Looking back over the past 25 years of midwifery education enables us to learn from old ways of working and the related events that took place, to help plan for a future where the women is at the centre of personalised safe care. In the first edition of British Journal of Midwifery, it was noted that a change in the content and the implementation of educational programmes was essential to enable midwives to take full responsibility as the central providers of care during childbirth (Henderson, 1993). Today, midwives work in an environment as equal members of the healthcare team, and multidisciplinary working that recognises how human factors influence safety in maternity care is crucial to our understanding. However, recognition does not mean that we are always successful in achieving excellent standards of maternity care, something that has been documented in multiple maternity surveys over time (Lewis, 2004; Lewis, 2007; Centre for Maternal and Child Enquiries (CEMACE), 2011; Knight et al, 2017).
Looking back, in 1993, one author (LB) was a clinical midwife and another (EC) was an honorary lecturer in midwifery education. At that time, a key influence on practice concerned Changing Childbirth, a document to promote women's choice and control (Department of Health and Social Care, 1993). The report was quoted in educational standards for midwives and presented in multiple polices, yet despite continual reference, it is apparent that it remains difficult for midwives to achieve informed choice (Francis, 2013; Kirkup, 2015). Midwifery education is therefore an important way to raise awareness of respectful and compassionate maternity services, wherever women birth their babies.
Today, the authors have been able to reflect on their professional journeys, and the influence of continuing midwifery education. Acheiving higher degrees has led to a a moral and ethical desire to design undergraduate and postgraduate midwifery and nursing education, and the resulting programmes aim to facilitate the growth of each individual student towards their goal of becoming the best health professional that they can.
Looking back and looking forward at midwifery education
Midwifery education focuses upon a natural process of birth, where the anatomy and physiology of the birth process remains as it has for millennia. It is therefore crucial for every midwife to understand the fundamental physical and biological process of pregnancy, birth and parenthood. However, changes to the profession are rapid, and are related closely to women's lives, how their bodies respond to changing environments, and technology, meaning that midwifery education needs to be responsive, authentic and evidenced-based. An example of a responsive curriculum can be related to evidence around how women who have raised body mass index (BMI) experience childbirth. This cultural and anthropological shift instigated change in midwifery curricula to meet the needs of women, their families and the midwives who provide essential safe care. Responsive curricula are pivotal because a midwife has a clear role and responsibility throughout the childbirth continuum and in a variety of healthcare and social settings.
Keeping curricula up to date and responsive helps to increase the quality of education provision. High quality education involves a pragmatic approach that brings to life theory in the context of women's lives while developing an ever-increasing skill base. It is thought that through high quality midwifery education, midwives will improve outcomes and experiences of childbirth for women, children and their families (Council of Deans of Health, 2017).
Moving forward, it is increasingly important for midwifery education to meet the changing needs of women and their families on a global scale (International Confederation of Midwives, 2013; World Health Organization, 2013). Using this pivotal moment to reflect on midwifery education presents an opportunity to situate the past, and use it to provide a supportive and insightful link to the future (Gadamer, 2004). High quality education, developed over an ever-changing foundation of knowledge base will therefore lead us through the next 25 years of maternity care, where continual transformation is essential.
Midwifery certification
At one time, it was typical for midwives to undertake training following a nursing qualification—an option that continues in a small number of universities today. Preparing midwives for professional practice during the 1980s and early 1990s involved knowledge development based on factual content, skills acquisition and assessment via a final written and oral examination, before a certificate was awarded to provide eligibility for professional registration. In 1996, the introduction of a diploma awarded by a higher education institution enabled the development of a theoretical framework to underpin the design and content of the midwifery curricula (Fraser et al, 1997). As training for midwives progressed, achievements were demonstrated at diploma- or degree-level qualifications.
The typical path of training as a midwife after completing a certificate of nursing was interrupted when there was a desire to raise the profile of normal birth, and this focus led to direct-entry midwifery becoming more common. At the same time, in the mid-1990s, midwifery education moved away from hospital training schools and into universities. Midwifery tutors transferred from the NHS to the university setting, and both students and midwifery lecturers were expected to transfer their loyalty to their university. This cultural and intellectual shift embraced new ways of learning that relied more on evidence, analysis and the development of a critical, questioning approach to underpin teaching, learning and assessment. The original final written and oral examination then gave way to continuous theory and practice assessments. Empowering midwives to critically question evidence and practice helps future clinicians to bridge the gap between women's expectations and those of the profession.
