Midwives are an essential part of healthcare who offer timely, effective and family-centred services. The care provided by midwives has a major effect on the well-being of mothers and babies (Halldorsdottir & Karlsdottir 2011:806). This is particularly true in many low- and middle-income countries where midwives provide the preponderance of maternity care (UNFPA 2011). Despite the potential powerful influence of midwives, many challenges are being faced whilst providing quality care including the need to reduce maternal mortality rates, growing litigation and a shortage of resources.

In South Africa, an institutional maternal mortality rate of 134 per 100 000 live births – a rate almost exclusively from public healthcare facilities (Department of Health Republic of South Africa 2017), far exceeds the international goal for fewer than 38 deaths per 100 000 (UN 2015). Furthermore, 60% of these deaths have been deemed preventable with avoidable factors and substandard care as major contributors. It has been estimated that two-thirds of maternal and newborn deaths, as well as stillbirths, could be eliminated by 2035 if midwifery healthcare standards were improved (Nove et al. 2021:e24). Additional contributing factors include failure to accurately assess patients, delays in referral, failure to follow standard protocols and poor monitoring (Moodley et al. 2014:58). The problem is further complicated by excessive surgical birth rates – particularly in the private sector where rates have exceeded 60% for more than a decade (Council for Medical Schemes 2017/2018). Failure to promote physiologic birth lies squarely on the World Health Organization (WHO), which currently does not recommend an ideal Cesarean birth rate (WHO 2015a), as well as on midwives and physicians who have failed to combat unnecessary birth interventions.

Midwives in South Africa have been involved in an increasing number of medico-legal cases reflecting concerns about the nature and quality of care. At the current time, the Gauteng province – the most populous province in South Africa, faces medico-legal claims amounting to R29 billion with the vast majority for alleged medical negligence related to infants afflicted with cerebral palsy because of poor intrapartum management in public facilities (Bloom 2019). Such claims have depleted monies needed to ensure adequate staffing, equipment and facilities.

Whilst increased attention is being directed to address the root causes for medico-legal action, little attention has been directed at examining midwifery-related factors. Surprisingly, recent examination of rising medico-legal maternity related cases failed to make any mention of midwives (Oosthuizen & Carstens 2015; Taylor et al. 2018).

Over the last few years there has been a sharp deterioration in healthcare at public hospitals and clinics in the Gauteng province, marked by shortages of medicines, collapsing infrastructure, broken equipment, inadequate provision of staff and misuse and misallocation of funds (Maphumulo & Bhengu 2019:2–3). A lack of adequate facilities and resources leaves midwives feeling drained and exhausted, struggling to cope with an overwhelming workload.

Many hospitals in South Africa that provide services to thousands of pregnant women annually, experience a shortage of qualified midwives. To combat shortages in the public sector, administrators often deploy nurses who are not midwives to maternity sections. Ongoing midwifery shortages and site reassignments result in midwives who are fatigued, burnt out, performing at less than full capacity and unable to promote improved perinatal outcomes (Matlala & Lumadi 2019:7). These problems are compounded by a physician shortage with many of those who are available opting for service in private facilities leaving the public system – which serves the vast majority of the population, chronically short staffed. Because of the physician shortage, midwives play a crucial role in reducing maternal mortality and morbidity.

Research from South Africa has found patients with expressed dissatisfaction regarding the quality of midwifery care. More than half of women who have given birth in the public sector reported ‘narratives of distress’ (Chadwick, Cooper & Harries 2014:862). These narratives included consistent complaints of negative interpersonal relationships with caregivers, lack of information, neglect and abandonment. These same concerns have been voiced by women in other research, along with concerns about denial of a labour companion, being left alone and denial of care (Hastings-Tolsma, Nolte & Temane 2018:e47–e48; Jewkes, Abrahams & Mvo 1998:1785–1791; Jikijela, James & Sonti 2018:8; Kruger & Schoombee 2010:87; Maputle & Nolte 2008:60–61; Sengane 2013:6–8). Alternately, midwives interviewed regarding experiences in managing women in labour, viewed their care as midwifery or institution-centred rather than woman-centred (Bradley et al. 2016:157; Lambert et al. 2018:256; Maputle & Hiss 2010:12). Midwives were observed to have told mothers what to do and how to behave, imposing their authority and responsibility to ensure that rules were followed.

