The International Confederation of Midwives (ICM) define midwifery as working in partnership with women to provide holistic care which optimises normal biological mechanisms and cultural experiences of childbirth (ICM, 2017). Although this definition remains relevant, the knowledge-base required to provide competent care and safeguard normality is changing (Nursing and Midwifery Council [NMC], 2019a). Simultaneously, due to advancements in modern medicine and changes to public health, the UK childbearing population is presenting to maternity services with an increasing range of medical comorbidities (Smith and Dixon, 2008).
Excellent bioscience education in midwifery is essential for understanding the normal physiology of childbirth and neonatal adaptations to life, complications that may arise, pre-existing medical conditions, and relevant pharmacology (Macdonald and Johnson, 2017). Bioscience refers to the science of living things and for the purposes of this proposal encompasses: human anatomy, physiology, pathophysiology, pharmacology, microbiology, biochemistry, genetics and immunology (Cambridge Dictionary, 2019). The new draft ‘Standards of Proficiency for Midwives’ produced by the NMC demonstrate a huge shift in the knowledge and skills expected to competently provide holistic care for women (NMC, 2019b). Much discussion has emerged surrounding the direction that midwifery education may now take (Hundley et al, 2018) and this article aims to address whether there is a case for enhanced bioscience content within undergraduate midwifery curricula.
A systematic literature search and review has been performed to critically evaluate and summarise the body of evidence available, and ensure this research is necessary and of benefit (Smith and Noble, 2016). Databases were searched using keywords in the PEO format, namely: student midwife/midwife, bioscience (expanded definition) and education/undergraduate using advanced search and Boolean operators. Databases searched include CINAHL plus, Medline, Cochrane library and Google scholar. The search yielded one partially relevant journal article as well as relevant grey literature.
Nursing and midwifery share a regulating body; however, the skills and knowledge required to practice safely differ significantly (World Health Organization [WHO], 2017). Arguably, as the childbearing population increases in medical complexity, midwives will be required to broaden their sphere of practice to encompass some nursing skills and knowledge (Smith and Dixon, 2008). Insufficient literature concerning midwifery bioscience education made it necessary to encompass nursing keywords into this literature search. Some findings within nursing may be applicable to midwifery, or indicative of where research questions may or should be asked.
The problematic nature of achieving appropriate bioscience learning for undergraduate nurses has been discussed extensively in national and international healthcare literature (Davis, 2010; Taylor et al, 2015; Perkins, 2019). Davis (2010) conducted a case study of experienced UK-registered nurses commencing post-graduate study; numerical data yielded by 42 short, structured questionnaires were supported by semi-structured interviews, in which 40.5% of participants answered that the undergraduate bioscience education they received did not adequately prepare them for practice.
Furthermore, Molesworth and Lewitt (2016) completed a phenomenological study of first- and second-year nursing students in Scotland to discover that, despite valuing bioscience, student nurses felt their teaching and knowledge was poor. However, the sample size was very limited, with seven participants in the first year and only three in the second year (Molesworth and Lewitt, 2016). Patients and healthcare colleagues agreed that the level of bioscience knowledge within the nursing profession did not meet their expectations (Jordan et al, 2000; Friedel and Treagust, 2005). Considering this evidence, similar issues must be investigated for midwifery, especially in view of the new draft standards, which prescriptively list the physiological, pharmacological and pathological processes qualified midwives must have knowledge of. Bioscience understanding underpins these new standards midwives are expected to meet, despite a current lack of education in this area.
Clancy, McVicar and Bird (2000) found that insufficient bioscience knowledge can cause both nursing students and experienced staff to lack confidence discussing scientific concepts and care decisions with other health professionals. Moreover, Prowse and Heath (2005) suggested that better bioscience knowledge within nursing could lead to improved collaborative multidisciplinary team (MDT) working, although it must be noted that these studies are 19 and 14 years old, respectively. The draft standards reiterates that midwives are expected to be a member of the MDT with the ability to advocate for clients, challenge the care decisions of other health professionals and safeguard normality (NMC, 2019b). Accordingly, as the population becomes more medically complex, enhanced bioscience knowledge may be required to confidently enter this MDT forum. Andrew et al (2015) identified that improving the relevance and quality of bioscience teaching can mitigate this issue within student nurses, midwives and allied health professionals, as well as increasing student confidence. However, the sample of only 82 students for a quantitative study could be deemed insufficient to argue a correlation.
Bioscience knowledge of registered nurses has been reliably linked with patient outcomes (Prowse and Heath, 2005; Cho et al, 2015; Perkins, 2019), although the explanation for this is unclear. In China, Cho et al (2015) found a statistically significant correlation between patient mortality and the level of nurse education. Prowse and Heath (2005) argue that better bioscience knowledge improves patient outcomes because of more successful collaborative working within the MDT. Regardless of the rationale, global evidence consistently indicates that better bioscience knowledge within the nursing profession leads to better patient outcomes.
The above discussion is specific to nursing and cannot be generalised to midwifery; however, the MBRRACE-UK (2017) confidential enquiry reports that in the period 2013-2015, 68% of maternal deaths had a known pre-existing medical condition. Of this 68%, improvements in care for 41% may have made a difference to the outcome. It is not possible to draw conclusions surrounding whether enhanced bioscience education for midwives could have led to improving these outcomes; however, as demonstrated by MBRRACE-UK, it is known that there are care improvements to be made by the MDT in maternity, of which bioscience education could be one.
Despite consistent messages that bioscience learning within nursing is insufficient and impacts upon client safety, the issues within education have failed to be addressed. Taylor et al (2015) noted that hours spent delivering bioscience content varied hugely between institutions and that nurses lacked confidence teaching bioscience concepts. The historical shift of nursing from a medical model of care to a profession concerned with social sciences may have left a bioscience knowledge deficit within the nursing workforce and, therefore, the mentors and lecturers (Perkins, 2019). The same issues could persist within midwifery where similarities may lie in the hours dedicated to bioscience education and the level of knowledge possessed by educators. Other barriers to bioscience learning include students' prior knowledge, learning style, and how relevant they deem the content (Andrew et al, 2015).
Within nursing ‘the bioscience problem’ has been reliably identified and barriers to overcoming the issue investigated (Perkins, 2019). For midwifery, it has only been speculated that bioscience knowledge is insufficient within the profession (Smith and Dixon, 2008). The NMC has published draft standards which will likely lead to higher expectations for bioscience knowledge within the profession (NMC, 2019b), but current bioscience content must be reviewed to determine its adequacy for student midwives and how midwifery curricula can be developed to support students to meet the new standards.