity services are not dedicated or comfortable with their placements and work environment. Such a process could assist in unifying the midwifery cadre and improving dedication.

3. Introduce a provincial register of competent midwives

The workshop concluded that establishing a register of known competent midwives will greatly assist in ensuring that staff with an interest in maternity services provide the services in maternity sections. Such a register will also assist in determining the human resource needs for maternal services. This could be done on a voluntary basis, or could be enforced through regulations issued in terms of the provincial Health Act.

4. Establish clinical facilitators in all institutions where nursing students train

Nursing educators and the professionals working in training institutions strongly support that clinical facilitators need to be re-established in all facilities through which students are rotating. These individuals could play a pivotal role in ensuring clinical skills and competencies at institutional level and an important role in the quality assurance programmes at institutional level. This action may also address the experience gap between nurse educators not in active clinical practice. Consideration should be given to establishing dual appointments between the nursing training institutions and the province, as has been done with medical staff.

5. Preventive programmes such as family planning and sexually transmitted infections need to be strengthened

Lack of focus on preventive programmes, including prevention of pregnancy and transmission of HIV, was regarded as a high priority in the province. This is largely attributed to confusion within services in the province and a lack of dedicated skilled midwives to ensure the necessary expertise for a focused specialised care approach. All the delegates agreed that family planning should be a top priority and that professionals with focused specialisation in family planning must be reintroduced as a matter of urgency. Problems in maternity units and in child health will not be addressed unless dedicated family planning services are reintroduced. These services also play a role in other programmes such as HIV and could effectively be funded though external sources, and are likely also to be linked to social mobilisation to ensure penetration within communities.


The discussion provided the opportunity to place issues on the table. Although the magnitude of problems identified was large, some achievable objectives were identified.

Issues relating to standardisation of training, direct-entry training of midwives and some form of competency-based register or privileging are also of national concern, and the Free State province could assist in developing national strategies. Maintenance of delivery skills will become more important in the future for both medical and midwifery practitioners if a reduction in maternal and infant deaths is to be achieved.

Staffing and facility standards as well as the values and needs of personnel could be useful areas of research and could provide areas for postgraduate study.

Health workers need to recognise that preventive programmes are a top priority and that these programmes should include social mobilisation.

Such discussion platforms will assist in redirecting the political will to prioritise a reduction in maternal and child mortality.

Actions such as introduction of midwifery as an autonomous profession need to be considered, and the gap between medical professionals and midwifery needs to be closed. Midwives are ready to take up their responsibility and assist the country to move forward. To facilitate change, nationwide initiatives have to be considered. There is no doubt that some action is required if South Africa is to achieve the Millennium Development Goals.

I would like to give special recognition to Mrs Elgonda Bekker (School of Nursing, UFS) and Dr Busi Kunene (Midwife AIDS Alliance), who assisted in conducting the two-day workshop and facilitated group discussions, and Professor Dave Woods for giving an introductory lecture via Skype.

M G Schoon

Maternal and Child Health Task Team

School of Medicine

Free State University, and Free State Department of Health
Table I. Priority actions

1. Schools providing training in midwifery in the Free
State need to standardise training and output.

2. Preventive programmes such as family planning
and sexually transmitted infections need to be

3. Facilitate value clarification in the midwifery

4. Introduce mechanisms to strengthen competencies.

5. Support processes to introduce direct and multiple
entry into midwifery as a profession.

6. Mobilise communities around maternal services.

7. Establish a research platform for maternal and child
health issues.

8. Establish multi-professional integrated teams in the
maternal and child health domains in all district

9. Introduce a provincial register of competent midwives.

10. Establish and maintain regular perinatal review
meetings in all institutions.

11. Advocate for occupational health support for all staff
working in maternal services.

12. Establish an information centre to centralise all
available information on maternal services and best

13. Develop a support structure for managers in maternal

14. Establish clinical facilitators in all institutions where
nursing students train.
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