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

Skill mix

The midwifery workforce is based on the principles of normalcy of care in an enabling environment. Midwifery is defined as a global, unique and highly specialized form of healthcare practice that provides care for women in relation to the normal event of pregnancy and birth. (Fullerton, Severino, Brogan & Thompson, 2003). Midwifery is industry specific. The concept normalcy of pregnancy and birth is questioned for clarification by Anderson’s (2003:48) The WHO (Gould 1996 in Bojỡ, Hall-Lord, Axelsson, Udẽn & Larson 2003: 76) confirms that normal birth is the normal physiological process of labour and vaginal birth when few or no interventions occur or is needed. Midwives according to the WHO practice in this normal paradigm and have a duty to practice according to the best available evidence. The availability of the supportive system for referral of complications is of utmost importance. In this regard the number and availability of medical practitioners become of importance.

Graham et al, 2001 found a powerful correlation between the midwife /medical partnership and the MMR. Embedded in an enabling environment is ratios and skill-mix of staff with particular reference to the number of doctors dedicated to maternal health. Table 2 gives the ratios of doctors in general for selected countries.

Table 2 Doctors Per 100,000 of the Population (South Africa at a glance 06-07 Editors Inc)

Country per 100,000
South Africa	69
Brazil	206
China	164
Cuba	591
India	51
Kenya	13
Mexico	171
Poland	220
UK	166
USA	549

The HDR Review, (2003: 523) indicates that 60% of the medical doctors in South Africa are in private practice with a ratio of 225: 100,000 of the population. The ratio of doctors for the public sector is 29:100,000 of the population. The shortage and mal-distribution of doctors affect the midwifery practitioner, compounded by a shortage of resources. (HDR Review 2003: 541). The lower the number of doctors in a healthcare system the more nurses is needed and the more ‘task shifting” will occur in healthcare. There is a 33% shortage of medical doctors in the public sector, with fewer doctors in the rural areas and a concentration in urban areas. When the skill-mix is ideal the midwife can do what they do best namely give supportive care for normal birth as the scope of the midwife, including upholding the 3 C’s of evidence based midwifery care based on the midwifery model principles: of continuity of care, choice of provider & control (Carr, 1994 & Dower, Miller & O’Neill, 1999).

Non-nursing duties:

Midwives are involved in many tasks that are not clinical. McCrea, et al. (1992) in McKenna (2001: 53) found that midwives routinely undertook a large number of non-midwifery duties. The researchers concluded that this added unnecessarily to the midwives' workload, to low morale and high staff turnover. In Ireland, Savage (1997) estimated that the midwives in her study spent 50% of their time in non-midwifery duties. In the research setting for the present study, Ruddy et al. (1997) calculated that midwives spend eight of 24 hours undertaking what were perceived to be non-midwifery duties (Ruddy et al. 1997). The non–nursing duties should be minimized in midwifery practice and has not been determined in the South African healthcare system where patients are transported between levels of care accompanied by a midwife as a requirement.

Other factors that impact on the midwifery workforce are the geographical distances, Parkhurst, 2005 (2005:131) found that a densely populated country like Bangladesh with few geographical barriers quick and easy emergency transport is the norm in contras to most African settings. It is important that the contextual constraints of each context be factored in when the midwifery workforce is planned.
Benchmarking

The contextual differences make it difficult to find a suitable example for benchmarking maternal healthcare and the midwifery workforce. Several examples are identified using various points for comparison.

• Parkhurst, et al (2005:136) did a four-country comparison with Uganda, (MMR 1100/100,000) Russia (MMR 75/100,00) and Bangladesh (MMR 600/100,000) based on low and middle income status factors, and found that high levels of skilled attendance with an in appropriate skill-mix or miss allocation of staff can lead to sub optimal care.

• A comparison with Brazil: (MMR 260/100,000) is done on the basis that

• The GDP% spending of the public-private mix is comparable with SA

• Brazil is a developing country like SA.

• Because of an innovative intervention strategy to reduce maternal mortality.

Brazil

Brazil with the assistance of the The Pan American Health Organization (1998) declared a DECREE 1998 Governmental Decree 2181/98 to make an Ethical Commitment to decrease maternal mortality. (Girot, Endres and Wright, 2005) Stakeholders included midwives represented on the highest level of decision-making. The approach included the development of Midwifery units established for “humanized” maternity care to deal with all low risk births. (Normalcy of birth). The goal was to have 10% of all births take place in these units.