Competence of student accoucheurs on clinical practice as perceived by midwives in Limpopo Province, South Africa

Abstract Student accoucheurs were perceived to be uncomfortable conducting intimate clinical procedures, hence the struggle to attain the required clinical learning experiences when allocated in maternity wards. A qualitative explorative, descriptive, and contextual design was used. Five focus group discussions of midwives were purposively sampled. Data was collected through focus group discussion using a semi-structured interview guide. Data was collected until data saturation was reached. Data were analysed through Tesch’s open coding method. Trustworthiness was achieved through credibility, transferability, and confirmability. Ethical principles were adhered to and included were informed consent, beneficence, right to self-determination, confidentiality, and anonymity. The findings revealed two themes: the perceptions of the competence of student accoucheurs during clinical practice and the strengthening of clinical accompaniment. For improving the practice and competence of student accoucheurs, maternal directorate should consider recruiting, appointing, and placing or promoting existing accoucheur managers to manage maternity units to improve gender equity and role modelling for student accoucheurs in midwifery discipline. The willing and passionate must form part of the staff establishment in the maternity care units in order to familiarise women with nursing care rendered by student accoucheurs. The training institutions should incorporate cultural diversity in teaching student accoucheurs in midwifery care to ensure that they are equipped with knowledge to render maternal health to women of different cultures


