Pregnancy can cause women to change their patterns of alcohol and substance use (Stone, 2015; Forray, 2016) and it is likely that the advice and support of midwives will have an impact on women's understanding in avoiding risk (Fleisher, 2011; Schölin et al, 2019). This advice should be up-to-date, consistent, factual and non-judgemental to encourage women who are misusing substances to successfully engage with maternity services (Radcliffe, 2011). Midwives in the UK have reported wanting more support and education on the impact of teratogens on fetal development (Winstone and Verity, 2015) and Schölin et al (2019) reported that 69% of midwives in the UK received fewer than 4 hours of alcohol training pre-qualification, 19% had received no training and only two-thirds of midwives provided information about the effects of alcohol consumption in pregnancy to pregnant women. A similar picture emerges for illicit drug use during pregnancy (Magdula et al, 2011; Mora-Ríos et al, 2017).
First year undergraduate midwifery students are likely to have little experience, knowledge, confidence and skills in caring for pregnant women, including those who may misuse substances such as drugs and alcohol. Midwifery students may also have preconceived stigmas about pregnant women who misuse substances that need addressing (Geraghty et al, 2018; Doleman et al, 2019). In addition, research has indicated that pregnant women who misuse substances find engaging with antenatal services difficult as they fear negativity and hostile interactions from healthcare professionals, including midwives (Kerker et al, 2004). The negative attitude of staff towards pregnant women who misuse substances has been reported as having a more significant impact on them than the medical care they receive (Hall and van Teijlingen, 2006). These studies highlight the importance of midwives providing judgement-free evidence-based advice on substance misuse during pregnancy and the need to consolidate knowledge on its impact during pregnancy in undergraduate midwifery education (Schölin et al, 2019). It is important to manage and support women who are misusing substances by developing ongoing respectful partnerships (Miles et al, 2013; Schölin et al, 2019).
Researchers have recommended that undergraduate midwifery curricula should address midwifery students' knowledge, in recognition of the real-world impacts on both mother and baby from substance misuse during pregnancy. The aim of this is to improve the quality of antenatal advice and support, which will lead to better prevention, intervention and recognition of the signs and symptoms of fetal alcohol syndrome and drug misuse (Winstone and Verity, 2015; Howlett et al, 2019; Schölin et al, 2019). The literature highlights a gap in midwifery knowledge, including in understanding the impact of teratogens on fetal development as well as on the newborn baby exposed to substance misuse during pregnancy. This gap could be addressed at the undergraduate level.
Within the undergraduate midwifery curricula various teaching strategies including simulation are used to enable students to gain the relevant knowledge and skills around safe, woman-centred care (Durham and Alden, 2012). Simulation-based education as a learning strategy is well established (Vermeulen et al, 2016) and is seen as a vital pedagogical resource within midwifery education (Chitongo and Suthers, 2019). Students value the opportunity to use simulators in acquiring knowledge and confidence, increasing self-efficacy, developing critical thinking skills and proficiency within a safe environment prior to entering into practice, as a means to improve maternity care (Cant and Cooper, 2016; Doolen et al, 2016; Yuill, 2017; Chitongo and Suthers, 2019). Using simulation during education is an approach based on experiential learning theories such as Kolb (1984) and Bloom's (1956) Taxonomy. Students gain concrete experience from interacting with the simulator rather than simply listening or reading about a topic. Students can then reflect upon their observations and experiences with the simulator, as well as actively experiment with simulated practice (Zigmont et al, 2011). As a result, students become immersed in a constructionist pedagogy relating theory to practice and consideration of future actions (Kolb, 1984).
Simulation-based education cannot replace ‘real-life hands-on’ clinical practice but can ‘bridge the gaps’ between simulation and life practice (Lendahls and Oscarsson, 2017). Simulation can help improve knowledge and clinical performance, for example around obstetric emergencies (Gundry et al, 2010; Yuill, 2017). In this situation, it enables students to be immersed in a semi-realistic safe, classroom-based facilitated environment where they can assimilate clinical knowledge and gain skills mastery through kinaesthetic awareness and reflexive observation (Dow, 2012; Chitongo and Suthers, 2019). Through carefully planned, structured and constructive simulator sessions, students can learn from practising scenarios within a positive pedagogical dialogue with the lecturers (Brady et al, 2015; Council of Deans of Health, 2017). More importantly, reflective debriefing sessions post-simulation experience enables students to embrace the use of simulators as new technology and question how they relate to practice (Dreifuerst, 2012).
