Medical students' experiences working with midwives on NHS labour wards: a qualitative study

Investigations into avoidable adverse events in intrapartum care have repeatedly found multidisciplinary teams fail to understand and appreciate each others' role (Kirkup, 2015; Royal College of Obstetricians and Gynaecologists (RCOG), 2017; Knight et al, 2019). Collaboration between midwives and obstetricians is central to current efforts to provide families with an experience of childbirth that is both safer and more personalised (NHS, 2020). Among the current generation of medical students are tomorrow's obstetricians. Their introduction to maternity multidisciplinary team culture is likely to influence how they collaborate – or not – in future (Zwarenstein et al, 2009; Downe et al, 2010). Therefore, it is important to consider how medical students perceive midwives after placements on NHS labour wards.

The RCOG (2009) undergraduate curriculum states, ‘witnessing the birth of a baby gives students exposure to a unique event, where they will learn the importance of patient-focused care, including communication skills, dealing with pain, team working and the importance of patient choice’.

Research suggests midwives have great potential to teach medical students (Radoff et al, 2015; Cotter et al, 2016). However, barriers to learning may include competition with student midwives, bias against males, unclear learning goals, and a ‘them and us’ culture (Quinlivan et al, 2003; Lempp and Seale, 2004; Anderson et al, 2017; Bhoopatkar et al, 2017; Cheng et al, 2018; Rahimi et al, 2019). Much evidence to date comes from surveys or studies with broader questions, hence it lacks detail on personal experiences. However, the literature consistently gives a sense of interprofessional friction, which may be a legacy of patriarchal medical dominance over the management of childbirth (Donnison, 1977; Reiger and Lane, 2009; Hastie and Fahy, 2011; Renfrew et al, 2014).

It is now more than a decade since RCOG and the Royal College of Midwives (RCM, 2008) identified a need to foster a stronger rapport between midwives and medical students. Yet there is no recent evidence from labour wards on this important aspect of multidisciplinary team dynamics. This study is the first of its kind to focus on how medical students feel about such placements with midwives in the NHS.

The primary aim of this study was to explore medical students' memories of working with midwives during intrapartum care. Secondary research questions also considered contextual factors that might affect such students' experiences, including facilitators of and barriers to meeting learning goals. Additional points of interest included how medical students' interactions with midwives might influence their own interprofessional conduct, their respect for midwives as practitioners and their perceptions of childbirth.

Methods

The study took an epistemological position of ‘critical realism’, which sees reality as being uniform but also mediated by perceptions and beliefs (Barnett-Page and Thomas, 2009). The data collection and transcription process was designed to create a body of text data that could be processed using framework thematic analysis (Ritchie and Spencer, 1994).

Sampling and recruitment

Medical students who had worked with midwives during intrapartum care in hospitals across England were recruited for this study. Participants were recruited via online adverts sent to university medical societies and contacts. A total of 10 participants were recruited, as the project prioritised quality (in-depth discussion and analysis) over quantity, because the researchers had limited time (Ritchie and Spencer, 1994).

The inclusion criteria were that participants had to be a current NHS medical student or junior doctor whose medical education occurred in the NHS in England, with clinical experiences with midwives or be seeking to work with midwives, and they had to have experiences of training during or after 2010. Doctors whose training involved extensive periods outside the UK or whose experiences of training took place before 2010 were excluded. These criteria were selected to ensure the focus of the study was on work with midwives in English hospitals that incorporate experiences of interprofessional culture and NHS dynamics in recent years.

Data collection

In-depth, semi-structured interviews were conducted by telephone or videocall in 2016. Conversations lasted 40–70 minutes. Response bias was minimised through neutral questioning, with open probes to allow participants to direct the discussion according to their own experience (Table 1) (Byrne, 2012). The interviews were recorded and transcribed by the first author. The authors are both midwives by training. They reflected on the ways their professional standpoint might bias the questioning and analysis process, to mitigate this.

Data analysis

Background literature generated a priori codes to create an initial framework from which new themes could emerge from what participants said (Ritchie and Spencer, 1994).