Introduction
Nursing is perceived as a traditionally feminine profession, a stereotype that may be closely linked to Florence Nightingale's approach to care. However, over time, nursing and midwifery evolved to include males. In South Africa, chapter 2 of the Constitution always stipulates upholding gender equality (South African Nursing Council, 2006). Consequently, the percentage of male nurses in the country has risen and continues to do so. Today, it is common to find accoucheurs in labour wards and neonatal units of maternity departments. The South African Nursing Council (SANC) Statistics, 1/2019, confirm the number of accoucheurs in Limpopo compared to those of female nurses. It was recorded that female registered nurses were 10,567, whereas male registered nurses were 1,549 (Ndou & Moloko-Phiri, 2018).
Midwifery clinical training is part of an integrated course, namely a four-year diploma or degree leading to registration in General, Psychiatric, and Community Nursing and Midwifery (SANC, 1985, as amended), which aims to provide for the personal and professional development of the student. Admission to the course requires that all four disciplines be followed as there is no choice of a particular course to follow for a diploma or degree. The SANC Regulation R2488 guides midwifery training to conditions under which registered midwives may carry out their profession. In terms of SANC Regulations R425 of 1985 and R2488 of 1990, male nurses in midwifery clinical training are required to perform clinical procedures on females, some of which can be very intrusive (SANC, 1985(SANC, , 1990. During training, lecturers teach theory and correlate it to clinical practice. Clinical practice in the clinical placement sites should allow students to apply their theoretical knowledge in a natural environment, develop nursing skills and clinical reasoning, and observe and adapt to the professional role (Gemuhay et al., 2019). The clinical skills are demonstrated to all students, and they are expected to demonstrate them back through simulation before they perform the skill to a real patient. This is followed by clinical evaluation.
The basic clinical procedures to be mastered in midwifery may include performing abdominal palpation, and pelvic assessments; performing internal examination to recognise the different stages of labour; observing, monitoring, and interpreting all stages of labour; delivery of infants; examination of the placenta, and management of post-delivery complications including resuscitation of the newborn infant (SANC 1990, paragraph 6[1], 7[1], 8[a]). To be deemed competent, all student midwives (males or females) are expected to conduct all the prescribed clinical procedures, which are critical. These procedures include 30 abdominal palpations, 25 personal delivery, 25 vaginal examinations, five episiotomies, and suturing.
During clinical accompaniment, researchers noted that female students were more confident performing and completing all the procedures in the midwifery discipline than their male counterparts. Further, male students were uncomfortable conducting intimate clinical procedures and had difficulty completing midwifery registers. The midwifery workbooks contained critical intimate clinical procedures like; vaginal examination, pelvic assessment, episiotomy suturing, delivering the baby. This was evidenced by data obtained from the Nursing College during 2016-2019 amongst students registered under regulation R425, as presented in Table 1.
Student accoucheurs had an insufficient number of personal deliveries and pelvic and vaginal examinations-as the SANC required. To qualify for the summative examination, the students were expected to perform fifteen (15) internal (vaginal) examinations, 15 deliveries and receive instruction in the supervision of at least thirty (30) pregnant women as per SANC Regulation R254 (SANC 1997). This was in line with Inoue et al (2006) findings in Australia that providing intimate care to women clients was a challenging experience for male students and invoked negative feelings when they invaded women's personal space. Tzeng et al. (2009) believed male students experienced challenges of attaining the required clinical learning experiences when allocated to maternity wards due to gender stereotypes and socialisation. This was accentuated by midwives' perceptions that midwifery is not for males but a female profession (Bwalya et al., 2015). The study conducted by Rikhotso (2010) indicated that male students were rarely involved in childbirth activities. They were sometimes called names, harassed, and in most instances, were used as scapegoats for any wrongdoings in the ward. EL-Sayed and EL-Nemer (2013) affirm that midwifery staff indicates that female students are better than their male counterparts.
Midwives as supervisors are essential in developing students' confidence in clinical practice, Jordan and Farley (2008), to ensure that competence is attained (Licqurish & Seibold, 2008). As role models, they influence students positively or negatively (Hughes & Fraser, 2011. Cameron et al. (2010 believed midwives are supposed to be supportive, empathic, and act as advocates for students during clinical exposure.; Zidarič and Skubic (2015) corroborated that the environment in which students are allocated should be such that they can expect support and empathy from colleagues.; Setumo (2013) thought that the students' experiences in clinical practice were characterized by poor working relationships between themselves and the staff in maternity wards and that students received insufficient support from the clinical environment affecting achieving the learning outcomes.; Keogh and O'Lynn (2007) indicate that midwives had negative attitudes towards student accoucheurs as they were reluctant to participate in the full range of caring interventions. Student accoucheurs were sometimes requested to excuse themselves when the female peer or midwife performed intimate procedures, such as vaginal examination, childbirth, or catheterization. However, student accoucheurs were only accepted by their colleagues and permanent staff during obstetric emergencies and difficult deliveries because this was congruent with masculine qualities (Tzeng et al., 2009). Several studies have been conducted on the experiences and perceptions of male student nurses during clinical midwifery placement (Achora, 2016; Buthelezi et al., 2015;Mohamed & EJ-Niemer, 2013;Mthombeni & Phaladi-Digamela, 2015;Ndou & Moloko-Phiri, 2018). However, there have been limited studies that focus on midwives' perceptions. Understanding midwives' perceptions when supervising student accoucheurs during midwifery clinical training could bring forth required information to be considered to enhance clinical competence, ultimately The study aimed to determine midwives' perceptions of the clinical competence of student accoucheurs when allocated for clinical midwifery placement in the maternity of the five district hospitals of the Limpopo province. The objectives were to describe the perceptions of the competence of student accoucheurs during clinical practice and to suggest an intervention to strengthen clinical accompaniment for students during clinical placement.

Research design
A qualitative explorative and descriptive design was used to describe midwives' perceptions of the clinical practice of student accoucheurs when allocated for midwifery clinical learning experiences at five training hospitals in Limpopo province. The five hospitals are found in the districts of Vhembe, Mopani, and Capricorn in Limpopo. The hospitals were: Nkhensani, Siloam, Donald Fraser, Elim, and Seshego.

Study population and sampling
The population comprised all midwives in maternity wards at the training hospitals in Limpopo Province, South Africa. Non-probability and purposive sampling were used to select five hospitals. The facility should be designated as a training facility for students who are training under the regulation R425 leading to registration as a Nurse (General, Psychiatry, Community) and Midwifery was selected (South African Nursing Council, 1985 as amended). The Human Resources Officers of hospitals assisted the researcher in identifying all the midwives with work experience of two years in maternity wards. Convenience sampling was used to sample 10 midwives from each hospital, totaling 50, resulting in conducting five focus group discussions.