There are different typologies of simulators, ranging from static or low fidelity simulators to medium fidelity simulators to fully interactive high-fidelity simulators (Meller, 1997). Low fidelity simulators are not interactive and are non-computerised mannequins or body parts, such as a task trainer to help student midwives undertake vaginal examinations (Brady et al, 2015) or using a birthing simulator (MamaNatalie®) to train students about the third stage of labour (Joho et al, 2021). Medium fidelity simulators facilitate greater student interaction and demonstrate more physiological characteristics (such as heartbeat and breathing sounds) but, according to research, are not as realistic as high fidelity simulators (Rudd et al, 2010; Brady et al, 2015; Fatane, 2015). Medium fidelity simulator examples include the lower torso of a pregnant woman to facilitate learning around breech birth (Brady et al, 2015) and the postpartum haemorrhage simulator (Ntlokonkulu et al, 2018). Finally, the most realistic high-fidelity simulators are fully interactive, such as a full body birthing simulator that mimics a woman during labour and birth (Cooper et al, 2012).
This article considers the question: does the use of low and medium fidelity drug and alcohol neonate simulators enhance undergraduate midwifery student's knowledge about the impact of teratogens on pregnancies? The overall objective of the study was to explore the use of drug and alcohol neonate simulators as a pedagogical tool to enhance knowledge of the impact of teratogens during pregnancy and the early postnatal period. The aims were to ascertain whether students could recognise the physical impact of teratogens on the neonate while interacting with the simulators and to explore whether midwifery students understood their role as future midwives when working with pregnant women who may be misusing substances.
Methods
Study design and setting
This study used two neonatal simulators (Figure 1). The low-fidelity (non-interactive) fetal alcohol syndrome simulator illustrates the effects of gestational alcohol consumption on the neonate including the physical facial phenotype malformations (thin upper lip, smooth philtrum and small palpebral fissures) (Figure 2). The medium-fidelity (interactive) drug affected simulator demonstrates a painful facial expression, smaller size for gestational age and emits cries and tremors of a baby experiencing neonatal abstinence syndrome and withdrawal symptoms from an on off switch located on the simulator's back (Figure 1).
Figure 1. Left: static low fidelity fetal alcohol syndrome simulator. Middle: medium fidelity drug affected simulator. Right: reverse view of the medium fidelity drug affected simulator on–off switch 
Figure 2. Guide for the three diagnostic facial features of fetal alcohol syndrome
Sampling and recruitment
A total of 50 midwifery students from a university in the southwest of England were recruited. The students were a third of the way through their first year of an undergraduate midwifery programme and were being taught the topic ‘protecting the unborn environment’, which focused on teratogens and the impact to fetal development. Recruitment was based on students who were willing to partake in the taught session activities and share their experiences.
Design
A powerpoint presentation outlining the effects of teratogens on the developing fetus and newborn baby was provided to facilitate knowledge. At intervals during the session, students were encouraged to interact with the fetal alcohol simulator and drug affected simulator individually and within small groups.
Data collection
During the taught sessions when students interacted with the drug and alcohol simulators, they were asked questions relating to the physical attributes of each simulator including observation and listening. Students then answered questions as a group on worksheets, which were collected by the first author at the end of the session. The questions for the students are shown in Box 1.
Further data collection consisted of a ‘thought shower’ where students were asked to explore how the simulators could be used to teach others in a beneficial and effective way and how they might educate pregnant women on the teratogenic effects of alcohol and drugs through using the simulators. These data were collected on post-it notes. The final activity involved the use of a padlet, where students logged onto a website and responded to questions through that forum (Box 2).
Data analysis
The 6-stage framework offered by Braun and Clarke (2013) was used to thematically analyse the feedback obtained from the group activities, the individual post-it notes and the Padlet responses. Both researchers initially and separately familiarised themselves with the data from the sources described above (stage 1). Preliminary codes were independently analysed by both researchers including searching for patterns or recurring themes within the data (stage 2). The authors met to discuss the preliminary findings and to explore the emergence of the initial codes. The codes were organised into themes by examining in-depth, patterns, differences, and similarities within the data (stage 3). Relevant verbatim quotes were sorted and linked to each of the identified themes so there were identifiable distinctions between the themes, which were then reduced (stage 4) and given appropriate names (stage 5) (Braun and Clarke, 2013).
