Integrating public health practice into the graduate's role through pre-registration education

Public health and health promotion concepts

The historical emphasis on the prevention of infectious disease, through access to clean water and safe disposal of sewage, illustrates the medical and social policy roots of public health (Phin, 2009). Epidemiology is closely aligned to public health as it provides data about the factors associated with different health problems (Adetunji, 2009). The notion of ‘educating the public for the good of its health’ emerged early in the 20th century, (Naidoo and Wills, 2009). Early examples include posters and lectures to educate First World War military about venereal disease. These and other education strategies were used increasingly through the 20th century to tackle lifestyle diseases such as heart disease, stroke, and cancer (Naidoo and Wills, 2009). However, health education methods are often criticised for their ‘victim blaming’ and lack of awareness of the impact of social context on individual's behaviours (Scriven, 2010).

The terms ‘health promotion’ and ‘public health’ are often used interchangeably, although health promotion is sometimes seen as a means of achieving public health goals (Naidoo and Wills, 2009). The Ottawa Charter (World Health Organisation (WHO), 1986) outlined five key areas for health promotion practice (see Box 1).

WHO's key areas for health promotion

These key areas indicate how health promotion has a much broader remit than just education, and involves working with communities and wider populations as well as individuals. Today, health promotion is used as an umbrella term, encompassing strategies such as education, advocacy, using models of behaviour change, facilitating informed decision-making, empowerment, environmental health, community development initiatives, political lobbying, mass media communication, health needs assessment, audit, and practice development (Piper, 2005; Scriven, 2010; Hubley et al, 2013).

Public health in midwifery policy

Since the signing of the Ottawa Charter (WHO, 1986), UK health services have placed increasing emphasis on the prevention of disease and the promotion of health, and a range of public health practices have developed. In maternity care, public health practice has moved from simply providing information (education) to facilitating informed decision-making (empowerment), to partnership working with women and families to develop community initiatives together (e.g. breastfeeding support groups).

Over the last 25 years, successive UK government policies on maternity care, such as Changing Childbirth (Department of Health (DH), 1993), Making a Difference (DH, 1999), A Framework for Maternity Services in Scotland (Scottish Executive 2001), National Service Frameworks for Children, Young People and Maternity Services (DH, 2004), Maternity Matters: Choice, Access and Continuity of Care in a Safe Service (DH, 2007) have all called for the development of the midwife's role in health promotion. The Midwifery 2020: Delivering Expectations report (Chief Nursing Officers (CNO) of England, Northern Ireland, Scotland and Wales, 2010) again emphasises that future midwives must have a greater focus on public health and should become actively involved in developing services that work towards minimising health inequalities.

Similarly, the Marmot Review (2010) stresses that tackling heath inequalities is a key challenge for health professionals and recommends that focusing efforts at timely points along the health continuum may achieve maximum gain. For example, the provision of effective antenatal care for a disadvantaged woman not only improves her health but significantly improves the health and life chances of her child across their whole life course (The Scottish Government, 2010).

Considerable evidence from high-income countries indicates that poor perinatal outcomes are associated with low socioeconomic backgrounds. For example, Vos et al (2014) conclude that living in a deprived neighbourhood is associated with preterm birth, being small-for-gestational-age and stillbirth. While this association is recognised, it must also be acknowledged that the women most at risk of poor outcomes are often the least likely and least able to access antenatal care (Kapaya et al, 2015; Phillimore, 2016). Improving access to antenatal care and ensuring that this provision is strongly focused on health promotion must be seen as a vital contribution to the wider public health strategy (Public Health England (PHE), 2014). Furthermore, in an era of austerity and service reform, the fact that this approach can lead to significant financial savings cannot be ignored. For example, the Scottish strategy to reduce poor health outcomes recognises that promotion of healthier pregnancies and management of comorbidities leading to premature births will reduce demand on neonatal and paediatric services in the short-term and a wider range of public services in the long-term (The Scottish Government, 2010).

