Challenges faced by student accoucheurs during clinical placement at the free state maternal health care institutions

Background Anecdotal evidence suggests that student accoucheurs studying at the Free State School of Nursing in South Africa are faced with resistance, discrimination, rejection and unacceptability by pregnant women during their clinical placement at the Free State maternal health care institutions. Objective The aim of the study was to explore and describe the challenges faced by student accoucheurs regarding the maternal health care services they render to women. Methods An explorative, descriptive, and qualitative research design was employed to conduct the study. Purposive sampling was used to select student accoucheurs who met the inclusion criteria. Focus group discussion was used to collect data from the selected student accoucheurs. Data were analysed thematically, and the findings were triangulated with the integration of Peplau's Theory of Interpersonal Relations as a theoretical framework that guided the study. Results The findings in relation to the research question were synthesised under four themes: transcultural diversity, socio-economic factors, social interactions and relations, and gender inequality in the work place. Conclusion The study is a contribution to the emerging education and training of student accoucheurs body of knowledge in the Free State Province and to the global existing body of knowledge regarding the phenomena.


Introduction
The South African Nursing Council (SANC) introduced a four-year comprehensive programme leading to registration as a Nurse (General, Psychiatric and Community) and Midwife, Regulation R.425 of 22 February 1985 as amended 1 . According to this regulation, student nurses are expected to be trained in all the disciplines including midwifery irrespective of their genders over the period of four years.
The student accoucheurs, unlike their female counterparts are faced with various challenges during their clinical placement at the antenatal clinics as well as in the maternity units. These challenges include resistance, discrimination and rejection in the provision of ANC to pregnant women during their visits, deliveries and post-natal care in the maternal health care institutions. These challenges faced by student accoucheurs are not only present in South Africa but worldwide. It became evident in the study conducted by Bwalya et al. 2 in Ndola that male student midwives were ordered by Chief Besa and the late Chief Mushili to stop conducting deliveries at Fiwale and Mpongwe Mission Hospitals, both situated in Ndola rural area. This order arose from numerous complaints, rejection, segregation and unacceptability by pregnant women of the maternal health care services rendered by student accoucheurs. Pilkenton and Schorn 3 report that in the United Kingdom, some women prefer male midwives over female midwives as male midwives are perceived to be more caring and sympathetic. These authors further state that the rapport needs to be developed between the pregnant women and the male midwife.
African Health Sciences Vol 19 Issue 2, June, 2019 Anecdotal evidence suggests that student accoucheurs studying at the Free State School of Nursing in South Africa are faced with resistance, discrimination, rejection and unacceptability by pregnant women during their clinical placement at the Free State maternal health careinstitutions. Women remain adamant that student accoucheurs do not examine them and do not deliver their babies. They base their resistance on factors such as their cultural preferences and religious beliefs 2 . In countries such as Ethiopia, women believe that only God and their husbands are allowed to touch their bodies, especially their reproductive organs 4 . Some state that it is taboo for other men to see their reproductive organs other than their own husbands 5 . This study explored and described the challenges faced by student accoucheurs regarding the maternal health care services they render to women.

Methods
A qualitative, exploratory, descriptive and contextual study was undertaken to explore and describe the challenges faced by student accoucheurs regarding the maternal health care services they render to women.Hildegard Peplau's Theory of Interpersonal Relations was used as a framework for this study. This theory is a middle-range theory focusing on the relationship between the nurse and the patient 6 . Peplau's theory states that the nurse-patient relationship is the centre of nursing and that nursing is therapeutic because it is a healing art which assists an individual who is in need of health care 7 . This theory described four phases in nurse-patient relationships that overlap and occur over the time of the relationship: orientation phase; identification phase; exploration phase and resolution phase 8 .