Ethical considerations
Ethical clearance was obtained from the University of Venda Ethics Committee ref no: SHS/14/PDS/ 03/2110. Approval and permission to access facilities were obtained from the Limpopo Provincial Department of Health, the Chief Executive Officers of the five district hospitals. An informed consent form was signed by participants. Ethical principles were voluntary participation, beneficence, right to self-determination, anonymity, and confidentiality were ensured.

Data collection methods
The researchers made an appointment to meet the participants at a convenient venue and comfortable for them during the comfort breaks. An information leaflet detailing the study purpose and rights of participants were given to all who volunteered to participate. Appointment dates were scheduled with each consenting participant regarding the suitable day and time for data collection. On the agreed date, the board room was arranged for data collection during their resting period. Focus group discussions through semi-structured interviews were done. The questions asked were: (1) what are your perceptions towards the clinical practice of student accoucheurs when allocated in midwifery units? (2) What interventions could be used to optimise their clinical practice? The interviews were conducted in English, and participants were welcomed to respond in different local languages (Tshivenda, Sepedi, and Xitsonga), and each lasted between 30-45 minutes. One participant responded in isiZulu and one researcher was proficient in this language. The voice recorder was used to capture raw data. Permission to use a voice recorder was sought with participants.
Various communication skills such as paraphrasing, probing, reflecting, and listening were used to encourage the participants to give additional information and for researchers to get clarity on specific issues that arose during the interview, as postulated by Polit and Beck (2018). Data was collected to the point at which no new information was obtained, and this pointed out that data saturation was reached.

Data analysis
The narrative data from the focus group discussion were analysed qualitatively using Tesch's open coding method as postulated by Creswell and Creswell (2018;de Vos, Strydom, Fouche, & Delport, 2011). The recorded interviews were translated into English by the language expert, transcribed word by word. The field notes and nonverbal cues (for example, silence/sigh, frowns, and lean back) were included in the transcripts. All transcripts were read to give meaning, and a list of similar topics was clustered. Data were coded, categorized, and grouped according to categories and sub-categories. A literature control was done to control the results of the study.

Trustworthiness
The criteria for ensuring trustworthiness as outlined in Polit and Beck (2018) were adhered to. Credibility was ensured through prolonged engagement and persistent observation during data collection. During the focus group interviews, the researcher spent time with the participants listening and observing them as they were interviewed. The participants were interviewed to the point at which there was data saturation. The recorded interviews were transcribed word by word and the nonverbal cues were included in brackets of the transcripts to ensure authenticity. A member check was also conducted to validate the truth and to confirm the findings. The voice recorder was used to ensure credibility. Transferability was ensured by thick descriptions of research methodology. Confirmability was guaranteed by accurate translation by the language expert. The presented information reflected participant's voice and inquiry conditions, not the researcher's biases (Polit & Beck, 2012). A consensus was reached between researchers and independent coder that the interpretations of data were congruent to research findings 3. Findings

Characteristics of the participants
Participants were recruited from 5 training institutions and there were no significant differences amongst them. Table 2, present their demographic profile related to experience, gender, and qualifications, was noted to correlate their perceptions towards the midwifery practice of student accoucheurs.
The findings related to demographic profiles from midwives who participated in the study showed that 36% of midwives had 2-5 years and 30% 5-10 years of experience working in maternity wards. This implies that they encountered different male students allocated for midwifery practice. The majority of 97% of participants were females, whereas 3% were a male working in maternity wards in 2015. This gender distribution of participants confirmed that the midwifery discipline is still dominated by females who support and supervise all students during clinical placement to accomplish learning outcomes. It is mandatory for midwives as professional practitioners to teach learners to all midwifery students including male students as the midwifery scope of practice prescribes. The findings indicated only 23% of participants possessed a Diploma in Advanced Midwifery as a specialisation, 33% in Nursing Education qualifications, and 100% with basic Midwifery which might enhance the training and learning for students during midwifery practice.
The findings revealed two themes with three sub-themes under each, as perceptions on the competence of student accoucheurs during clinical practice, as presented in Table 3. Competence can be defined as the ability to perform a specific task in a manner that yields desirable outcomes. This definition implies the ability to apply knowledge and skill towards new situations and familiar tasks.1 Each subtheme was discussed using relevant quotations from the participants. The direct quotes represent the participants' perceptions during the midwifery practice of student accoucheurs. Verbatim transcripts are presented without any attempt by the researcher to correct the grammatical errors.