The dissatisfaction with midwifery care processes has been documented for well over two decades (Jewkes et al. 1998:1794) and is consistent with global report of a lack of care in nursing (Scott 2014:177). In South Africa, midwives wear maroon epaulettes with a green bar to signify the specialty although in earlier times, midwives wore a green epaulet. The devices symbolise that the midwife is professionally qualified and can be trusted to provide top quality care. Prior to 1856, nurse training comprised of a 4-year diploma at a hospital-based nursing college, which was viewed as both rigorous and woman-centred. This training was subsequently replaced by a comprehensive 4-year qualification (including general nursing, midwifery, community and psychiatric nursing), which can be completed through a nursing college diploma or a university degree (Blaauw, Ditlopo & Rispel 2014). The current comprehensive training of nurse midwives in South Africa mandates an emphasis on four specialties within nursing. This was carried out to meet demands of the public health sector. This requirement has contributed to beliefs that new midwives are neither skilled nor are they competent in midwifery, thus they lack practical training (Webbelink 2019:103–105).

Working primarily in public, private and independent settings, midwives often face varied challenges including overcrowded labour wards, a lack of resources, misutilisation and a shortage of health personnel. These challenges correspond with growing reports by labouring women of substandard midwifery care in South Africa, particularly in public hospital settings (Human Rights Watch 2011), and escalating global recognition of neglectful, abusive and disrespectful treatment of women during childbirth, particularly in low income, low resource countries (Bohren et al. 2015). These factors likely influence the ability of midwives – regardless of employment setting, to engage in the care of women who foster improved perinatal outcomes and satisfaction. There is a dearth of research that explores the experience of midwives in caring for labouring women across practice settings and further study is required.

This qualitative, exploratory, descriptive and contextual study sought to gain a better understanding of midwives’ experiences of caring for women during birth. A constructivist approach draws on the belief that there is no single reality; rather efforts are made to elicit participant views of reality (Bergman et al. 2012:1). This approach allowed researchers to conduct an in-depth examination of how midwives make meaning out of their experiences. The consolidated criteria for reporting qualitative research (COREQ) guidelines were used to guide report of findings (Tong, Sainsbury & Craig 2007).

This research highlighted several findings of concern. Whilst policy to move birth to the institutional setting has likely been instrumental in the reduction of maternal mortality and morbidity, it has altered the psychosocial elements crucial in providing a midwifery model of care (Bradley et al. 2016:127–158). Institutional emphasis on technological birth – irrespective of setting has left midwives struggling for a voice in systems dominated by the medical model. As the global need for midwifery care continues to grow, there is a need to reconsider the extent to which midwives participate in the establishment of care practices.

The first theme, proud to be a midwife, reflected self-esteem, diversity of practice, the interesting nature of work, care of healthy people and professionalism. These categories embodied factors that were viewed as essential in being the best midwife and have been identified as key components of being ‘with woman’ (Bradfield et al. 2019:6). The categories have also been identified as essential in transitioning into specialty practice with a sense of belonging to the team and organization (Harvey et al. 2019:10). The attributes that participants identified as contributing to pride in being a midwife have been identified as central to advanced midwifery practice (Goemaes et al. 2016:36).

The relationship with physicians and authorities was important sentiment in how midwives viewed the second theme, regulations and independent function. Midwives in public hospitals generally felt that they could function independently in the absence of physicians but that hospital authorities did not always allow them to make decisions or create change. Regardless of private or public employment setting, midwives voiced lack of appropriate utilisation. For those in the private sector, midwives were restricted from practicing consistent with preparation; midwives in the public facilities were hampered from practicing a midwifery model of care because of system burdens and poor resource appropriation.

The third and fourth themes were resource availability and work burden. A lack of resources, such as equipment and supplies, access to technology and especially the shortage of physicians and midwives, together with large influx of patients – many immigrants, had a serious effect on the practice and care provided by midwives. Prior research has found that recent immigration, younger age and little formal education increased the risk for negative birth experiences for women in public facilities (Oosthuizen et al. 2017:1). Lack of resources noticed in this study no doubt contributed to a central theme, which underscored the lack of time midwives spend with women. This ‘time poverty’ report has been confirmed by patients in other research, demonstrating limited patient participation and collaboration with midwives (Boyle, Thomas & Brooks 2016:26). The midwife-to-patient ratio was a significant factor in labour wards where midwives literally ran from one birth to the next, a finding corroborated by mothers’ reports of childbirth experiences in South Africa (Hastings-Tolsma et al. 2018:5). Finally, there was widespread belief that administrative support for midwives was often lacking, as was space for providing family-centred care. Both administrative support and space for family engagement during labour were identified as crucial for midwifery functioning and demonstrated adequate resource availability. These components have also been identified as important to women crucial to the maternity health needs of women (Mohale, Sweet & Graham 2017:304).

The fifth theme centred on the image of the midwife influenced by respectful care, patient trust and public perception of the midwife. Current mainstream maternity services focus on medical risk status rather than on the individual woman – in total contradiction to a midwifery model of care and women know exactly what they want from their caregivers (Davison et al. 2015:774–775). Furthermore, mothers have also reported that attending midwives had inadequate listening skills (Maputle & Nolte 2008:60). As women surrender to the birth process, midwives must be available through supportive actions and openness (Lundgren & Berg 2007:225) and serve as both anchor and companion (Lundgren 2004:368). Where there is shared decision-making, women express greater satisfaction with birth (VandeVusse 1999:49).

