Keywords
midwifery care quality
influencing factors
How to Cite
Abstract
Introduction
Induction of labour is a widely used obstetric intervention performed when continuation of pregnancy poses risks to maternal or fetal health. In South Africa’s public healthcare sector, induction rates remain high. Outcomes are closely linked to the quality of care, which is influenced by clinical practices, health system factors, and resource constraints. Associated risks include failed induction, uterine hyperstimulation, and emergency caesarean delivery.
Purpose
This study aimed to explore factors influencing the quality of induction of labour practices among midwives at a district hospital in Tshwane, South Africa.
Method
A qualitative exploratory descriptive design was employed. The study was conducted at a busy district hospital in the Tshwane District, Gauteng Province. Purposive sampling was used to recruit 16 female midwives qualified in basic and advanced midwifery, aged 27–64 years, each with at least two years of experience and direct involvement in labour induction. Data were collected between July and August 2023 through in-depth semi-structured interviews. Interviews were audio-recorded with participants’ consent and transcribed verbatim. Data were analysed using the thematic analysis approach described by Braun and Clarke.
Results
Analysis revealed one overarching theme, systemic barriers compromising induction quality, comprising three subthemes derived from participant responses. Five participants reported (1) overbooking and heavy caseloads leading to rushed procedures; seven participants highlighted (2) increasing induction volumes alongside fixed staffing levels; and seven participants identified (3) inadequate institutional support, including limited access to guidelines, insufficient training, and lack of multidisciplinary support. These factors collectively undermine clinical decision-making, adherence to protocols, and overall quality of care, while also contributing to midwife burnout and adverse maternal–fetal outcomes.
Conclusion
The findings highlight systemic challenges at a district hospital in Tshwane that compromise the quality of labour induction. These results underscore the need for urgent interventions, including strengthened institutional support, implementation of a scheduling cap of three inductions per day, staffing reviews, and the establishment of quarterly induction of labour (IOL) review mechanisms.
References
Amod, H. B., Ndlovu, L., & Brysiewicz, P. (2024). Clinical mentorship of midwifery students: The perceptions of registered midwives in a selected public hospital in Gauteng Province. Health SA Gesondheid, 29, Article 2492. https://doi.org/10.4102/hsag.v29i0.2492
Allen, J., Kildea, S., Tracy, M. B., Hartz, D. L., Welsh, A. W., & Tracy, S. K. (2019). The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth, 46(3), 439–449. https://doi.org/10.1111/birt.12436
Argaheni, N. B., Maulina, R., Juwita, S., & Setyarini, I. A. (2024). Scoping review of midwives' workload: A comprehensive overview. Malaysian Journal of Medicine & Health Sciences, 20(Suppl. 9), 221–230. https://doi.org/10.47836/mjmhs20.s9.29
Bashir, S., Ansari, A. H., & Sultana, A. (2023). Knowledge, attitude, and practice on antenatal care among pregnant women and its association with sociodemographic factors: A hospital-based study. Journal of Patient Experience, 10, Article 23743735231183578. https://doi.org/10.1177/23743735231183578
Braun, V., & Clarke, V. (2022). Thematic analysis: A practical guide (1st ed.). SAGE Publications. https://doi.org/10.4135/9781526417299
Brink, H., & Van Rensburg, G. (2023). Fundamentals of research methodology for healthcare professionals (5th ed.). Juta.
Busetto, L., Wick, W., & Gumbinger, C. (2021). How to use and assess qualitative research methods. Neurological Research and Practice, 3(1), 14. https://doi.org/10.1186/s42466-020-00059-z
Chopani, A., Arabloo, J., Arkian, S. H., & Vatankhah, S. (2024). Identification of contextual factors influencing the successful implementation of in-service training policies for the health workforce in Iran. BMC Medical Education, 24(1), Article 1365. https://doi.org/10.1186/s12909-024-1365-0
Creswell, J. W., & Creswell, J. D. (2023). Research design: Qualitative, quantitative, and mixed methods approaches (6th ed.). SAGE Publications.
Elnasharty, M., Al-Dabbagh, R., Makramallah, I., & Ismail, A. (2025). Improving the quality of induction of labour in maternity services. BMJ Open Quality, 14(2), Article e002757. https://doi.org/10.1136/bmjoq-2024-002757
Fiolna, M. (2021a). Prediction of adverse perinatal outcomes following induction of labour (Master’s thesis). Canterbury Christ Church University.