The background literature (Box 1) was found using a MEDLINE database search for terms (including synonyms) relating to midwives, medical students and intrapartum care. As a result of the paucity of literature available, articles were included if they involved related dynamics, for instance the experience of junior doctors and midwives, or medical students and nurses. The net was widened via a google scholar search and article reference lists were combed for additional evidence. Topics from these texts were collated to generate codes.

Box 1.Background literature for data analysis

Each transcript was examined alongside a priori codes. Any excerpt that illustrated a code was tabulated in a spreadsheet (with a column for each code and a row for each participant). Data that did not fit the a priori codes were either accorded new codes, or the existing codes were relabelled to incorporate additional meanings. Some columns became combinations of codes. The framework was continually adapted to reflect the nuances of what participants said.

All themes were recorded on a large A2 side of paper so they could be visualised together and links be drawn, thus creating an overall sense of what the medical students had said (Ziebland and McPherson, 2006). The authors' interpretation was then sent to each participant to check it reflected their experience (Lincoln and Guba, 1985). The full data analysis process is outlined in Table 2.

Ethical considerations

The study was approved by the London School of Hygiene and Tropical Medicine MSc Research Ethics Committee (approval number: 10737). Recruitment was kept away from the authors' workplaces to preserve anonymity of the medical students, and thus the NHS staff and clients they describe. A £10 shopping voucher was offered as thanks for participants' time.

NHS approval was not required as there was no contact with/research into patients themselves. The London School of Hygiene and Tropical Medicine deemed the university committee sufficient.

Results

Participants

The 10 participants came from a range of demographic backgrounds with equal numbers of male and female participants (Table 3). They had all been at different universities and hospitals across England.

Summary

The codes were organised into themes: facilitators of collaboration, barriers to collaboration and factors that might do both. The barriers included:

• Midwives' turf and autonomy
• Legacy of midwife-obstetrician friction
• Women's privacy
• Student midwives took priority
• Hearsay
• No time
• Labour: fast and unpredictable.

The facilitators were:

• Teamwork
• University preparation
• Fitting in
• Pushing back professionally
• Currying favour socially
• Midwives willing to teach.

The factors that might do both were:

• Team culture
• Senior midwives
• Hanging around
• Demographic markers (class, ethnicity, gender)
• Luck
• Different hospitals, different dynamics.

Overall, these themes built an overall narrative of students' perspectives. All medical students reported that midwives were central to their initial impressions of intrapartum teamwork. Viewed as the ‘gatekeepers’ to labour rooms, midwives were seen to be the primary facilitators for medical students to witness the physiological process of labour and vaginal birth. Students were enthusiastic about midwives who sought consent for them to enter, taught them clinical skills and often also exemplified the ‘human touch’. However, several participants also reported being shut out of birth rooms without understanding why, and feeling a sense of hostility. The majority of participants perceived moments of interprofessional friction. Their accounts suggested they believed a factor in this was the pre-existing multidisciplinary team culture on the labour ward where they were placed. Students who perceived midwives as hostile often reported engaging in strategies to ‘win them over’.

Midwife gatekeepers held key to learning

All participants reported that midwives were central to their initial impressions of intrapartum care. Midwives were repeatedly likened to ‘gatekeepers’, duty-bound to protect labouring women from unwanted intrusions. Midwives were also seen to be the primary facilitators for medical students to witness the physiological process of labour and vaginal birth.

One student noted that the need to be sensitive with women and offer privacy made it difficult to meet intrapartum learning objectives.

‘This speciality is quite unique…it's not appropriate for someone who's a complete stranger to rock up and go “can I just watch you give birth?”’

British Asian female, Midlands

Nevertheless, several participants reported midwives welcomed them warmly and seemed to enjoy teaching, proactively seeking consent for them to participate.

‘I remember a midwife calling [my mobile] at about 7pm and saying “there's a delivery happening right now do you want to come in?”’

British Asian male, South East

There were several accounts of ‘really special’ placements where the shared endeavour of putting a woman and her family at the centre of care had become ‘a highlight’ of the students' education to date.

‘It was magical.’

White Irish female, North East

‘There were candles; the midwife was holding their hand and breathing with them.’