The role of the midwife

The Midwifery 2020: Delivering Expectations report (CNO, 2010), describing the changing picture of UK maternity services, highlights that midwives are caring for growing numbers of women with complex health needs such as older mothers, obese women and those with significant mental health conditions. There are also increasing numbers of pregnant women with limited English and significant social disadvantage (Knight et al, 2016). Similarly Sanders et al (2016), when exploring midwives' public health role, confirmed the complexity and breadth of health challenges that they encounter. It is clear that in today's society, the woman's social context and its consequences should be considered as carefully as her medical and obstetric risk.

Public Health England (PHE, 2014) has clearly articulated how the midwife's role may enhance health and wellbeing for individuals, communities, and wider populations. Firstly, midwives are to directly affect perinatal mortality by following strategies such as reducing smoking rates, lowering the incidence of infection, and improving antenatal surveillance. To achieve these goals, they are encouraged to ‘make every contact count’—a key concept in the strategy to ‘help people to stay independent, maximise wellbeing and improve health outcomes’ (DH, 2013). The recent review of UK maternity services has been responsible for strengthening the midwives' public health role in key areas such as poor maternal mental health (National Maternity Review, 2016).

These expectations are laudable as midwives clearly have the potential to improve the health and quality of life for mothers and their babies in both the short and long-term, and so influence overall population health. However treating health promotion as a ‘bolt-on’ extra to existing maternity provision may simply foster the development of additional services (Jones et al, 2002). Wwhat in fact is needed is a wholesale transformation of midwifery services that promotes models of working that embed midwifery into the wider social framework of health and wellbeing. For example, midwives working within a social model of care based in community settings such as Children's Centres are much more able to discuss health issues, facilitate interventions and help parents access services that address wider aspects of health, such as young parent outreach, economic, education and employment support, and safeguarding services (Stringer and Butterfield, 2005). However, to achieve the wide-ranging outcomes of the public health agenda, the midwifery workforce needs relevant knowledge and appropriate skills, including the ability and willingness to engaging in multidisciplinary working (DH, 2013).

As public health activity often has a long-term outlook, the outcomes may not be observed for years or even decades into the future, so the benefits of public health practice are often not immediately obvious. Evaluation of such services and research into satisfaction, feasibility, and outcomes is essential to improve the evidence base and inform education and service development.

Incorporating public health activity in midwifery practice is not new. Audrey Wood (1957), then general secretary of the Royal College of Midwives (RCM), persuasively argued that the midwife should be engaged in activities supporting the future health of populations, especially health education and working with multidisciplinary teams. Definitions of the midwife have consistently cited health education and counselling as integral to this role (Central Midwives Board, 1978; NMC, 2009). More recent definitions have encompassed a partnership role with women and families, the promotion of wellbeing (Chief Nursing Officers of England et al, 2010; ICM, 2013), and consideration of health across the life-span (DH 2013; Walsh, 2013). In midwifery practice today, these activities include smoking cessation, screening tests, nutrition advice, and support regarding the management of raised body mass index. Midwives undertake surveillance to identify those women affected by mental ill-health and domestic abuse, and specialist midwives focus on groups with particularly complex needs, such as asylum seekers, and those affected by HIV. Furthermore, public health practice is now multidisciplinary and includes other health professionals, local authority services, social scientists, the voluntary lay sector and public and private organisations working together (West-Burnham, 2017). The RCM, recognising the need to support existing midwives with this expanding aspect of their work, have devised a public health model for practice and a range of online resources (RCM, 2016).

