This series of six articles, inspired by themes from the Royal College of Midwives' (RCM, 2023) State of Midwifery Education report will explore the current landscape and challenges in educating the future midwifery workforce. The series will describe and comment on the current higher education environment in the context of the international literature, making suggestions for improvement that student midwives, midwives and midwifery educators can consider in their practice. The series will discuss issues of gender, ethnicity and diversity, pay and conditions, practice and the academic level of the profession.
Higher education: the staff and students
In March 2023, the professional body for midwives, the RCM (2023), sent freedom of information requests to the 55 UK universities providing midwifery education at the time, to gather data for the State of Midwifery Education report. The main principle behind freedom of information legislation, an act of law, is that people have the right to know about the activities of public bodies. Universities are considered public bodies, since they receive public money.
When organisations receive freedom of information requests, they have an obligation under the Act, to respond to the request (Information Commissioners Office, no date). Respondents, in this case universities, have to state whether they have any information within the scope of the request, in this case for information on students and staffing in each university's midwifery education department, and provide that information, usually within 20 days. Given this requirement, it is surprising that the response rate was 93% and not 100%. The RCM (2023) report also noted that not all questions were answered in the responses that were received.
The data from 2023 were compared to previous freedom of information requests from 2010 onwards, although not all years were surveyed because of the pandemic. Nevertheless, most UK universities responded, and it is therefore likely that the findings are representative. The longitudinal nature of the freedom of information requests mean there are interesting, albeit worrying, trends and comparisons in the report.
The first finding presented in the RCM's (2023) report related to midwifery educators' qualifications, based on three time periods (2017/2018, 2020/2021 and 2022/2023). Three types of qualification were stated: master's degree (only), doctorate and studying for a doctorate. The RCM cited a ‘striking drop’ in these qualifications, from 70% holding a master's degree in the first period to 43% 5 years later. A similar reduction was noted in midwifery educators holding a doctorate (20% to 12%) or studying for one (10% to 6%) in the same period.
The second noteworthy finding was that the age profile of midwifery educators is younger than it was a decade ago (RCM, 2023). In 2010/2011, the number of midwifery educators under 40 years old was approximately 7%. By 2022/2023, this proportion had increased to approximately 26%.
The third finding drawn on in this article is the increase in student numbers per cohort over time. The average number of students per university in 2022/2023 was 206, up from 122 in 2011/2012. This equates to an increase of 68%. Additionally, the number of students who are leaving courses has risen. In 2011/2012, nine students left their midwifery programme per institution. In 2021/2022 the figure was 14.9 per university (RCM, 2023).
As the report summarised, the increase in student numbers and earlier academic careers for midwives are seen as positive. However, midwifery as a profession must balance the need to increase the academic credentials of educators with the drive to retain students. The new plans to continue increasing the number of midwifery students and retain current staff, as set out in the NHS England (2023) long-term workforce plan, are welcome. However, the commitment to continued professional development for midwives, in order to address the workforce challenges, needs more detail on its funding model. The decline in continued professional development over the last decade has contributed to professional difficulties and some of the trends noted in the RCM (2023) report.
Midwifery as a profession
The difference between an occupation and a profession has been studied by sociologists over the last 70 years (Riska, 2001). In that time, there have been varying perspectives of the concept of ‘the professions’ (traditionally considered to be medicine, law and religious practices). Initially, the functionalist sociologists (specifically Emile Durkheim and Talcott Parsons) saw the role of professions being based on expert knowledge and service orientation. The professions had a particular relationship with clients based on trust (Riska, 2001). Other definitions have expanded on this to include ethical codes, a recognised qualification and professional regulation (van Tiejlingen, 2015). These functionalist aspects are reflected in the International Congress of Midwives' (2023) position statement on midwifery as an autonomous profession. It states that the following five key elements are essential: a unique body of knowledge, a code of ethics, self-governance (such as the RCM), processes for decision-making by its members and recognition from society through regulation (in the UK, this is the Nursing and Midwifery Council (NMC)).
There are four routes into midwifery, where unique knowledge is gained in theory and practice. Most students in the UK are enrolled on pre-registration 3-year bachelor's degrees, with some universities offering a 4-year master's degree. There are fewer students on the shortened 2-year route for nurses and there is an apprenticeship route only in England (RCM, 2023). The move to an all-graduate profession in 2009 was welcome, so that the graduate profession could make autonomous decisions and continue their education post-graduation (Chief Nursing Officers for England, Northern Ireland, Scotland and Wales, 2010). The expectation was that this change would allow access to relevant, timely, academically robust continued professional development and sufficient time to undertake this. However, the reality has been different.
The personal and professional benefits of postgraduate master's level midwifery education were discussed by Walker and Spendlove (2018). They included developing cognitive and intellectual skills that contribute to decision making in complex environments, the ability to undertake empirical research and contribute to the professional body of knowledge, enhanced leadership and change management theories, application to practice and reflection. If midwifery is to maintain its professional status, Walker and Spendlove (2018) asserted that midwives needed to engage with postgraduate study, to reaffirm and extend its unique knowledge base to advocate for women and educate the future workforce.
However, since 2016, there has been 30–50% less continued professional development funded by Health Education England (Greatbatch, 2016; Jones, 2016; Merrifield, 2017; Davies, 2019). Ironically, the decline of post-registration continued professional development may have enabled the midwifery academic workforce to accommodate the increase in pre-registration midwifery students. Greatbatch (2016) acknowledged the detrimental impact for pre-registration learners as fewer registrants undertook mentorship training, meaning there were fewer midwives in practice able to fully support student learning. This lack of support may have led to the increase in midwifery students leaving their courses (RCM, 2023). Regardless of the unintended consequences of continued professional development cuts, academic and/or qualificatory expertise of practising midwives has not remained at the same level as it was 8 years ago.