Fiolna, M. (2021b). Induction of labour: Indications, methods, and outcomes. Best Practice & Research Clinical Obstetrics & Gynaecology, 77, 102–112. https://doi.org/10.1016/j.bpobgyn.2021.07.006
Ganesh, N. (2025). SA’s healthcare system—Challenges and solutions. Cipro. https://www.cipro.co.za/decoding-south-africas-healthcare-challenges/
Liu, M., Wu, Z., Liu, G. G., Xiao, L., & Li, S. (2025). Barriers and facilitators for stroke patients’ adherence to rehabilitation in China: A qualitative study based on medical experts. Scientific Reports, 15(1), Article 31525. https://doi.org/10.1038/s41598-025-31525-x
Malatji, R., & Madiba, S. (2020). Disrespect and abuse experienced by women during childbirth in midwife-led obstetric units in Tshwane District, South Africa: A qualitative study. International Journal of Environmental Research and Public Health, 17(10), Article 3667. https://doi.org/10.3390/ijerph17103667
Mattock, R., Bojke, C., Wright, J., & Stacey, T. (2025). The impact of midwife workload on delivery of care, and mother and baby outcomes in maternity settings in OECD countries: A systematic review. PLoS ONE, 20(8), Article e0329117. https://doi.org/10.1371/journal.pone.0329117
Michail, A., Fasoulakis, Z., Domali, E., Daskalakis, G., & Antsaklis, P. (2025). Role of the Bishop score in predicting successful induction of vaginal delivery: A systematic review of current evidence. Cureus, 17(7), Article e87467. https://doi.org/10.7759/cureus.87467
Mokwena, K., & Madiba, S. (2022). Exploring the challenges of providing quality intrapartum care in a rural district hospital in South Africa: A qualitative study. Midwifery, 114, 103457. https://doi.org/10.1016/j.midw.2022.103457
Mustafa, M., Babiker, M., Abusin, F., Mohammed, T., & Awadalla, T. (2024a). Outcomes of outpatient versus inpatient induction of labor: A systematic review and meta-analysis. Cureus, 16(9), Article e68527. https://doi.org/10.7759/cureus.68527
Mustafa, R., Memon, J., Saeed, N., & Ishaque, S. (2024b). Maternal and neonatal outcomes following induction of labour: A retrospective cohort study from a tertiary care centre. Journal of the Pakistan Medical Association, 74(1), 150–155. https://doi.org/10.47391/JPMA.9377
Ngwenya, M. W., Muthelo, L., Rasweswe, M. M., & Mothiba, T. M. (2025). Midwives' practice challenges in triaging expectant mothers: A qualitative study in Mpumalanga maternity units, South Africa. Frontiers in Medicine, 12, Article 1610724. https://doi.org/10.3389/fmed.2025.1610724
Okeke, N., & Ngunyulu, R. (2025). Barriers and facilitators influencing midwives' implementation of South Africa's maternal care guidelines in postnatal health: A scoping review. Primary Health Care Research & Development, 26, Article e16. https://doi.org/10.1017/S1463423625000015
Pattinson, R. C., Fawcus, S., Gebhardt, G. S., Howarth, G., Khulu, T., & Masuku, S. (2021). The role of district hospitals in reducing maternal and perinatal mortality in South Africa. South African Medical Journal, 111(8), 733–738. https://doi.org/10.7196/SAMJ.2021.v111i8.15748
Polit, D. F., & Beck, C. T. (2022). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer.
Renjith, V., Yesodharan, R., Noronha, J. A., Ladd, E., & George, A. (2021). Qualitative methods in health care research. International Journal of Preventive Medicine, 12, Article 20. https://doi.org/10.4103/ijpvm.IJPVM_321_19
Sourinejad, H., Namazi, N., Afshar, P. F., & Khoshknab, M. F. (2025). The cognitive error styles of midwifery students in clinical decision-making: A directed qualitative content analysis. Journal of Advances in Medical Education & Professionalism, 13(4), 339–350. https://doi.org/10.30476/JAMP.2025.107111.2191
Thorsen, M. L., Hollenbach, D., & Haddad, L. B. (2023). Facilitators and barriers to patient-centred induction of labour: A scoping review. Birth, 50(3), 487–499. https://doi.org/10.1111/birt.12735
Tukisi, K. P., Dlakude, V. D., Hlatshwayo, S. I., & Dlamini, F. (2025). Factors influencing late antenatal booking in Tshwane District: Pregnant women's perceptions. African Journal of Primary Health Care & Family Medicine, 17(1), Article e4870. https://doi.org/10.4102/phcfm.v17i1.4870
World Health Organization. (2022). WHO recommendations: Induction of labour at or beyond term. https://www.who.int/publications/i/item/9789240040823
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.