Ethical considerations
Ethical approval was obtained from the University Research Ethics Committee (number: 22036). An email with a participant information leaflet and a participation agreement form was sent out to all students. At the start of the session, both verbal and written consent was obtained. Students were reminded that they could withdraw at any point and non-participation would not impact on their studies. In addition, if the students found the content distressing there were services based at the university they could be directed to if need be. No student was identifiable from the feedback obtained from the group activities, the thought shower or the Padlet.
Box 1.Questions for students post-interaction with simulatorsFetal alcohol simulator student questions
- What do you notice about the physical features that are different from the features of a typical baby?
- What are the non-visible effects of antenatal exposure?
- What would life be like for a child with these physical abnormalities and the for parents/guardians of a child with fetal alcohol syndrome?
Drug affected simulator student questions
- What do you notice about the physical features? Are they different from the features of a typical baby?
- What are the physical effects of antenatal exposure to drugs on the newborn baby?
- How is the cry different from the cry of a healthy infant?
- What would life be like to care for an infant showing the effects of antenatal drug exposure?
Box 2.Padlet questions
- What additional knowledge have you gained from interacting with the simulators that you might have missed from the lecture provided?
- How did interaction with the simulators enhance your understanding of the teratogenic effects on the fetus?
- What advice would you give a pregnant woman who is taking drugs?
- How did you see your role as a student midwife if a baby displays features/symptoms of fetal alcohol syndrome or drug affected syndrome?
Results
The findings were categorised into three main themes: kinaesthetic learning, ‘in their shoes’ and the midwifery role in educating others. The final theme had three sub-themes: visual aid to enhance knowledge, specialised services and practical suggestions.
Kinaesthetic learning
Many of the students indicated that they valued interacting with both neonatal simulators, and the simulators appeared to enhance their knowledge.
‘To see the physical effects boosted my understanding of the effects as I am a visual learner and was then able to discuss with my peers’
Group activity response
‘I felt the doll interactions shocked me yet has added depth to the information I give to women’
Padlet response
Students found that interacting with the static fetal alcohol syndrome simulator was visually impactful:
‘Visually seeing the effects on a baby helps to realise the real damage teratogens can have and the sad reality’
Padlet response
Students appeared to easily identify the features of the simulator affected by fetal alcohol syndrome, which include thin upper lip/protruding lips/mouth, prominent forehead/flat nose, lack of philtrum, small and skinny.
Switching the drug affected simulator button enabled students to hear the shrill cry and feel the tremors.
‘Hearing the doll crying had an impact on learning and made me think more about the importance of educating women’
Group activity response
‘In their shoes’
Students appeared to assimilate how teratogens would impact the child in the long term, such as when going to school and on the family. The impacts they identified included bullying at school, continuous medical care, challenging behaviour and learning difficulties, long-term non-visible effects (for example behavioural difficulties when older) and guilt.
Students were also aware of their role and responsibilities when considering the impact that teratogens may have on the woman herself and the fetus:
‘Be sensitive, do not judge them or make them feel bad’
Padlet response
‘Deliver info so it doesn't sound like a telling off, to support women emotionally and practically with my knowledge’
Padlet response
‘To be aware of the signs and symptoms to be able to identify a baby suffering withdrawal, perhaps for a mother who hasn't disclosed substance abuse’
Padlet response
‘Support for parents as damage has been done and psychological effect on them would be harsh’
Padlet response
Midwifery role in educating others
This theme encompasses several sub themes related to using the simulators to educate a wider audience around the impact of substance misuse during pregnancy.
Visual aid to enhance knowledge
Many students said that knowledge around teratogens' impact on the fetus needed to be known before pregnancy.