Funding for midwifery education
In the past, funding for midwifery education places remained with the Strategic Health Authority (SHA), which allowed midwifery students to avoid the annual tuition fees paid by other university students. Before April 2013, the number of commissioned places for student midwives rested with the SHA, workforce deaneries and primary care Trusts, responsibilities that were devolved from the Department of Health and Social Care via Nursing and Midwifery Professional Advisory Boards. However, academic progression has since been influenced by decommissioning student bursaries, and since September 2017, student midwives pay fees and access the student loans system, instead of receiving the student bursary.
In the past, funded university places were constrained by limits and a fixed number of students available each year; resulting in robust competition for student places. Now, despite a national shortage of midwives, higher education institutions remain limited by the places they can offer, which is restricted by the amount of clinical placements available, and the number of qualified mentors able to support learning and assessment in the clinical area. Establishing the delicate ratio between educational places available and clinical placements is an ongoing issue within midwifery practice. This ratio is underpinned by close working partnership between higher education institutions and clinical practice, in which each complements the value of the other. This is crucial to our understanding as Nursing and Midwifery Council (NMC) standards (2009) stipulate that the practice content of a midwifery programme should be no less than 50%.
Upon qualification, midwives are responsible for their continuing education and professional development. Many midwives choose to study at Master's level and others choose to go further and engage in PhD studies. However, postgraduate students studying midwifery as a second degree are not eligible for a loan to support their studies, and this may further reduce the numbers of students wishing to access shortened 18-month midwifery programmes, alongside an overall reduction in undergraduate applications. As a result of funding changes, issues of completion and retention of students are likely to continue the shortage of registered midwives. Limited and declining funding has led to increased interest in the potential value of apprenticeships as a model for midwifery education and practice, and this move may be the key to sustaining a vision for longevity.
Quality assurance
The quality of midwifery educational programmes are monitored and audited in a number of ways to establish safety, equity and establish a robust attention to detail. Quality assurance processes also ensure that professional and academic standards are up to date and aligned to the NMC and Quality Assurance Agency for Higher Education (QAA) standards. This involves annual monitoring of courses, linked to revalidating programmes (usually every 3-5 years) (QAA, 2017). Alongside these processes, graduation data, including final employment information, contribute to the reputation and standing of the university and the midwifery programmes it runs.
Another perspective of quality assurance is the annual national student satisfaction surveys. These surveys focus on final year students, whose perceptions of the course and the institution are reported in the national media and are available to be scrutinised by prospective students. In turn, these statistics contribute to university league tables and influence which courses continue to run.
Quality assurance is a duty of the NMC (2017a; 2017b). Midwifery programme providers receive regular monitoring visits, during which the quality assurance framework identifies weak; acceptable; and well-developed levels of risk, based on resources; admissions and progression; practice learning; fitness to practice and quality assurance. These themes are listed annually as a red, amber or green rating, and are self-reported, as part of a supportive process to reduce the burden of regulation on well performing educational institutions. A full review and visit is nevertheless scheduled every 3 years. The NMC acknowledges midwifery programmes in which acceptable levels of risk control are demonstrated.
The NMC education standards were published in 2009. The NMC are now reviewing the standards for midwifery education and these are scheduled for publication in 2019.
Patient and public involvement is now common in the recruitment of student midwives. Looking forward, it is possible that service users will have an increasing influence, whereby their opinions are captured to inform standards of maternity care given by students in their particular clinical environment. Including this additional perspective will help to triangulate and enhance the quality assurance process in the future.
Conclusion
It is important to recognise there is wealth of knowledge and skill that underpins the foundations of midwifery education. Those foundations have evolved in response to demographic and anthropological changes over time. Dynamic and responsive curricula are essential to underpin maternity care today. Educational skills, born from questioning evidence and practice, will help to bridge the gap in expectations between women, their families and the profession. It is crucial to recognise the changing landscape of midwifery education, which reflects that the specific focus of the student midwife, and the demographic characteristics of that workforce, are changing in response to funding opportunities. Those who are exposed to the joys and the perils of childbirth through midwifery education are the future of our profession, but they incur emotional and financial stress when working in a culture of high expectations. Midwifery education will need to include reflexivity, emotional resilience and self-care to meet the challenge of safe maternity care in 2025. The challenges include achieving continuity of carer by 2021 and halving rates of stillbirth, neonatal and maternal death, and brain injuries that occur during or soon after birth by 2025 (Department of Health and Social Care, 2018), and embracing an apprenticeship model may be a way forward for the future of midwifery.
‘Limited and declining funding has led to increased interest in the potential value of apprenticeships as a model for midwifery education and practice, and this move may be the key to sustaining a vision for longevity’