Black African female, South East

But not all students had a positive experience of the placement. Participants acknowledged the importance of getting to know women and the process of labour, but some said it felt like they had to ‘earn’ the chance to see a birth. Several students reported that they were shut out of birth rooms, did not understand why and that they felt a sense of hostility.

‘The woman was happy [for the student to go in, but then the midwife-in-charge said] “She's kind of getting to the end so you shouldn't really be going in with that one”, which was difficult.”

White British female, North West

Another student, who had been interested in obstetrics, said he was put off the specialism altogether after finding interactions with midwives ‘really stressful’. He believed one particular individual had actively tried to stop him from entering a room.

‘[The midwife said to the woman] “he's a medical student, you don't want him here do you.?”…I was very affronted because obviously the mother's like “well no not really”.’

White British male, South East

Students' strategies to gain favour

Some students said they only managed to see vaginal births after ‘gaining favour’. They reported achieving this via social strategies, including giving compliments, joining in with chit-chat or undertaking menial tasks that indicated subservience.

‘I would suck up as much as possible. I made cups of tea for most of the morning [laughs] and did little menial things.’

White Irish female, North East

Some students offered ‘an extra pair of hands’ in clinical situations.

‘It's a very difficult thing to do because you're effectively bribing them, almost, actively or passively, but I don't think it's as cynical as that. I think you're trying to prove that you're part of the team.’

White British male, South East

Others consciously adopted the same workplace routine as midwives.

‘[The student arrived early] at 7.30am handover, all ready to go, in scrubs.’

White British female, South East

Medical students also suggested that their experience with midwives depended on them asserting their learning needs.

‘I had to stand up and say “I really need to see a vaginal birth here”.’

White Irish female, North East

Another participant reported ‘pushing back’ on occasions when he felt that midwives were being obstructive. He said some of his peers seemed intimidated but that he – perhaps as a result of his age, as a mature student – had made a conscious effort to explain calmly that a core course requirement was to witness birth.

‘If you didn't embrace that [the need to robustly assert that you needed to see vaginal births], you had a really crappy time.’

White British male, South East

Factors underlying medical students' experiences in the labour ward

The participants' experiences were influenced by the wider multidisciplinary team culture in the maternity unit where they were placed and by their gender.

Multidisciplinary team culture

All participants indicated that a key influence on their experience with midwives was the multidisciplinary team culture of the maternity unit where they were placed. Good leadership seemed to foster a positive team culture, particularly between obstetricians and midwives, which in turn seemed to set the tone for many student encounters with midwives. This affected both medical students' experience of intrapartum care and the opportunity (or not) to acquire clinical skills.

Several students who reported being nurtured by midwives related this to a non-factionalised way of working. One had been told by more senior students to expect obstructive midwives but on her ward, midwives invited her to join them on tea breaks.

‘[They] were welcoming…It was really good.’

White British female, South East

Students who reported passing easily into midwives' domain usually noted a collaborative ethos led by senior clinicians.

‘A very good consultant…on very good terms with everyone on the ward.’

White British male, Midlands

One student remembered an obstetric emergency being managed by an interactive multidisciplinary team, with a collective focus on working through it together.

The importance of leadership was noted by several participants, who mentioned the role of the midwife in charge. One participant remembered a sense of relief when he felt that the coordinator was proactively trying to support his learning.

‘[She] would assess the situation and try to assign me to someone who was about to give birth…and introduce me to the midwife.’

British Asian male, South East

While many medical students reported witnessing a positive multidisciplinary team culture in maternity units, there were also examples of students experiencing poor culture. Several medical students recalled labour wards in terms that denoted a battle: ‘domain’, ‘territory’, ‘turf ’, ‘space’ and ‘power’. All reported feeling some degree of interprofessional tension at some point in a placement. One young woman was broadly positive about midwives but still did not feel wholly accepted.

‘It definitely felt like treading on eggshells a little bit.’

White British female, North West

One student raised the issue of clashes in clinical ideology. He felt he had been poorly prepared about the standpoint central to midwifery that pregnancy and childbirth are often an essentially healthy process, rather than a pathology requiring treatment.

