This final paper brings together some of the unfinished threads from previous publications. The series introduced the move to an all-graduate profession in 2009 in the first paper, saying how this was welcomed (Chenery-Morris and Divers, 2024a). The graduate profession could make autonomous decisions and continue their education post-graduation. However, funding for postgraduate midwifery education has reduced (Chenery-Morris and Divers, 2024a), despite initiatives such as National Institute for Health Research funding and advanced roles in the profession, including consultant midwives. The Nursing and Midwifery Council (NMC, 2019) future midwife added more to the undergraduate curriculum, but did not change its academic level or length of the programme, meaning student midwives have more to learn in their degree. One addition, examination of the newborn, is likely to further reduce postgraduate study opportunities for qualified midwives. This was implemented shortly after two other regulatory changes that potentially reduce postgraduate module opportunities.
The question of whether midwifery as a discipline in the university was academic enough was posed in the second paper (Divers and Chenery-Morris, 2024b), discussing how this has an impact on the predominantly female workforce. Midwifery educators do not join the higher education workforce with PhDs and the authors have seen a reduction in master's level qualifications recently on academic applications. The Royal College of Midwives' (RCM, 2023) report described a ‘striking drop’ in master's level qualifications of midwifery academics working in higher education, from 70% holding a masters in 2017/2018 to 42% in 2022/2023, and a decrease from 20% to 12% for doctoral qualifications. The allied health professional higher education workforce was more likely to have doctorates or be studying for one compared to nursing and midwifery (Council of Deans for Health, 2019). However, many allied health professions (such as diagnostic radiography, physiotherapy, paramedic science and operating department practitioner) have higher male representation in higher education (Council of Deans for Health, 2019). There are also differences between these professions in the likelihood of a doctoral qualification. Paramedics and operating department practitioners had lower levels, with 3% of paramedics studying for a doctorate and 14% studying in the operating department practitioner higher education workforce (Council of Deans for Health, 2019). It would be interesting to see if these proportions have dropped over time as midwifery qualifications have. One interesting observation is that speech and language therapists had the highest percentages of doctorates (53%). They are also a predominately female, albeit small, profession, although it is notable that they have been established in the university for longer than midwifery.
However, in the authors' opinion, it is not just the academic level of educators that has decreased; this is reflected in midwifery practice. The newly published labour ward coordinator education and development framework (NHS England, 2023) states how important the role is and suggests four ways that midwives can evidence their skills. The list includes academic credit at level 6 or 7, but this is not foregrounded; a midwife could therefore evidence her skills by undertaking non-credit bearing training or compiling a portfolio instead. Furthermore, a current NHS job advert for a band 8d deputy chief midwife lists a master's degree as essential, but also states experience of working at a senior level as an equivalent to this. The authors would argue that applicants should have gained a master's degree over their career if they are working at this senior level.
The relatively recent past
In 2008, the move from diploma-level pre-registration midwifery education (which was introduced in 1996) to an all-graduate profession was supported (NMC, 2009). Many universities had been offering graduate level pre-registration midwifery for a decade or more, and a few were offering master's level courses too. However, since this time, there have been several changes that have affected UK midwifery education directly or indirectly. Table 1 shows some of the key changes and their implications, with respect to decisions that have affected the academic level and continuing professional development of practising midwives. These will have a further impact on maternity care and on transition into academic careers.
| Date | Source | Title | Change | Impact |
|---|---|---|---|---|
| 2013 | Parliamentary and Health Service Ombudsman | Midwifery supervision and regulation: recommendations for change | Supervision of midwifery revoked on 31 March 2017 | Removal of the statutory midwifery committee from the Nursing and Midwifery Council. |
| 2015 | Government | Spending review | Removal of NHS bursary for student nurses/midwives and allied health professionals | Reduced the number and demographics of applicants: fewer mature students applying who often have other existing degree qualifications (Hambridge et al, 2023) |
| 2016 | Government | EU membership referendum | Fewer EU-educated nurses and midwives practising in UK | EU-educated nurses and midwives leaving the UK and Nursing and Midwifery Council (2024a) register, but 74% practising outside the UK. |
| 2017 | Nursing and Midwifery Council | Education consultation | Proposals to change standards for student supervision and assessment | Introduction of practice supervisor, practice assessor and academic assessor roles (Nursing and Midwifery Council, 2018). |
| 2018 | Nursing and Midwifery Council | Midwifery standards consultation | Examination of newborn now included in pre-registration curriculum (Nursing and Midwifery Council, 2019) | Need for qualified midwives to undertake this qualification at master's level will reduce |
Three of the major changes that have affected midwives' ability to engage with post-registration study are: removal of supervision of midwifery, removal of mentorship and introduction of the examination of the newborn. While each decision was the result of an individual consultation, collectively they have been implemented in a relatively short period of time (between 2017 and 2019) and, the authors argue, have had a negative impact on the academic qualifications of practising midwives.