Public health in midwifery education

Public health learning in midwifery education was limited until the 1990s, when the Acheson Report (DH, 1998) gave a high priority to reducing inequalities for childbearing women and young children, providing a mandate to embed public health and health promotion within the role of the midwife. In addition, the Labour government put these issues firmly on the agenda with their Making A Difference policy (DH, 1999). However, the literature on public health education in midwifery programmes remains sparse (McNeill et al, 2012). In 1995, public health education in midwifery programmes was based on a medical model using ‘information giving’ strategies to tell people what they needed to do, thus reflecting a top-down approach to health promotion (Smith et al, 1995). The main topics considered to be part of the midwife's remit included smoking, sexually transmitted infections, domestic abuse, parent education, and breastfeeding (Smith et al, 1995). Placements for student midwives were also medically or obstetrically focused with little opportunity to learn about the wider social aspects of health (Smith et al, 1995). McNeill et al (2012) explored the incorporation of public health and health inequalities education in midwifery education programmes across the UK and found this to be very variable. Indeed, three institutions reported that they did not cover the principles of public health; five did not teach any epidemiology, and the topics of homelessness, obesity, diet, and alcohol were only covered in a limited manner (McNeill et al, 2012). McKay (2008) and McNeill et al, (2012) both concluded that student midwives had limited understanding of the midwives' role in health promotion, and lacked awareness of the practical application of public health. In contrast, a small study recently reported that students felt well-prepared for their public health role (Sanders et al, 2016). Sanders et al (2016) noted that student midwives included discussions between midwives and women about flu and whooping cough vaccinations, and intrapartum strategies such as optimal timing of newborn cord clamping after the birth as part of midwives' public health role.

Studies with midwives have revealed variable attitudes and approaches towards their public health role—some considered it to be irrelevant, while others believed it to be very important (Lavender et al, 2001). Furber (2000) found that while midwives stated that they preferred approaches focusing on populations, they were more likely to use individual ‘information giving’ approaches to promoting health. Other evidence indicates that midwives are reticent in addressing some public health topics. For example, Lazenblatt et al (2010) surveyed hospital and community midwives throughout Northern Ireland and although most respondents (92%, n=448) reported that they felt midwives had a role in supporting women who were victims of domestic abuse, only 28% (n=135) had asked women about this. Taylor et al (2013) confirmed that health professionals, including midwives, lacked confidence in discussing domestic abuse with women. Other studies indicate that midwives are hesitant about broaching the subject of smoking because of concern over jeopardising the midwife-woman relationship (Condliffe et al 2005), or beliefs that smoking cessation is not a high priority for women (Hill et al, 2013). More recently, almost a quarter of third-year midwifery students across the UK reported that they do not feel confident in recognising mental illness and emotional wellness (RCM, 2014). This is concerning as psychiatric illness has consistently been reported as a predominant cause of maternal death in the UK over recent years, and inadequate multidisciplinary working is a known contributory factor (Knight et al, 2015). Emerging evidence also stresses the potential impact of poor maternal mental health during the first 1 000 days of a child's life, on mother–child relationships, early development, and on the child's future health and wellbeing (Leadsom et al, 2013; Kingston and Tough, 2014). So again, the potential deficit in midwifery skills for recognising those at risk and supporting mothers with mental health challenges is worrying.

To enable midwives to fulfil the public health duties associated with their role, the development of the following knowledge and skills within pre-registration programmes needs to be strengthened by the implemention of:

Recommendations for integrating public health in pre-registration midwifery education programmes

Whitehead (2007) proposed that public health education should be an obvious theme cutting through curricula. The spiral curriculum model (Neary, 2002), incorporating iterative processes, will facilitate this. Using this model, learning starts at a descriptive level early in the programme, and is revisited several times later in the course at a deeper and more analytical level when topics are reviewed and applied to more complex situations (Harden and Stamper, 1999). The spiral model fosters synthesis as students build on previous knowledge when they have greater expertise through practical experience and intellectual maturation (Harden and Stamper, 1999; Neary, 2002). Furthermore, evaluations of spiral curricula indicate that this model makes learning more manageable for students as it facilitates topic familiarity (Grove et al, 2008). Using the example of breastfeeding education early in a 3–year programme, students learn about the physiology of lactation, simple care practices that support breastfeeding and how the psychosocial context affects mothers' feeding choices and practices. Later in the programme, they explore the challenges mothers can experience, and review breastfeeding support needs in more complex scenarios. Finally, using public health principles and concepts within contemporary health policy, they develop their skills for breastfeeding promotion through strategies that support mothers at individual, community and national levels, for example, honing their skills for one-to-one mother-centred discussions about feeding, developing innovations such as establishing local breastfeeding support initiatives and using evidence to lobby for policy change.