‘To break the ice a little bit, I said, you know, “so how many patients do you have here?”…and then this midwife just goes [aggressive tone] “we don't have patients, we have women, and nothing's wrong with them”. And I thought “ooh bloody hell”…I'd got off on the wrong foot.’

White British male, North West

Many participants said the overlap of tasks, such as vaginal examination, was a source of friction particular to maternity teams.

‘It is different from other specialities, because…midwives do a lot of the things that we [obstetricians] would be doing really, so midwives can be quite independent…you need to be a bit careful really in terms of what you do.’

White British female, South East

Another student felt his relationship with midwives was fraught with hierarchical complexity.

‘Do midwives think they outrank medical students but they don't outrank doctors or do they outrank everyone when it comes to birth?’

White British male, South East

One student linked some of his difficulties to the history of obstetricians dominating midwives.

‘I think there is a knee-jerk to a legacy.’

White British male, South East

Responses also suggested a new generation of tension might be ongoing, as medical students felt they were competing with student midwives for access to labour rooms. Several participants felt their relationship with midwives was compromised because student midwives were prioritised over medical students.

‘[I felt at the] bottom of the food chain.’

White British male, Midlands

‘It feels like the student midwives …have more rights than you do.’

Black African female, South East

Interprofessional rivalry linked to overlapping tasks appeared to be self-perpetuating in a future generation of midwives and doctors.

A subtheme of multidisciplinary team culture that emerged during the research was a comparison between district general hospitals and university teaching hospitals. District general hospitals were perceived as more socially and professionally divided, in contrast to multi-ethnic, urban university teaching hospitals where multidisciplinary teams were described as more diverse and collaborative.

‘If I'd only studied at the district general hospital, I'd probably think not bitterly, that's a strong word, but slightly negatively towards midwives, whereas [at the university teaching hospital] it was just this overarching feeling of being a team. It was the midwives and the doctors and there was this fluidity…everyone working together and that left me feeling really positive about working with midwives.’

British Asian male, South East

Another participant from the midlands observed that at a university teaching hospital, midwives (often from European Union countries) seemed more socially open and initiated teaching sessions. He compared this to some local white British midwives at the district general hospital who he described as being socially ‘inhospitable’ and professionally ‘apathetic’.

Gender

Some students believed that the ease (or not) of establishing a rapport with midwives was also influenced to an extent by gender.

The student who heard a midwife tell a woman ‘you don't want him in here, do you?’, suspected that being male was a contributing factor to her blocking his entry. Some men said they found it harder to make small talk and strike up the kind of rapport that might lead to a better working relationship. They cited common topics of staffroom conversation among midwives as fashion, cooking and ‘being a mum’.

Discussion

These results underscore the critical role that midwives can play in introducing medical students to intrapartum care. It demonstrates that they have power to help shape the experience of future doctors, some of whom will become obstetricians, and the potential implications this might have in multidisciplinary teams and safer births (O'Neill et al, 2008; National Institute for Health and Care Excellence, 2015; NHS, 2020). The novel value of this study lies in its detailed narratives; to the authors' knowledge, this is the most in-depth view of how medical students may feel and think at this impressionable time in their careers. It is important not to over-interpret the data; this study reflects only the perspective of medical students, rather than the full picture incorporating views from midwives and other clinicians.

These results demonstrate two significant areas where midwives can help shape medical students' placements. First, in developing medical students' clinical skills. Midwives are in a strong position to demonstrate to future doctors how the bodily function of having a baby works and that childbirth is generally safe (Brocklehurst et al, 2011). When a midwife invites a medical student to help support a woman whose labour is progressing well, this offers balance to their perception of birth, which might otherwise be skewed by medical education, which focuses on managing complications.

A midwife's style of caring also made an impact on the participants. This suggests that midwives are in a position to demonstrate the compassionate ‘soft skills’ of midwifery, such as therapeutic touch, reassuring eye contact, quiet encouragement and intuition about what a labouring woman needs. By inviting a medical student into a room where being ‘with woman’ comes first, a midwife shows the future doctor how neurohormonal processes and maternal experience are optimised (RCM, 2016; Bohren et al, 2017; Olza et al, 2020).