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Orientation phase -during this phase, the nurse and the patient meet for the first time.
• Identification phase -the patient responds selectively to people who can satisfy her needs.
• Exploration phase -the patient takes advantage of all the services available and makes more demands than during the orientation phase.
• Resolution phase -the patient's needs have been met and as a result, both the patient and nurse become stronger individuals. The study was conducted in the Free State Province in South Africa. The School of Nursing in the Free State Province has three sub-campuses providing a four-year comprehensive course (R425), which place their students at the Free State maternal health care institutions. The Free State School of Nursing places student accoucheurs at the six district hospitals, five regional hospitals, one tertiary hospital and 21 primary health care clinics accredited by the SANC. Data was collected by using an interview guidethat was developed based on the research question and the study objectives as well as the literature review. Focus group discussions were used to collect data. The researcher purposively selected four to eight student accoucheurs per focus group discussion session. The researcher conducted seven focus group discussions which were guided by data saturation. Homogeneity of the group was safeguarded by selecting only student accoucheurs at their fourth-year level of training placed at the Free State maternal health care institutions. The timeframe for each focus group discussion was estimated between 1-2 hours to allow the participants enough time to express their views regarding the phenomena. Focus groups were conducted at the Free State maternal health care institutions in a private room to ensure privacy and non-disruption of organizational daily activities. The researcher laid ground rules for the group and gave the participants information about the scope of discussion which assisted the participants to understand what was expected of them 9 . The researcher initially posed a grand tour question: "What are your views as student accoucheurs regarding being accepted by women during your clinical practice at the Free State maternal health care institutions?" This was followed up by probing open ended questions to ensure clarity of the participants' responses.
A voice recorder and field notes were used to collect data. Thereafter, data was organised and stored using ATLAS TI programme. This programme helped the researcher to systematically organise data into themes and sub-themes with codes to evaluate and interpret qualitative texts 10 . A qualitative content analysis was used to allow for the interpretation of the underlying meanings of the texts 11 .

Findings
Thirty-two student accoucheurs voluntarily participated in the focus group discussions.All participants were black males, never married, and were between 20-24 years of age.Four common major themes emerged from the focus group discussions with the student accoucheurs. Several sub-themes emerged during the focus group discussions with student accoucheurs. Themes and sub-themes are presented in Table 1.

Trans-cultural diversity
During the discussion, the participants verbalised that they believed that women who are from traditional rural areas are socially and culturally sensitive regarding pregnancy as this is regarded as sacred to them. They also indicated that some women, such as those who belong to the Muslim religion, are religious sensitive regarding the male's involvement during pregnancy and labouring process. One participant responded as follows:"I remember one night I was left with one case to complete my register but, I was denied the opportunity by a Muslim family to assist during delivery as this was seen astaboo,…" (FG4) Marital status was also a contributory factor in non-acceptance of maternal health care rendered by student accoucheurs. The participants indicated that married women tend to become more resistant towards them in comparison with unmarried women. This was what one of the participants had to say:"…Mh…some women do not want to be seen naked by another man other than their own husbands,especially married ones… whereas unmarried women can be a bit accommodating as mostly they arrive alone at the maternal health care institutions". (FG 5) The majority of the participants indicated that age was a contributory factor to non-acceptance by women in rendering the maternal health care. This was evident in the student accoucheurs' verbatim responses as they stated that older women perceive them as their own sons. According to student accoucheurs' views, culturally it was unacceptable to be seen naked by a person younger than them or by a person of the opposite sex. This was narrated as follows:"Eh…culturally it is unacceptable to them to undress for a younger person of the same age as their own sons or of opposite gender."(FG 2). Some participants verbalised that trained midwives make them feel unwanted in these units by shouting at them in the presence of the patients, hence women become reluctant of the maternal health care services rendered by student accoucheurs. This was one of their responses: "… some midwives shout at you in the presence of these women which lower your self-confidence and trust from them. Maybe that is the reason why most accoucheurs are not placed in these units." (FG7)