Supporting midwives
First, the removal of statutory supervision of midwifery in 2017. Neither of the authors were supervisors of midwives, nor did their university offer the course, so they have no vested interest in its continuation or removal (except as midwives and academics). The authors recognise the reasons for the change: both the failings in care and the two-tier regulatory system (Parliament and Health Service Ombudsman, 2013). However, the need to support midwives was previously enshrined in law. It no longer is. New models of supervision were introduced in 2017 in each of the four countries of the UK (Table 2). However, as these models are not statutory, there is no obligation by trusts or health boards to fund this education.
| Country | Model | Reference | Observation |
|---|---|---|---|
| England | Advocating for education and quality improvement-A-EQUIP | NHS England (2024) | Role of professional midwifery advocate introduced. Other three countries retained the term ‘supervisor’ (Macdonald, 2019) |
| Northern Ireland | Reflective supervision for nursing and midwifery | Northern Ireland Practice & Education Council for Nursing and Midwifery (2024) | Three elements of reflective supervision: effectiveness, learning and support. |
| Scotland | Clinical supervision for midwives and maternity care assistants | NHS Education for Scotland (2024) | Designed to support midwives. Review of Scottish model noted limitations with implementation. Three functions: practice, professional and restorative supervision |
| Wales | Clinical supervision for health and care professionals and healthcare support workers | Public Health Wales (2023) | Training requirement stated but no academic level |
Many universities deliver supporting programmes for the above models at level 7; however, some are offered at level 6. More worryingly, there are also many ‘free’ e-learning packages that offer foundational knowledge and attendance online or in person to develop these skills, but the courses do not appear to have an academic level or assessment. This may undermine the knowledge and skills needed for this essential role in supporting the maternity workforce. There are publications about the professional midwifery advocate and supervisor's role (Key et al, 2019; Thomas, 2022); however, there is a paucity of research on this change, probably because it is quite recent. To remedy this, for the professional midwifery advocate role, a research proposal on its impact, effectiveness, professional wellbeing and retention of midwives has been submitted (Engward et al, 2024). There are likely to be evaluations and forthcoming publications about the supervisor's effectiveness and role in supporting midwives in the devolved nations too.
Supporting students
The introduction of three new roles (practice supervisor, practice assessor and academic assessor) was discussed in the fifth paper in this series (Divers and Chenery-Morris, 2024c). However, there is no NMC approved course that registrants must undertake to meet these requirements, unlike its predecessor (mentorship). While the authors understand the reasons why an NMC approved course does not add regulatory value, assurance or consistency, it did offer registrants the opportunity to start on a post-qualification academic qualification (often a level 7 module). This supported practice learning, the registrants' career development and potential retention in the midwifery profession. The level 7 mentorship qualification also provided a baseline for midwives who wanted to move into higher education.
More recently, changes to practice learning for student midwives may be on the horizon (NMC, 2024b). The NMC commissioned the Nuffield Trust to review practice learning, not only in terms of the number of clinical hours (2300, which is far more than any other health profession), but also the number of births, antenatal and postnatal experiences that student midwives need to complete to qualify. The Nuffield review will be presented to the NMC in January 2025, although the emerging findings were reported at the Council for Deans for Health Conference in October 2024 (Palmer, 2024). The quality of the learning experience rather than the quantity of hours was highlighted, along with the depth versus breadth of the competencies. ‘Taskification’ was the term used to explain how students felt trying to meet these competencies and numbers (Palmer, 2024). The lack of continuity of support for students in practice was also an emerging theme (Palmer, 2024).