In interview of women giving birth in a public hospital in South Africa, narratives of distress were based on negative interpersonal relations with midwives, lack of information, neglect and abandonment and the absence of a labour companion (Chadwick et al. 2014:862). In the absence of midwifery attention, labouring women experience a sense of isolation and loneliness (Kruger & Schoombee 2010:90). Midwives in our research reported that support persons were not allowed with women in most public hospitals because of a lack of space and privacy concerns for other patients. This means that if midwives were not present, most women were totally without support during labour and birth. Physical presence must be provided – particularly at transitional phases, if midwives are to engage with labouring women (Borrelli, Spiby & Walsh 2016:108). Where there is a sense of midwifery presence, physical and ontological safety and respectful care, women report a positive birth narrative (Chadwick 2019:6).

The importance of continuous presence of the midwife with women during labour has been emphasised in the literature. Whilst the overall influence of continuity of the carer on partnership with patient is unclear (Freeman 2006:39), continuous presence of the midwife has been associated with an increase in the woman’s sense of control and coping (Bohren et al. 2017:3), affecting a woman’s choice of pain relief (Aziato, Ohemeng & Omenyo 2016:1; Bohren et al. 2017:21; Howarth, Swain & Treharne 2011:92) and is important for maternal-child attachment and well-being of the new family (Aune, Amundsen & Aas 2014:93; Howarth et al. 2011:93). It is proposed that midwives who work ‘with’ woman in labour, experience a greater sense of job satisfaction and find their work emotionally rewarding (Hunter 2004:270–271). Furthermore, midwives regard continuous presence and support as essential in providing quality care during labour (Aune et al. 2014:93).

The participants in this research were aware that midwives in the public setting were often accused of disrespectful, non-caring behaviour towards women in labour. The fact that these same complaints have not been observed in the private or independent maternity hospital settings suggests that the difference in empathy is likely related to the climate of the institution (Miller & McLoughlin 2014:813). Midwives interviewed by Kruger and Schoombee (2010:97) spoke of becoming so angry and frustrated that they had violent feelings towards patients. It was mostly the ‘disobedient’ or ‘resistant’ patients that they felt had to be treated harshly. Burdens in the public system are likely a root cause of midwifery behaviour. It has been observed that the practice of midwives is moderated – even distorted, by context. Working in systems that are dominated by a medical model create the use of interventions antithetical to the philosophy of midwifery care; such philosophical dissonance may contribute to high exodus rates (Downe, Simpson & Trafford 2007:137–138).

Mistreatment of women in labour – whatever the reason – is a global health problem in need of directed intervention (Bohren et al. 2015:23; Vogel et al. 2016:671). A potentially important starting point would be implementation of tools to measure women’s perception of respectful maternity care (Sheferaw, Mengesha & Wase 2016:7–8). Use of such tools would heighten awareness of patient satisfaction with care during birth, as well as provide data for midwifery use to create needed change.

The trusting relationship between the midwife and the woman during childbirth has received emphasis in the literature. Interpersonal competence is one of the five main aspects in Halldorsdottir and Karlsdottir’s (2011:810–811) evolving theory on the empowerment of childbearing women. Many authors have emphasised that the quality of the relationship/partnership is a vital factor in the quality of midwifery care and key to a positive labour experience (Bo’Borrelli 2014:7–8; Hunter 2004:269–270; Lundgren & Berg 2007:226). In our research, midwives reported being unable to form a relationship with labouring women in both the public and private setting. A partnership case loading model should be considered as a strategy to foster a relationship between midwives and patients and promote patient decision-making (Boyle et al. 2016:27). In addition, models with the potential to reduce in-patient volume should be explored as a means of increasing midwifery availability and social support for women. One model that has been successful in sub-Saharan Africa is the maternity waiting home (Kaiser et al. 2019:9), although further research is needed to determine its impact on midwives working in overburdened and under-resourced systems and where there is failure to use midwives consistent with education.

The long working hours, too many patients, a midwife shortage and the lack of resources, are all factors that affect working conditions (Manyisa & Van Aswegen 2017:36) and lead to exhaustion amongst midwives. These factors likely create high levels of persistent stress that contribute to midwifery attitudes, professional presentation and interactions with patients. Chronic stress levels can adversely impact midwifery health and have been linked with depression, hypertension, diabetes and obesity (Schultz, Chao & McGinnis 2009:2). This study did not inquire about personal health status of the midwife; research is needed in this area.