Exposure to public health/health promotion knowledge and practice

Education by knowledgeable teachers and public health specialists (Whitehead, 2007) who can accurately link the discussion topic to health inequalities is vital for students to really engage with this material (Mabhala, 2013). For example, a session about mental health disorders should include discussion of how mental health challenges affect women and their children both in the short term and in their future life. This could be followed up with a consideration of the skills midwives need to identify and support at–risk women and examples of relevant local public health initiatives and services developed or used by midwives. The application of theory to practice is an important part of learning and understanding for health professionals (McKay, 1998), so teaching methods should facilitate this, enabling students to meld public health knowledge into their core midwifery understanding (Mabhala, 2013).

Jones et al (2002) argue that if one is to successfully integrate health promotion into care one must move away from the narrow focus on lifestyle and offering ‘heavy-handed advice’, which marginalises the socioeconomic and environmental influences on health. Instead, the universities should be equipping students with the skills to empower women and support them to make small but significant changes to their circumstances and behaviour. Important skills include being able to create an environment where information is a transaction between client and professional and being an effective advocate, representing the interests of women and their families when they cannot speak for themselves because of illness, disability, or disadvantage (Scriven, 2010).

Incorporating the concept of salutogenesis into midwives' public health education is one method that may be utilised to enhance wellbeing (Lindstrom and Eriksson, 2005). Salutogenesis focuses on wellbeing and an individual's capacity to solve problems and develop a ‘sense of coherence’ (Antonovsky, 1979). The utilisation of these principles may support the development of strategies and interventions that may promote health and wellbeing for childbearing women (Ferguson et al, 2013).

Furthermore, in order to assess needs and develop new public health interventions relevant to that population, students require opportunities to gain skills in data collection and analysis (Naidoo and Wills, 2009).

Pedagog

While lectures and reading are important pedagogical methods, in order to develop higher levels of understanding and critical thinking, interactive teaching methods (face-to-face or online) including discussion and debate with peers are important to enable students to engage, consider other viewpoints, and challenge attitudes (Crookes et al, 2013). Case scenario discussion and problem-based learning are particularly useful for critical review of collaborative working and thinking laterally (Mabhala, 2013). Online case study discussions may also promote in-depth learning (Sheringham et al, 2015). The ‘unfolding case study’, using a scenario that progresses through the pregnancy, birth, and postnatal time period, enables discussion, reflection and decision-making on care and management to be reviewed as situations change (Carr, 2015). Workshops, role-play (online and face to face), and video review for practising communication skills will support developing confidence in this area (Berkhof et al, 2011; Warland and Smith, 2012). Furthermore, engaging in learning activities with students from other disciplines that midwives may work with, such as mental health nurses, pharmacists, doctors, and social workers, will develop awareness of professional roles, build confidence, and strengthen future multidisciplinary working (Kilminster et al, 2004).

Clinical Placements

Exposure to clinical placements where public health practice can be observed is vital (Whitehead, 2007). Examples include opportunities for students to spend time in children's centres to familiarise themselves with the range of facilities for families. ‘Bespoke placements’ with specialist midwives focusing on safeguarding, mental health, teenage pregnancy support, and sexual health will provide greater understanding of the specialist's role, expertise, and help clarify the students understanding of their role as midwives (McNeill et al, 2012). Shadowing other professionals such as dieticians, social workers, family support workers, and welfare right officers, and visits to charities such as MIND and those supporting ethnic groups or refugees will enable students to broaden their understanding in supporting women and families with complex needs. Finally, exposure to clinical audit processes will improve skills in health needs assessment and service evaluation (Naidoo and Wills, 2009).

Conclusion

Midwives have a key health–promoting function. Developing teaching about the public health role of the midwife within the undergraduate curriculum will enhance the knowledge, skills and motivation of newly qualified midwives and so contribute to improving maternal and infant health outcomes and the reduction of health inequalities.

Key Points