The authors are hopeful that the requisite number of hours student midwives (and nurses) need to complete might reduce. If they do, there would be more time to prepare students midwives with the skills they need to feel confident and prepared in practice, since they fare less well with respect to their happiness and confidence than their nursing and nursing associate counterparts in their early careers (NMC, 2024a). Some newly registered midwives felt underprepared and overwhelmed because they had not had the breadth of experiences they needed on placements, and some spoke about a lack of support (in practice and university). The midwifery curriculum was already full, and level of responsibility for practice great, hence the quicker progression from band 5 to 6 for midwives (Divers and Chenery-Morris, 2024b). It was therefore somewhat surprising that the NMC added more.
The midwifery curriculum revisited
During 2017/2018, the pre-registration midwifery standards were reviewed again by the NMC. A public consultation on the draft standards ran during 2019 (NMC, 2019). A key question asked during the consultation was to what extent the future midwife should be able to conduct a full systematic physical examination of the newborn infant at the point of registration; 67% of midwives, 83% of other healthcare professionals and 62% of organisations agreed or strongly agreed that the future midwife should be able to conduct this examination (often called ‘NIPE’ or ‘newborn and infant physical examination’). However, concerns were voiced about whether this could be achieved in a 3-year degree programme (NMC, 2019). As some universities already included some, if not all, of the theoretical examination of the newborn content and/or practical components, it was determined this was not just possible in the three years but essential.
The Council of Deans for Health (2017) report noted that 13.7% of UK midwives were newborn and infant physical examination practitioners at the time. Extrapolating these numbers, approximately 5500 midwives had then undertaken a post-registration qualification to become a newborn and infant physical examination practitioner (approximately 13.8% of workforce). These midwives would usually have undertaken a needed master's level module to further their skills, meet service need and advance their career. While examination of the newborn courses continue to be offered across the UK, these will undoubtedly cease or significantly reduce when there is sufficient critical mass of midwives qualifying with newborn and infant physical examination under the new standards to meet demand. Therefore, one further opportunity for post-registration master's education will be lost.
During the consultation process (NMC, 2019), the length and structure of the midwifery pre-registration qualification was explored. Concerns were expressed about fitting ‘everything required’ into a 3-year, 4600 hours degree programme, in addition to concerns about the confidence levels of newly qualified midwives. While 38% of midwifery respondents wanted a 4-year degree (which could have been at master's level), there was more support for this notion from educators and employers (42% and 46% respectively) (NMC, 2019). The RCM also preferred the 4-year option, stating that it was ‘hugely ambitious to expect students to become competent, confident and safe in all the proficiencies’ in a shorter timeframe. However, because midwifery courses were no longer funded by the government (Department of Health and Social Care and HM Treasury, 2015) and students were fee paying, the added burden incumbent upon the individual was recognised and this opportunity was not taken forward.
Research capacity and barriers to this in practice and at university
One of the additional aspirations of the ‘future midwife’ curriculum (NMC, 2019) was to increase midwifery research and scholarship. Building research capacity for nurses, midwives and allied health professionals has long been on the UK national agenda (UK Clinical Research Collaboration, 2008). However, there are challenges with this. Despite funding and pathways to apply for research funding through the National Institute for Health Research since 2017, relatively few midwives have accessed this (Avery et al, 2022). Additionally, clinical academic careers have slower progression through the salary bands (Avery et al, 2022). This difference with academic pay compared to practice was noted in a previous article in this series (Divers and Chenery-Morris, 2024a). With fewer incentives for clinical academic midwifery roles, it is no wonder that embedding a research culture into practice is still a challenge (Avery et al, 2022).
Some of the barriers to increasing research capacity start with the undergraduate curriculum. In a survey of clinical academics, 50% of allied health professionals had undertaken primary research during their undergraduate programme, compared to 37% for nurses or midwives (Avery et al, 2022). While this may have changed with the future nurse and future midwife curriculum, the huge number of clinical hours required of nursing and midwifery students (2300 hours) reduces the time available for primary research compared to allied health professional students. Therefore, the NMC practice review may enable universities to change the emphasis from literature-based dissertations to primary research to better prepare midwives for academic careers, in practice or academia.