Theme 1: The perceptions of the competence of student accoucheurs during clinical practice
During midwifery training, all students receive similar learning content together. Students were further continuously supervised and corrected by midwives until they could perform confidently on their own. It was during a summative assessment at the end academic learning programme  where the institution of learning, in preparation for exit then, the student is assessed. At the district hospitals, it was where midwives primarily assisted in the delivery of pregnant women, and doctors were only called when there were some complications. However, it emerged from the findings that student accoucheurs, too, encountered different perceptions from the unit midwives during their clinical placement. Student accoucheurs were experiencing challenges in attaining the required clinical learning experiences when allocated in maternity wards due to gender stereotypes and socialisation (Tzeng et al., 2009). This was accentuated by midwives' perceptions that midwifery is not for males but a female profession (Bwalya et al., 2015). One of the roles of midwives working in labour words was supervising these student accoucheurs to achieve clinical competency. However, their perceptions of the clinical practice of student accoucheurs were not known. Under this theme, three sub-themes emerged.

Sub-theme 1.1: lack of commitment
The study's findings revealed that most midwives (82%) perceived that male students lacked commitment to learning when placed in maternity wards. When student accoucheurs were assigned to monitor women during the first stage of labour, they would do that but needed constant supervision. They would go for extended tea or lunch when they break for tea. Participant 1 Focus group discussion (FGD) 3 said: "Some student accoucheurs would dodge, and they don`t like to spend more hours in labour ward. Sometimes they are lazy, and they are here to fulfill the requirements of the college/ university", this confirms and contributes that they would not comply with the requirements of the qualification.
To support those student accoucheurs who were not committed, Participant 8 FGD 1 said "some when they are asked about what or to produce their objectives, only few will produce them. This makes it difficult to guide them appropriately". Participant 4 FGD 2 said, "male students are not serious (frowning) it's better to work with female students".
Another participant 2 in FGD 5 confirmed their lack of commitment to performing skills when saying: "Most of them are unable to expel clots after delivery. They don't volunteer and participate in examining or conducting delivery. (Smiling) They prefer to collect blood and accompany women to c/section at the theatre. They seem to forget that case register needs to be completed with 15 personal deliveries". Male students were not confident in performing specific intimate procedures.
Most participants in the district hospitals reported that male students show less interest in midwifery practice; thus, it was difficult to supervise somebody who lacked enthusiasm. Sayman (2014) supported participants` views in his study that one male student who was a participant reported how he disliked the obstetric practicum because he had no point of reference and found a means to decrease the amount of time by always staying at the back of a corner.
Contrary to the above perceptions, 18% of participants reported that male accoucheurs were committed during midwifery clinical practice. This was supported by participant 6 in FGD 1 who verbalized: "I worked with those happy to be allocated in labour and maternity ward. When they are interested, they were eager to learn and could be good midwives because they performed the procedures correctly and they take time when examining pregnant women".
Participant 8 in FGD 2 indicated that:

" . . . those who developed the interest they precisely do the procedures [sic], they can spend time with women, counselling, or giving them information. They are not like some practicing midwives who sometimes do not rush when assessing women."
At the end of the block, few student accoucheurs were completing their midwifery case registers. Participants further indicated that student accoucheurs felt that holding the new-born babies and seeing the joy they brought to their parents was a fantastic experience. These were the positive experiences of male students when performing practical midwifery skills.

Sub-theme 1.2: cultural factors
Historically, men without medical backgrounds were not allowed to attend a pregnant woman. However, qualified male midwives (accoucheurs) or male doctors do attend to women during childbirth. At obstetric units, most doctors who conduct deliveries are male doctors. Homebirths were done by elderly women in the village; thus, men were uninvolved in such activities. Cultural factors seem to impact the clinical learning of male students in maternity wards (Pilkenton, 2008).