Socio-economic factors
The participants indicated that socio-economic backgrounds of women play an important role in the choice of maternal health care provider in the Free State Province. The participants based their arguments on the women's choices determined by their financial stability. During focus group discussions, it became evident that financially stable women could choose the midwife and attend a private hospital or if they are at a public hospital their opinions regarding the choice of care is more respected. They agreed that it was different for financially unstable women, as their circumstances forced them to attend public hospitals. One of the participant responded as follows:"… Women with money hardly come to the public hospital for maternal health unless they have other unknown reasons…" (FG5).
The participants also mentioned that they experienced different treatments from women of different educational levels. They stated that most educated women knew that males can study towards any profession including that of accoucheurs. This was noted in the following excerpt: "…eh most educated women understand that we are in training and we should fulfil certain objectives and gain experience." The majority of the participants reported that uneducated women do not want to be treated by student accoucheurs. They indicated that this could be due to lack of knowledge about nursing, that males also follow the same course as their female counterparts to become a nurse. This was noted in the following verbatim response:"Uneducated women, mostly tend not to understand that and some just refuse point blank. …eh…this lead to us not gaining any experience and struggling in accomplishing the required objec-tives…." (FG6)

Social interactions and relations
The participants stated that a good interaction between a midwife and a pregnant woman plays a major role in maternal health care. According to them, such interaction alleviates women's preconceived ideas and fears about pregnancy, labour, delivery and the midwife that will be assisting them. The participants also mentioned that building a nurse-patient relationship was important in the maternity unit. They stated that this could be a challenge because most women are socialised into building sound relationships between females, especially during pregnancy. The participants further indicated that needed to be empowered with knowledge, skills and support to build a good nurse-patient relationship with women in the maternal health care. This was identified in these response:"It becomes difficult to provide maternal health care if a woman does not trust you because this involves giving instruction and physical touch such as palpations including per vaginal examinations. At this stage that's when I need more help regarding knowledge and support how to gain the women's trust and have a good nurse-patient relationship you know…" (FG3) The participants further reported that lack of communication skills with women was a contributing factor to women not accepting maternal health care rendered by them. They indicated that some vernacular words used to instruct women during delivery could sound vulgar and embarrassing if said by a male to a female. Therefore, there should be a clear, less embarrassing method of communication that should be used for ANC, labour and postnatal care and this is noted in the following quotation:"…sometimes I feel shy to ask a woman to push in SeSotho as this word may sound vulgar if used by a male to a female." (FG5) The participants also raised a concern that within the maternal health care institutions where they are placed for their clinical practice, they had never seen an accoucheur The participants suggested that accoucheurs should be visible in the maternal health units as this would cause a paradigm shift in perceptions and views about males in these units. These were their suggestions:"…I would suggest that Nursing Managers should look into the manner they distribute their staff in the institutions."(FG2). Another participant said: "I think gender equity when doing allocation should be considered by Nursing Managers." (FG1)

Discussion of the findings Transcultural diversity
The Free State maternal health care sector provides services to women from diverse cultural backgrounds. This was evident during the participants' responses which revealed that their practices and beliefs differ regarding how they perceive males' involvement in their maternal health care. Pilkenton and Schorn 3 argue that other reasons for refusing males in the delivery room were related to the cultural ideologies of women. Women were taught by their elders that to prevent these bad spirits from affecting their children during birth, men must stay away from the birth room for a period of ten days. Peplau's theory of interpersonal relations describes this as an exploration phase 6 . During this phase, the patient takes advantage of all services available by making more demands about her care. Peplau's theory states that a nurse should play a surrogate role. This implies that a student accoucheur takes the place of a female midwife by rendering maternal health care services to pregnant women. It is imperative that student accoucheurs understand pregnant women's concerns and fears and cultural backgrounds and respect them.

Socio-economic factors
According to Haque 12 , women and their families' socio-economic status, such as level of education, occupation and income, is the most important indicator for utilization of antenatal care, choice of place of delivery, and types of assistance during delivery. Many uneducated women lacked knowledge regarding the nurse training programme. Bwalya et al. 2 argues that health care systems need to intensify information, education and communication in creating community awareness about the training of accoucheurs.