‘When women are pregnant, it's too late. Give talks in schools/colleges’
Padlet response
‘Women aren't fully aware of teratogenic effects. Need to educate every woman as mandatory education starting from school particularly as [fetal alcohol syndrome, neonatal abstinence syndrome] effects aren't always visible’
Padlet response
‘Set up youth groups where all teenagers attend including vulnerable ones who already drink/take drugs/smoke’
Padlet response
In addition to providing education to young children and teenagers, students also felt that the simulators could be used to educate women at pregnancy booking visits.
‘Use [fetal alcohol syndrome/neonatal abstinence syndrome] dolls in maternity classes and provide verbal information at booking’
Padlet response
‘Dolls could be very useful at booking appointment time, especially if the woman discloses drug/alcohol addiction and wants to know effects on her baby’
Padlet response
‘Talk to women with visual aids/video showing on screens in waiting rooms’
Padlet response
‘At booking appointment discuss with them the effects of drugs and alcohol and provide them with relevant leaflets and information so they are aware no alcohol’
Padlet response
One student stated that they could be used to alert pregnant women to reduce their substance misuse.
‘Use shock tactics with women who think a small amount of alcohol is ok during pregnancy. Seeing the effects of that on the doll’
Padlet response
Specialised services
Student responses also suggested that specific antenatal classes could be offered for women who identified at the booking visit as having problems with substance misuse and the simulators could be shown to add context.
‘Make it mandatory to ask this at booking appointment recorded on notes with advice to attend classes’
Padlet response
‘Practical antenatal classes, where women can measure out 1 unit of alcohol between different beverages to compare/teach them about teratogens effecting fetus’
Padlet response
‘Run parentcraft sessions for pregnant women who drink/take drugs and set up classes after booking rather than post 20 weeks’
Padlet response
Practical advice
The students were able to state what recommendations they might offer to women following interaction with both simulators.
‘Explaining what the effects are and at each stage, backing up with long-term and short-term effects to the baby’
Padlet response
‘That there is help available and to go for it to give your baby the best start in life’
Padlet response
‘To advise her of all the different outcomes that could happen if she continues to take drugs. She may be more inclined to stop if she was aware of the damage’
Padlet response
Discussion
Literature exploring the use of neonatal simulators within the undergraduate midwifery curriculum is limited and typically confined to neonatal resuscitation (Cooper et al, 2012). This study reports on the use of low-fidelity fetal alcohol simulators illustrating the effects of alcohol consumption and medium-fidelity interactive drug affected simulators demonstrating the effects of neonate abstinence syndrome on the neonate. Research by Schölin et al (2019) revealed that midwives in the UK have identified a lack of knowledge within the undergraduate midwifery programme in relation to the impacts of substance misuse. Similar findings were reported by Winstone and Verity (2015).
Overall, the results indicated that the use of the simulators was a useful pedagogic tool in engaging students, facilitating knowledge around the teratogenic effects of substance misuse during pregnancy and in the postnatal period and of their role as future midwives in educating others. The simulators appeared to be effective in improving understanding from a single interaction as the students engaged better during the taught session. This may be because of the kinaesthetic effects of being able to hold, touch, feel and listen to the simulator, particularly the medium fidelity simulator, which could be turned on via a switch on its back. In addition, the fetal alcohol syndrome simulator showed the physical impact of the effects of alcohol on the neonate (dysmorphic facial features, and a smaller and skinnier stature) which students easily recognised. They were able to appreciate the immediate and possible long-term impacts of gestational alcohol exposure.
This study's findings may help to bridge the known ‘theory-practice’ gap (Power and Cole, 2017), as neonatal simulators can be used to prepare students to confront situations that they may only face when qualified (Yuill, 2017). Pregnancy being a ‘teachable moment’ or ‘golden period’ in women's lives (Royal College of Midwives [RCM], 2017) provides an opportunity for midwives to explore issues around drug and alcohol use. However, it might be a difficult subject for students to broach. Therefore, the use of neonatal simulators could be utilised in the form of roleplay at undergraduate level, which would help students to practice and enhance their communication skills with potentially difficult public health messages (McNeill et al, 2012). The use of neonatal simulators at the undergraduate level does enable students to engage with realistic public health situations, but further research around this approach is required (RCM, 2017).