A study of 31 midwives from across England, ranging from aspiring advanced practice midwives, trainees and practitioners to consultant midwives, was undertaken in 2022 (Sanders et al, 2024). An emphasis was seen on academic achievement, with many self-funding their masters or PhD (Sanders et al, 2024). Barriers to protected time for study or funding opportunities to continue their studies were noted. These barriers were linked to the need to cover patient facing roles but also to changes in management. Ambitious midwives were not always encouraged to undertake advanced clinical practice education, with leadership and management opportunities and study foregrounded instead. However, a shift is needed in healthcare service that enables research training and capability building to transform services (Sanders et al, 2024). A new position statement from the RCM (2024) regarding advanced practice for midwifery may assist with this direction of travel.
In university, the transition to academic identities was an exceptional theme from a literature review of 14 international research papers (Grant et al, 2022). Nursing and midwifery academics struggled with scholarly identities; it took 10–15 years to develop this. Scholarly imposter syndrome was noted and a barrier to building research capacity. The qualitative nature of much of the nursing and midwifery research was also seen as less valuable in the university setting (Grant et al, 2022). However, the authors argue that midwifery needs more qualitative and interactional research (Chenery-Morris and Divers, 2024a). The review isolated four subthemes from the literature to develop research skills (Grant et al, 2022), including inclusive practice and ensuring all colleagues are included in research. Grant, Robinson and Laver name their indigenous colleagues, as they work in Australia; in the UK, we especially need to include our global majority academic midwives (Chenery-Morris and Divers, 2024b), as they are in the minority in higher education.
Workshops, connections to experienced researchers and writing retreats are also beneficial to develop research skills and scholarly identities. The overarching theme of we are not ‘there yet’ with academic research capacity across schools of nursing and midwifery (Grant et al, 2022) resonates with the authors' experience. Their conclusion is that we are not academic enough yet, as midwifery educators and as a profession. But there is potential. If midwifery academics are struggling with their academic identity in higher education, it is no wonder that practising midwives struggle with research capacity in practice.
A hopeful future?
More positively, since publication of the series' first paper in January 2024, there have been several potential changes that may enhance the chances of elevating the academic level of midwives generally, and specifically those entering or progressing in higher education. In addition to the NMC (2024b) review of practice learning, they are also considering regulation for advanced clinical practice for registrants (NMC, 2024c). A previous article in this series discussed how midwifery academics teach for more weeks per year and have increased workloads compared to other academics (Divers and Chenery-Morris, 2024b). If, following the review of practice learning, the 2300 clinical hours that students must undertake is reduced, this could have potential benefits for both students and academics alike.
Following the NMC's (2024c) announcement regarding regulation for advanced clinical practice, the RCM (2024) published a new position statement on advanced practice for midwifery. The RCM position is that experience and expertise post-qualification is enhanced by master's level education encompassing four pillars of knowledge: education, leadership, practice and research. The authors welcome this position to support the upskilling of midwives, not only because the academic level across the profession in higher education has decreased (RCM, 2023), but because there has also been a national decrease in the uptake of post-registration midwifery education. The education pillar is particularly welcome because this is essential for midwives' professional development, whether they remain in clinical practice or support the next generation of midwives in higher education. However, there is another potential barrier to the advanced clinical practice course; many are delivered via an apprenticeship in England and government funding for this level 7 qualification is no longer certain.
Conclusions
Regulatory changes have meant the midwifery curriculum includes more content than it did a decade ago (notably newborn and infant physical examination), despite remaining at the same academic level. The regulatory landscape is still shifting and changes to funding may further impede midwives from advancing their academic qualifications and commencing research careers. While these changes were consulted on individually, collectively over a relatively short period of time, these have eroded the academic expertise of qualified midwives. This trend was noted in the academic level of midwives in the university in the RCM report on which this series was based. This trend needs to be reversed because midwifery is not ‘there yet’ in its academic development in the university or practice. However, there is an appetite for career progression, with midwives who want to remain ‘with women’ in practice and for others who want to move into academia. If we harness this, it can only be beneficial for outcomes for women, students, midwives and the profession.