Thus, midwives can offer medical students a unique opportunity to learn about physiological labour, birth and compassionate care. These are critical skills in the face of a ‘caesarean epidemic’ (Visser et al, 2018). If a medical student fails to witness straightforward birth as a counterpoint to witnessing complicated birth, this may influence future clinical decisions. Risk theory suggests that lived experience influences a person's evaluation of the likelihood of a particular event occurring again, regardless of what they may have read about statistical chance (Tversky and Kahneman, 1974; Kates, 1977). Furthermore, the Lancet Series on Midwifery noted that if all clinicians adopt the values of midwifery, this could play a part in reducing caesarean section rates (Renfrew et al, 2014). The present study's findings that midwives can offer profound learning experiences about birth is corroborated by studies in comparable settings (Cotter et al, 2016).

While medical students can learn a great deal from midwives, the placements described in this research had not always yielded positive memories. Several students reported experiencing hostility, or that they were shut out of birth rooms and did not understand why, which has also been found in Australia and New Zealand (Bhoopatkar et al, 2017; Cheng et al, 2018). The present study indicates that medical students saw midwives as gatekeepers to labouring women and some believed they had to ‘earn’ their access to labour rooms. Indeed, many participants' accounts were dominated by their efforts to ‘oil the wheels’ socially, for instance by making tea. It is not the first time medical students have reported having to engage in a ‘hidden curriculum’, which includes social tactics (Lempp and Seale, 2004).

The second way midwives can shape medical undergraduate placement is as social figures, by modelling multidisciplinary collaboration. The present study's participants appeared acutely aware of the multidisciplinary team culture in their maternity units. Where this was fostered by good leadership, the students tended to have better learning experiences. Unfortunately, all participants had moments where they sensed (or felt they had to see off) tension with a midwife. Several excerpts from the interviews are akin to what Downe et al (2010) warn is an ‘initial antagonism between the two groups [that] is then likely to continue when junior staff become more senior’. So, a midwife who seems unfriendly may kickstart a self-perpetuating cycle of hostile interprofessional behaviour that is magnified later, when medical students become obstetric consultants and team leaders. This might risk perpetuating a style of working that does not foster multidisciplinary collaboration and which has been associated with avoidable harm to women and babies (Francis, 2013; Kirkup, 2015; Cumberledge, 2016; Ockenden, 2020; Care Quality Commission (CQC), 2021).

It is important to acknowledge other factors that may compromise the relationship between midwives and medical students. First, time-limited placements make it difficult for medical students and midwives to achieve a social rapport when they have just a few days or hours together. This may be different if medical students had longer obstetric placements. A recent letter to the British Medical Journal described how, during the COVID-19 pandemic, a group of medical students volunteered in a maternity unit in London. They said, ‘being integrated into the team for so long led to considerably more learning opportunities than on a regular placement’ (Alberman et al, 2020).

Second, the present study suggests that tensions arise from a discrepancy in how student midwives and medical students are managed at a national level. Consistent with other studies (Akkad et al, 2008; Cheng et al, 2018), the present study found that medical students felt they were at the ‘bottom of the food chain’ because midwives appeared to prefer ‘their own’ student midwives. However, midwives were simply following the Nursing and Midwifery Council (NMC, 2019) Code, which requires them to teach student midwives but makes no mention of medical students. A more practical issue is that generally student midwives are allocated named midwife mentors, while medical students are not. There have been repeated calls for this to change (Department of Health, 1999; 2007; RCOG and RCM, 2008; Cumberledge, 2016) though little progress has been made so far (CQC, 2021).

A more upfront discussion is still needed on sensitivities that seem to exist between some medical students and midwives. Given the importance of multidisciplinary collaboration and the challenge of negotiating personal pressure points in any workplace, it is worth considering initiatives known to help. The Labour Ward Leaders Pilot Programme has shown foresight in helping real-life multidisciplinary teams identify and pursue a ‘shared vision’ (RCM et al, 2017; NHS, 2020). Another interactional tool is ‘Whose Shoes’, which has also been effective in helping maternity clinicians understand each other's experiences (Phillips, 2016). Ultimately, the ongoing efforts in national leadership must consider the nuances of sub-dynamics, such as the one addressed in this study (RCOG and RCM, 2015).