Participant 8 in FGD 2 indicated that:
"The challenge is culture (inside culture, there are norms and beliefs). It was a common belief among participants that men should not be involved in childbirth. Even when the current generations allow partners in birthing centers during childbirth, the participant further said, "in our culture, men (not those who are doctors) are not allowed to participate in childbirth".

Participant 4 in FGD 1 said
"It is difficult for male students to interact with pregnant women when allocated in maternity. You could observe that they didn't want to perform vaginal examinations. They were allocated in maternity wards because it is a course requirement. Once they have completed their registers, you would rarely see them in labour ward as they were always working in postnatal ward".

Participant 9 in FGD 5 expressed similar views about culture when said:
"Culture is a barrier that makes it difficult for male students to adapt. In my opinion, there are specific tasks that you cannot command male students to do, like wiping feaces unless this happens when he is managing a woman and is alone.
(Head shaking) I observed that they were uncomfortable conducting vulval swabbing before internal examination when a woman is in labour or putting a catheter, it was difficult for us.

Participant 1 FGD 1 said: Because he is a man, some midwives at times l call female students to insert a catheter for him.
It was observed that professional midwives would intervene so that the male student complete the procedure.
Participant 9 in FGD 5 continues to say: He is a man; at home, he is treated like a man, he will feel embarrassed, and he ought to be respected.
But midwives were reminded that male students needed the practice to assist women during childbirth. Participants indicated that some women refused the health care provided by male students. It was difficult for male students as women preferred female students to conduct procedures on them.

Sub-theme 1.3: non-competence leading to non-achieving of the clinical requirements
The current study revealed that 97% of participants indicated that student accoucheurs lacked interest during midwifery practice as they dodged clinical practice, especially during their allocation in the labour ward. Participant 2 in FGD 3 indicated that: "Male accoucheurs showed less interest in managing women during the first stage and conducting delivery. Some usual dodge at the practically [sic] situation. In the end, they complete their training being incompetent.
The participant continued by saying: "During summative assessment with their lecturer, they are usually not yet competent and their registers being incomplete. They don't completed during the specified period. If they do complete the programme, they don't prefer to be allocated in labour and maternity".
Participant 5 in FGD 2 supported the notion when stating that: "Most male students don't report all findings when performing PV examinations, like the station, effacement, application, position, moulding, etc., they usually say dilatation of the cervix. They feel embarrassed and seem uncomfortable to see the nakedness of women and some older than them. Male students were also perceived as afraid to touch blood and perform vaginal examinations.
The participant continued by saying: (Smiling) They enjoyed putting up drips and wheeling women to the theatre for C/section. They are there in maternity just to fulfill college/university requirements. More than a half (50%) of them are not interested in midwifery qualification . . . " Participants in the current study indicated that some of the student accoucheurs, when assigned to progress women during the first stage of labour would need constant follow-up and monitoring, which could assist them in achieving the required tasks.

Theme 2: Strengthening of clinical accompaniment
Recommendations and suggestions to strengthen clinical accompaniment for the training of accoucher students during midwifery practice were made. Participants perceived that male students did not demonstrate competency during midwifery practicals, whereas their allocation in the maternity ward was to fulfill academic requirements. It was perceived that professional midwives working in primary health care facilities, colleges, and universities, or hospital settings should be involved in the supervision of male students for their positive learning outcomes. Under this theme three themes emerged.

Sub-theme 2.1: facilitate acceptance of student accoucheurs
Midwives at primary health care facilities play a vital role in clinical supervision and enhancing of midwifery training of student accoucheurs since most pregnant women attend antenatal care at the clinics. The community should be made aware that student accoucheurs are allocated to provide care at clinics and would also be available in maternity wards. This information enabled pregnant women and their spouses to adapt to the situation when they find student accoucheurs in the maternity wards. Participant 6 in FGD 2 had a similar view about the student accoucheurs that the community needs to be empowered by indicating that: "The public must be made aware that there are male student midwives in maternity wards through the health information from clinics." One male midwife (accoucheurs) as participant 4 in a district hospital revealed that people in the community were unaware that male students could conduct deliveries in maternity wards because the community knew the doctors. He indicated that some men in the community ridiculed and laughed at him when they heard he was working in labour wards conducting deliveries.