A further finding from the study was that although many students were able to put themselves into the shoes of these women and empathise with their situation, one student felt that the simulators could be used during antenatal classes as a visual aid to ‘shock pregnant women’ into understanding the impact of teratogens during pregnancy. This ‘tactic’ suggests that simply explaining the impact of substance misuse would not be as effective as using the simulators to reinforce the visual and physical impact of drugs and alcohol on the neonate. According to Schölin et al (2019), the more experienced qualified midwives become, the more the notion of using shock tactics is overridden by building more trusting relationships as a way to tackle these issues. Therefore, first year student midwives are still in the early stages of learning how to communicate with pregnant women who misuse substances in a person-centred manner within a humanised framework of care (Way and Scammel, 2016). Midwife–woman relationships are important when having to communicate public health messages (McLellan et al, 2019).
A study undertaken by Winstone and Verity (2015) highlighted that just 20% of midwives provide information about antenatal alcohol use if there was a known risk factor, which indicates that there is unwillingness by midwives to discuss alcohol. Kelly et al (2014) identified that when students can anticipate what happens in the workplace, this can lead to contextual experiential learning where students are able to recall simulation experiences. This in turn enables students to use their knowledge when providing antenatal care. In this study, student midwives could think reflectively about their role in the future to help educate pregnant women earlier. They recognised that prevention is key, although many also reported that if features of fetal alcohol syndrome or neonatal abstinence syndrome were present then the damage had already been done and all they could do is to be supportive and compassionate.
Research by the RCM (2017) demonstrated that in order to address important public health messages, such as avoidance of using drugs and alcohol during pregnancy, midwives need to be confident in their knowledge. Their research highlighted a need for further training and greater understanding around certain teratogens, such as alcohol and drugs. Students learn theoretical knowledge during the undergraduate programme around public health and protecting the fetus; however, this knowledge is likely to fade over time (James et al, 2019) unless learning is consolidated with experiential understanding gained from direct experience with drug and alcohol issues during pregnancy. To address this gap, neonate simulators can be used to maintain ongoing knowledge post-qualification through mandatory update training sessions. However, this needs further research as this area is not considered in the mandatory training provided to midwives by maternity services within NHS hospitals (RCM, 2017).
Limitations
Despite the positive impact of the neonate simulators as creative pedagogy, there were several limitations to the study. First, only one cohort of student midwives participated in this research meaning the findings are not generalisable but may be useful to other higher education institutions who are considering the use of neonatal simulators within their undergraduate programme (Carminati, 2018). Second, the taught session was only 90 minutes in length and more time would have been beneficial to enable an in-depth exploration of the issues being covered. However, a large amount of rich data was evident during the analysis.
Nevertheless, this study's findings support previous research on simulation-based education in terms of improving knowledge, enhancing confidence and developing clinical skills (Dow, 2012; Deegan and Terry, 2013; Kelly et al, 2014; Lendahls and Oscarsson, 2017). This reflects the view of the Department of Health (2011), which has stated that simulation-based learning should be used to increase students' learning to benefit and improve patient care. Additionally, the present study's findings support the use of question-and-answer debriefing sessions post-simulation interaction (Guhde, 2011; Chitongo and Suthers, 2019) to enhance positive pedagogical dialogue between students and lecturers around the issue of substance use during pregnancy.
Conclusions
The immediate impact from interacting with the fetal alcohol syndrome and neonatal abstinence syndrome simulators was evident, as the midwifery students showed increased awareness of the influence of drugs and alcohol on the newborn during the teaching session. Students had a stronger appreciation of their roles as future midwives in educating pregnant women about the impact of substance misuse during pregnancy. The authors suggest that the use of the simulators could be a useful integrative educational strategy that other higher education institutions could incorporate within their undergraduate curricula for health sciences students.
Key points
- Neonate simulators are useful pedagogical tools for the undergraduate midwifery curriculum.
- Simulators can bridge the gap between theory and practice.
- Students were able to show empathy towards women with babies' showing fetal alcohol syndrome disorders and neonate abstinence syndrome.
- There is a need for ongoing education for post-qualified midwives on the impact of drug and alcohol use during pregnancy.
CPD reflective questions
- How will qualified midwives keep their knowledge up to date on these issues affecting pregnant women that use drugs and alcohol during pregnancy?
- How should neonate simulators be used as part of mandatory training for post-qualified midwives?
- How can neonate simulators be incorporated as standard in the UG midwifery curriculum?