Social interactions and relations
Society is socialised to believe that there are activities that can be performed by each gender due to the nature and strength of gender. Wood and Eagly 13 state that society establishes gender roles, beliefs and expectations regarding the division of labour. Hence, people respond more favourably to those who conform to gender role expectations in social interactions and relations. Pregnant women are socialised to interact with other women and form effective relations with each other. Therefore, the presence of student accoucheurs in the maternal health care institutions tends to be unacceptable to women. Student accoucheurs identified a gap in their communication skill with regards to history taking and giving instructions effectively to pregnant women without discomfort and feeling of embarrassment. Peplau's theory of interpersonal relations identification phase states that in this phase, the patient responds selectively to people who can meet her needs 6 . This became evident during discussions with student accoucheurs who said that pregnant women become reluctant to divulge information during history taking. According to Kozhimannil, et al. 14 , once a woman has chosen a provider for maternity care, the quality of that relationship is strongly influenced by communication.

Gender inequality in the work place
The nursing managers in the Free State Province place accoucheurs on a rotational basis in the units such as casualty, intensive care and general units except in the maternal health care units. Folami 15 attested to this by stating that male nurses were usually moved to technical areas such as operating theatres and emergency rooms because such areas appear more congruent with the masculine role of males. The lack of equal gender distribution in the Free State Province maternal health care institutions deprives pregnant women of exposure to the maternal health care services rendered by accoucheurs contributing to the resistance and discrimination against them.Therefore, student accoucheurs are faced with challenges in this unit leading to poor achievement of their required learning objectives. Folami 15 argues that the rejection or restriction experienced by student accoucheurs are based on socially constructed gender roles.
Implication of the findings to the maternal healthcare in the study area Provision of quality maternal healthcare service to pregnant women is pivotal. This requires skilful, competent and adequately trained midwife/accoucheur to render such service to women in midwifery discipline. It is evident from the study findings that a change in attitude by policy makers, nurse managers, nurse educators and maternal healthcare users is required for more effective execution of the 4 year comprehensive nurse training programme in the country. This will ensure compliance with regulation R.425 of 22 February, 1985 as amended, which mandates male student nurses to be trained as accoucheurs.

Recommendations
It is recommended that the training institutions mandated by the Free State Department of Health should consider revising their maternal healthcare policies to accommodate the training of student accoucheurs, and their placement in maternal healthcare units on completion of their training to improve their acceptance. The nurse educators should consider teaching communication skills and cultural diversity specifically in midwifery discipline in their clinical teaching to empower student accoucheurs with necessary communication skills with women of diverse cultural backgrounds in maternal healthcare. Whereas, consideration by nurse managers when allocating and distributing accoucheurs in the maternal healthcare units to ensure gender equity in the workplace is recommended. A wider study, involving several other stakeholders that are involved in the clinical training of student accoucheurs such as nurse educators, nurse managers and midwives at the Free State maternal health care institutions is recommended.

Limitations of the study
The study was based on the student accoucheurs in their fourth level of training, thus the study findings could have been different if student accoucheurs from the third level of training had participated in this study. Several stakeholders, whose information could have enriched the findings of the study such as nurse managers, practising midwives and accoucheurs, nurse educators and relevant influential family members of the pregnant women, were not included.

Conclusion
The study findings revealed that there is a gap based on cultural diversity of women that requires information giving to them and the community at large regarding the presence of student accoucheurs in these units. Furthermore, the training institutions needs to empower student accoucheurs with skills and knowledge on effective communication skills in midwifery discipline. This could lessen fears and reluctances of pregnant women to be cared for by student accoucheurs. The study is in line with nursing education in the midwifery discipline and human resource management. Therefore, the study is a contribution to the emerging education and training of student accoucheurs body of knowledge in the Free State Province and to the global existing body of knowledge regarding the phenomena.