Sub-theme 2.2: continuous support to student accoucheurs
The midwifery lecturers are facilitators of both the practical and the theory components for the midwifery qualification. Clinical preceptors should do the accompaniment for the practical component, however, throughout the learning process, there was no dedicated personnel to accompany students in clinical to supervise students in the clinical areas. The current study indicated that their lecturers should accompany and inspire them during midwifery exposure. Participant 7 in FGD 3 indicated that: 3.8.1. "The lecturer should accompany [sic] the students to clinical areas as they are already used to them." Another participant, 4 in FGD 3 indicated: "The Nursing College management should appoint somebody responsible for student's clinical learning because we are understaffed to look after them. Male students need constant supervision from lecturers." The accompaniment of students should be done twice a week in the clinical area for 30 minutes as prescribed by the South African Nursing Council (2006). In the training hospitals where the study was conducted, the responsibility of supervising the students remained entirely with the hospital midwives, who are also overworked and short-staffed.
Participants in the current study indicated that students should be accompanied by their lecturers to the clinical areas as they own the curriculum. Participant 10 (in FGD 5) from one district hospital had negative perceptions towards the allocation of male students by saying;

"lecturers must accompany them and see that they don't practice their clinical learning experiences"
Participant 7 in FGD 3 said, "lecturers just send students without coming to check whether practice what they learn in the theory component". Participant said, "Lecturers from the university were sometimes visible in maternity wards to support the students while the college lecturers were not coming".
The students' learning in the clinical areas was left entirely to midwives, who were also understaffed.

The perceptions of the competence of student accoucheurs during clinical practice
The findings as perceptions of midwives were based on the emerged themes and indicated that student accoucheurs felt not accepted and trusted by women patients. This may have increased the likelihood of them not fully participating in midwifery activities. Participants further indicated that most student accoucheurs were less confident performing clinical midwifery procedures. This was evidenced by when performing vaginal examination to monitor the stage of labour they will only report cervical dilatation as the findings and ignore for example, the station of the presenting part, presentation, application of the presenting part during contraction and effacement. Student accoucheurs would indicate they feel uncomfortable performing intimate procedures. It was further noted that they could not expel clots after delivery which could cause maternal complications like postpartum haemorrhage. The identified gaps confirmed that student accoucheurs lack communication skills in assessing women and giving instructions effectively during delivery without feeling discomfort and embarrassment (Madlala et al., 2021). Tesfaye, T. S., Alemu, W., & Mekonen, T. (2020) The training institutions must empower student accoucheurs with efficient communication skills and build a sound nurse-patient relationship in maternal healthcare. In the study (82%) participants perceived that student accoucheurs were less committed in mastering midwifery when allocated in the maternity ward. It was evident that student accoucheurs faced difficulties during their training, specifically in performing intimate skills in the midwifery discipline. These difficulties may be contributed by rejection, segregation, and discrimination by pregnant women based on their gender, including lack of support from their lecturers and midwives in maternity units, among other factors that contribute to these difficulties (Madlala et al., 2021). The student accoucheurs, if not constantly supervised, avoided being in the ward by extending the period of their tea and lunch period. The training institutions should incorporate cultural diversity in teaching student accoucheurs in midwifery care to ensure they are equipped with the knowledge to render maternal health to women of different cultures.
It emerged that women were attending maternal healthcare where student accoucheurs are placed from diverse cultural backgrounds which were religiously and culturally sensitive regarding pregnancy, labour and puerperium. Karout et al. (2013) concurred that a diverse culture differs in ethnicity, religion and language in which each group has its own value, belief system, tradition and different lifestyle. Hence it was taboo to most women to be seen naked, examined and delivered by student accoucheurs.
Participants confirmed that cultural factors had a negative influence on the training of student accoucheurs during midwifery practice (Karout et al., 2013). Some participants perceived that midwifery was not for males. Prideaux (2010), indicated that if the patient belongs to a specific cultural or ethnic group that holds the belief that male care of female patients is prohibited, the care provided by the student accoucheur would offend the cultural values held by the patient and her relatives. Cultural beliefs could harm achieving all requirements of student accoucheurs. Eswi and El Sayed (2010) found that in Egypt, more than half of the sample (67,7%) student accoucheurs preferred to deal with males rather than female patients and it was reported that abdominal and breast examinations, as well as perineal care, Ramesh et al. (2016) was the most embarrassing procedures to the students. This could have a negative impact to the quality of training received by student accoucheurs in maternal healthcare. Inadequately trained accoucheurs poses a risk to already challenged maternal healthcare with high rates of maternal mortality.