The fact that midwives leave patients in labour alone for long periods of time, prevents the provision of quality care. Midwives with high numbers of patients cannot assess patients regularly, which may contribute to the high numbers of maternal mortality and morbidity, as well as medico-legal cases. The inability to be with woman during labour and birth may well be an important component in failure to rescue from both unnecessary intervention (Hastings-Tolsma & Nolte 2014:587) promoting respectful normal birth.

Midwives the world over consider their relationship with childbearing woman as a major source of job motivation and satisfaction (Bloxosome et al. 2019; Kirkham et al. 2006). The basis of midwifery education, the midwifery model of care, is in direct contradiction to findings in this research. This model emphasises continuity of care by a midwife who is known and trusted and who employs watchful waiting (Hatem et al. 2008). The midwifery model of care supports the normalcy of pregnancy and birth and focusses on the natural, physiologic process of birth through vigilance (clinical skills and judgement, knowledge of self and limits, clinical objectivity, decisiveness, confidence, intelligence and intellectual curiosity), attention to detail (empowering women, integrity and honesty, humility, realistic, gentle, warmth, nurturing, understanding and supportive) and respecting the uniqueness of the woman (family-centred care, tolerance non-judgmental, compassion, interest in others, flexibility) (Bo’Borrelli 2014:8–10; Kennedy 2000:8). A midwifery model of care reduces the likelihood of intervention and makes it more likely that women are satisfied with their care (Sandall et al. 2016); neither public nor private settings in this study afforded midwives the opportunity to provide such care and is essential for adequate support of women and the promotion of physiologic birth (Stark, Remynse & Zwelling 2016).

Providing women-centred care has been found to be an important construct for midwives to be with woman (Bradfield et al. 2019). It is important that factors that threaten the nurse–midwife relationship and diminish the midwife’s role in being ‘with woman’ be addressed. This knowledge is urgently needed as it relates to the clinical education of midwives, which largely occurs in public facilities in South Africa. Care in those facilities may fail to promote relationship-mediated being and such care may best be cultivated in other settings (Borrelli et al. 2016:108). Where intentionally and authentically present, midwives are empowered by responses from women, promoting growth and self-confidence (Thelin, Lundgre & Hermansson 2014). Furthermore, student exposure to how midwives make clinical decisions significantly influences future professional behaviour (Daemers et al. 2017:11). An additional important strategy to consider is increasing student exposure to out-of-hospital birth that may better promote care practices supportive of labour and physiologic birth (Zinsser, Stoll & Gross 2016:98). Finally, research is needed to reveal how women view physiologic birth, how midwives support that desire (Darra & Murphy 2016) and ensure the shared decision-making desired by labouring women (Downe et al. 2018). These shifts, along with the development of guidelines detailing respectful midwifery care (Vogel et al. 2016), could promote WHO recommendations for health promotion during birth (WHO 2015b).

This research provides insight into the experiences of midwives in providing care to labouring women in varied healthcare settings. Challenges influential in providing care consistent with the midwifery model were described and were influential in the ability of midwives to address the health needs of women. The resulting stress that was experienced likely contributes to midwives leaving the profession (Banovcinova & Baskova 2014:253). Both in South Africa and globally, the need for midwifery care has never been greater and attention to midwifery services is urgently needed. In particular, the integration of educated, regulated and licensed midwives with a professional passion is needed – all factors in improved quality of care and sustained decreases in maternal and newborn mortality (Filby, McConville & Portela 2016:14).

Shortcomings in midwifery care may best be addressed through an upscaling of education, attention to quality of care beyond focus on mortality, emphasis on the setting for care (Homer et al. 2014:1153) and a reduction in stress-related factors (Leinweber & Rowe 2010:85). Midwives have been challenged to protect and promote women from health systems where women are ill-served (Hastings-Tolsma & Nolte 2014:592). The leadership and culture of health systems carry clear burden for the current crisis in caring and are notably blameworthy (Scott 2014).

Maternity care systems require cultural reform at a structural level to enable an opportunity for midwives to both reframe their relationship with patients and work more effectively with inter-professional teams (Dove & Muir-Cochrane 2014:1070). Promotion of midwifery processes offers a crucial vehicle for improving maternal-infant outcomes with midwives having the ability to enhance, humanise and empower women during the critical time of childbirth (Halldorsdottir & Karlsdottir 2011). This vulnerable time mandates a compassionate, caring environment with targeted processes that empower midwives as key stakeholders responsible for protecting the sacred space of birth (Fahy, Foureur & Hastie 2008). Such change will promote a reclaiming of the historical midwifery image of those green epaulet girls … those midwives of earlier times who embodied the respect, recognition and reward so richly deserved. It is an image sorely needed by the women midwives serve.