Strengths and limitations

This study is novel, being the first to focus solely on the experience of medical students with midwives during NHS intrapartum care, and thus offers unprecedented detail about this important dynamic. It introduces a nuanced range of midwife-related factors relevant to issues raised by recent studies, including medics' competition with student midwives (Cheng et al, 2018), gender bias and barriers to vaginal examination (Bhoopatkar et al, 2017), disorganised placements and ‘informal teaching’, which is ad hoc, so only some students benefit (Peters et al, 2017; Rahimi et al, 2019). Medical students are often overlooked in midwifery literature and this in-depth analysis is arguably transferable to comparable settings.

However, as a result of the non-random nature of recruitment (via online adverts), the sample may not encompass the full range of experience. Moreover, only one perspective of the midwife-medic relationship is offered; there remains a gap in evidence on how midwives experience this relationship. The authors' clinical experience as midwives risked biasing data collection and analysis, but they sought to counteract this through reflexive discussions. During the course of interviews, the first author noted down moments where a statement from a participant prompted her to feel emotions that might bias the interview process itself or the subsequent analysis. She then discussed this with the second author in an effort to see herself in context and maintain as neutral a position as possible – both during subsequent interviews and analysis. For instance, she noted the fact that she felt ashamed when a medical student described a midwife in charge who prohibited their entry to a labour room. Being emotional about this topic might have biased future data collection (perhaps moving the first author actively to seek further instances of such behaviour). The authors reflected on such dynamics, reiterating the study's intention to maintain a dispassionate stance. Field notes of such feelings and conversations were kept alongside transcripts to create self-awareness and reduce interpretation bias during the analysis process. Participants were also given the chance to check findings, thus improving trustworthiness.

Recommendations

A positive multidisciplinary team culture can enhance students' experiences and improve outcomes for mothers and babies. One way of promoting multidisciplinary collaboration is through joint training; as Ockenden (2020) recommended, ‘staff that work together must train together’. The authors argue that all those working in maternity, including medical and midwifery students, should participate in such training sessions.

There have been repeated calls to improve national (and global) educational leadership (NMC, 2008; General Medical Council, 2015; World Health Organization, 2017). The NMC and General Medical Council could consider making more specific demands regarding midwives' contribution to the education of medical students, for instance so that universities identify named midwife mentors with rota capacity for students of both midwifery and medicine. Peer education may help too; there have been ‘very positive’ evaluations of a project in Belfast, where student midwives taught medical students about optimising straightforward labour and birth (Anderson et al, 2017). These initiatives clearly require increased resources (eg protected midwifery time to engage in students' education) but, given the human and economic costs of unsafe births, it is an option worth considering.

Conclusions

This study suggests two areas where midwives can help shape medical students' placement: first, developing their clinical skills by providing a unique opportunity to learn about physiological labour and birth and compassionate care. Second, midwives can start a cycle of multidisciplinary collaboration that could be magnified later, when medical students become obstetric consultants and team leaders. Good leadership can promote a positive multidisciplinary team culture, which enhances students' learning experience and has been associated with better outcomes for mothers and babies.

This study only explored medical students' experiences of their placement on labour wards. Thus, there remains a gap in evidence on midwives' perspective, which merits future research.

Key points

• Midwives were perceived as ‘gatekeepers’ by medical students seeking experience in labour rooms.
• Medical students felt midwives had valuable expertise to share about labour care and teamwork.
• Some medical students reported experiencing interprofessional tension and hostility from midwives.
• Multidisciplinary team culture seemed a factor in medical students' experience of midwives.
• Our discussion notes that midwives may influence future obstetricians' approach to multidisciplinary team care.
• More evidence is needed on midwives' view of the medical student placement on NHS labour wards.

CPD reflective questions

• How might you feel if a medical student asked to join you in the care of a woman?
• What previous experience might influence your behaviour with medical students?
• Think back to a moment of multi-disciplinary teamwork. How did it go?
• What steps might you take to further understand medical students' learning goals?
• How can you balance a woman's need for privacy with students' need to learn?