Strengthening of clinical accompaniment
It was suggested that midwives at clinics should play a vital role to enhance the clinical competence of student accoucheurs as most pregnant women attend antenatal care at the clinics. This would offer students, opportunities to practice. The notion was supported by Bwalya et al. (2015) that there is a need for intensity information and counseling to encourage pregnant women to utilise skilled birth attendants, regardless of gender. The information given from the clinics would enable pregnant women and their spouses to accept the male students when they encounter them in the hospitals. Also, Chimimba (2014) had similar views that it would be necessary for the immediate future to let the media start talking about the availability of student accoucheurs in maternity wards.
Student accoucheur when placed alone in the ward, felt lonely and this led to less interaction with permanent staff and patients. This was confirmed by the findings of the study conducted by Meadus and Twomey (2011) one participant reported that he was the only male allocated in the ward. He expressed that he would have found it much better if there had been another student accoucheur, as it would have given him the courage to practice midwifery. In the study conducted by Harding et al. (2008), one male nurse reported that his vulnerability came from the fact that the nurse is often alone with the patient, and in such circumstances; it is difficult to defend oneself against allegations, as they were not comfortable to conduct intimate procedures. Participants had opinions that at least two male student midwives should be allocated to maternity wards at the same time to share the experience and support each other. In the institutions of higher learning where the study was conducted, the percentage of male students in a class ranges from 14-23% which will impede the balancing of allocating female and male students in maternity wards. Similar findings were elicited in the study conducted by Setumo (2013), revealing that 72% of the midwifery students were females, and male students comprised only 28% of the sample population. Ngidi (2007) affirms that males in nursing are still in the minority.
The accompaniment of students to clinical facilities was not adequately done. Lecturers from college were rarely seen at clinical facilities as this can provide a valuable opportunity for them to apply various teaching strategies, observe teachable moments and use them effectively Mthombeni and Phaladi-Digamela (2015); Mthombeni et al. (2018) were of the view that nurse educators (lecturers) should design a structured accompaniment plan that is implemented for all learners, to make it possible for learners to grow through the guidance of lecturers in clinical settings. Also, Meyer (2012) indicates that for the clinical training of midwifery students to be successful, the students must be accompanied and supported in the midwifery environment by their lecturers.

Limitation
The study was only conducted at hospitals that are accredited to train the programme R425 regulation leading to Nurse (General, Psychiatry, Community) and Midwifery (SANC, 1985), in Limpopo province. Findings cannot be generalised to other hospitals in Limpopo Province and South Africa.

Recommendations
For improving the practice and competence of student accoucheurs, maternal directorate should consider recruiting, appointing, and placing or promoting existing accoucheur managers to manage maternity units to improve gender equity and role modelling for student accoucheurs in midwifery discipline. The willing and passionate accoucheurs must form part of the staff establishment in the maternity care units to familiarise women with nursing care rendered by student accoucheurs. The training institutions should incorporate cultural diversity in teaching student accoucheurs in midwifery care to ensure that they are equipped with knowledge to render maternal health to women of different cultures. Future research to be conducted on accoucheurs, midwifery and cultural diversity.

Conclusion
The provision of quality maternal healthcare service to pregnant women is pivotal. This requires a skillful, competent, and adequately trained midwife/accoucheur to render such service to women in the midwifery discipline. The findings confirmed that even though student accoucheurs were perceived as not competent to comply with clinical requirements, lacking interest and uncomfortable when conducting intimate procedures. Opportunities should be created for learning to take place. Lecturers need to commit to constant monitoring and supervision to enhance the clinical competence of student accoucheurs. This will ensure compliance with regulation R.425 of 22 February 1985 as amended, which mandates male to be trained as accoucheurs.