The 26th Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories sa (Pty) Ltd

Does South Africa have Midwives?

South African midwives were the first in the world to obtain state registration in 1981 through the Medical & Pharmacy Act (Act 34 of 1981), which regulated the practice. In 1944 the Nursing Act (Act 45 of 1944) governed by the Medical Council replaced this act and continued to give rights to midwives to practice as a private practitioner. (Abraham, Jewkes, & Mvo, 2001: 241 and Pretorius, 1976: 45) until the Nursing Council was established to give nurses and midwives direct representation in parliament. Act 50 of 1978 Nursing Act as amended (Nursing Bill Government Gazette No. 27904 of 12 August 2005). (Now Act 33 of 2005). The South African Nursing Council is the regulating body for midwifery.

Accordingly the SANC oversee the training and registration of midwives. It can be accepted that South Africa has midwives per definition as stated in the new Nursing Act, Act 33 of 2005 Chapter 2; 30 (2).‘A midwife is a person who is qualified and competent to independently practice midwifery in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice. This is in line with the definition of a midwife adopted by the International Confederation of Midwives 2005, Brisbane, Australia (ICM/WHO/FIGO 1992 in Fullerton et al 2003: 174) stating that; A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. Based on the definition and legal standing through the regulating body it can be accepted that South Africa has midwives.

The poor management of the midwifery workforce taints the perceptions of midwives in South Africa. An extant visitor from the USA related in SA their experience of childbirth in America at the hand of American midwives, noting that ‘Funny we don’t have midwives in SA?’ This is a perception from the private sector. Negative publicity from the public sector of midwives in an international publication asks ‘Why do nurses abuse patients? Reflections from South African Obstetric Services? (Jekwes, et al, 1998). This view was supported by Penn-Kekana & Blaauw, (2004: 20-22) confirming the poor quality of maternal healthcare. They report no norms and standards for staffing in any province.
How many midwives are practicing in SA?

There is no official database of the number of midwives practicing midwifery in South Africa. The South African Nursing Council is the regulating body that is responsible for the standards of practice, training standards and registration of midwives. The number of midwives registered is enrolled by SANC. The number of midwives that practice in the market is not known. The integrated training programme for nurses in South Africa leads to dual registration as a professional nurse (community and psychiatry nurse) and midwife. The number of professional midwives that are directly involved in midwifery from the registered pool of midwives care is not known. Thompson, Watson & Steward (2007) found that nearly 50% of nurses globally are qualified as midwives as well, with benefits for the practice. The information on midwives in South Africa is inconsistent, and this makes any inferences of limited value.

The workforce governance is the function of the healthcare system or market. In South Africa with a public and private sector Parkhurst, et al (2005; 133) find a ‘brain drain’ of staff to the private sector for better salaries and working conditions. There are an estimated 62,7% of nurses (HDR Review 2003: 537) employed in the public sector. All categories of nurses amount to a total of 190,449, of which 97,423 are registered professional nurses. 54,000 of the 97,423 professional nurses are also registered as midwives (SANC 2006). The number of this pool of registered midwives that are directly involved with maternal care is unknown.

There is a shortage of 32,734 nurses in the public sector. Due to unavailable data of the private sector no information can be given of shortages. The Health expert (Rispel & Behr, in v d Merwe, 1992: 24) indicates that more than 50% of all categories of nursing staff are working in the private sector. There is 1 nurse (all categories) for every 225 people in SA. The ration 1:250 for all categories and 1: 417 (1990) registered nurses are well within the WHO recommendation. The ratio nurse per population is 343/100,000 (all categories). (HDR Review 2003: 523). The WHO norm is 200/100,000. Eighteen percent (18%) of the nurses on the SANC rolls do not practice. The inter-regional differences are indicated in table 1 considered to influence the outcomes of care. Regions with better staff ratios also have a lower maternal mortality. (Saving Mothers 2004: 296)

Table 1 Staff ratios per province (SANC 2006)

Region Ration

Western Cape 1:190 Gauteng 1:195 Free State 1:238 Northern Cape 1:246 Kwazulu 1:267 North West 1:311 Eastern Cape 1:323 Limpopo 1:414 Mpumalanga 1:417

There are 773 midwives registered in advanced or post basic midwifery as an additional qualification (SANC: 2005) The number of midwives with an additional qualification that is working in direct clinical care is also not known.

Two in-service educational programmes, the DEPAM (Decentralized programme for Advanced Midwifery) and the PEP course played a role in the improvement of clinical skills of midwives and raised standards of care. Mativandlela, (1998) indicated that 2,537 manuals for training were dispatch to provinces before the DEPAM was approved as a post-basic training programme by the SANC. Advanced practice according to the WHO (1996) is contextual. In South Africa according to the SADHS (1998) only 30% of women see a medical doctor during pregnancy and 70% of care in the public sector is in the hands of midwives, necessitating the need of advanced practitioners.

It can be concluded that the number of midwives involved in direct care in South Africa is unknown in-spite of skilled attendance of 92%.

Skilled attendance

‘Skilled attendance’ as the evidence based principle for reduction of maternal mortality is according to Penn-Kekana, et al (2004) and Parkhurst, et al (2005) only the first step in understanding the complexity of healthcare and maternal mortality. South Africa and USSR in spite of near universal skilled attendance fail to reduce their maternal mortality. (Parkhurst, et al 2005:131). The USSR has double the number of midwives in the system against Western and Eastern European countries with mortality of 40/100,000 versus 5,5/100,000 for those countries. Skilled attendance does not indicate or correlate linear with staff ratios and the reduction of maternal mortality and is thus not a reliable indicator for quality of care.

There are two aspects locked up in the concept of ‘skilled attendance’ that are of importance. Graham in Parkhurst (2005: 128) find that the entire system must function in unison, the skills of the attendant and the enabling environment, for quality of care.

The ‘Skilled attendant ‘ is an accredited health professional (midwife, doctor or nurse) educated to proficiency to manage normal pregnancy and birth according to the (WHO/ICM/FIGO, UNFPA, World bank 2004a in MacDonagh 2005). The interpretation and understanding of skilled attendance and attendant varies in the literature. The second aspect of the concept of Skilled attendance refers to the partnership of skilled attendants with and in an enabling environment backed up by political will.

An enabling environment is dependant upon the functioning of the entire healthcare system. This includes, appropriate staff ratios, skill-mix, geographic distance, clinical standards, emergency care, technological inputs and standards for resources.