In addition to the functionalist perspective of a profession, the ways that professionals interact with their clients, other professions, students and colleagues have been explored by the sociologists (Riska, 2001). Interactionists study social action, social order and social identities (Atkinson and Housley, 2003). The tradition was born in America, but scholars from Europe have made significant contributions to this knowledge. In the UK, particular attention has been given to interactionist thought on educational and occupational socialisation; learning, becoming and career (Atkinson and Housley, 2003), which is particularly relevant here.
Newnham and Rothman (2022) clearly articulated the need for more qualitative research in midwifery. They state that quantifiable research has grown exponentially over the last few years and that qualitative and interactionist methods have not developed at the same rate. However, they argued that midwives engaged in research before it was required. The knowledge gained from experience-based wisdom was sometimes devalued as intuition instead of thoughtful knowledge. Midwifery would do well to reframe this intuition as tacit knowledge; something we know but cannot always explain how we know (Newnham and Rothman, 2022). It is precisely this concept that interactionists study. This was how the social and medical models of midwifery were developed.
Prosen's (2022) review of the midwifery literature on professionalism from 2009–2019 included international research. A total of 20 papers were included, with 14 of these papers using qualitative methodology. The study's aim was to determine barriers and enablers to midwifery professionalism. Differences in philosophies of care, such as the medical and social models and power imbalance between midwives and obstetricians, were seen to negatively impact on midwifery's ability to fulfil its professional requirement. Notably, these aspects have been cited in recent care failings and have led to a public enquiry into maternity services (Burns and Benjamin, 2023; Care Quality Commission, 2023; Dodd, 2023).
Differences in the professions in relation to their power have been described previously with midwifery being seen as a semi profession, because of the lack of autonomy in providing evidence-based care (Sonmezer, 2021). The irony of this is that during the continued professional development funding cuts, postgraduate medical education was protected (Greatbatch, 2016). So not only was the professional power of medics maintained, but opportunities for midwives and obstetricians to learn together were not afforded, upholding any established power imbalance.
Fortunately, opportunities in midwifery for professionalism come from relationships and respectful interactions with women, who are at the centre of midwifery care. Developing professional confidence, competence and identity through education and interprofessional collaborative practice further contribute to this overall aim (Prosen, 2022), and are the core functions of midwifery educationalists (Chief Nursing Officers for England, Northern Ireland, Scotland and Wales, 2010).
Midwives' transition to academia
A prerequisite for a lecturer post at the University of Suffolk, where the authors of this article work, is NMC registered midwife status and master's level study (other, more prestigious, universities require PhDs). While some applicants have a master's degree, many apply having completed one or more modules at master's level. Popular level 7 modules have included the newborn infant physical examination or modules pertaining to supporting practice learning and assessment (NMC, 2023). However, two new trends have become apparent in the midwifery lecturer applicant pool that the authors have witnessed over recent years.
First, applicants have frequently self-funded their master's level study and second, fewer have a level 7 practice learning qualification. This is a national and growing issue (Greatbatch, 2016). In time, there will be fewer midwives with level 7 newborn infant physical examination qualifications too, as this is now a prerequisite of the pre-registration curriculum (NMC, 2019). Currently, the authors have seen applications from midwives actively wanting to teach students and work in universities; they are younger and often need support to develop their academic careers, echoing findings from the RCM (2023) report. The authors do not think this is necessarily all negative for the quality of student education or the student's experience, but a slight reframing of expectations is needed, alongside careful consideration of the support that higher education institutions are offering to new academic staff.
A literature review of 10 international papers published between 2006 and 2020 in the UK, Australia and US examined the transition from clinical practice to academia for midwives (Gray et al, 2023). The papers all included midwives as a subset of the participants, making the findings pertinent to a range of health professionals. The transition to an academic role presented a steep learning curve for participants, as a result of educational qualifications, academic procedures and understanding of the different technologies used for teaching and assessment (Gray et al, 2023).
One of the themes from the review identified that midwifery academics had more informal support from their peers with this transition than other professions (Gray et al, 2023). This might be because midwifery teams are smaller than some of the other professional groups in universities and a smaller staff body understands the importance of peer support. It may also be that as a predominantly female profession, midwives are more likely to care for their new colleagues (gender and midwifery will be discussed in the next article in this series).
The review described how participants identified as clinicians first and academics second (Gray et al, 2023); the longer the midwife or healthcare professional had inhabited the clinical role, the harder this transition seemed to be. It could be argued that new, younger midwives joining academia will not have challenges surrounding transition and identity because they do not have an expert practitioner status to hold on to and their identity as clinicians is not as ingrained. Holding on to what is known, with uncertainty in what is new, is akin to Benner's (2001) novice to expert framework, where registrants were experts in practice but novices in academia. Therefore, this may be less of an issue with younger or less experienced clinical staff. There may be other potential benefits of a younger academic workforce, including digital literacy, embracing and engaging artificial intelligence in a way that must be essential and the use of simulation. Exactly why midwives are transitioning from clinical practice into academia earlier has not yet been researched, and probably needs to be.
The final theme identified in Gray et al's (2023) review was that there was a loss of clinical credibility for those moving from clinical practice into academia. The authors asserted that strong links with clinical practice can be maintained by link lecturer visits, and additional reading of evidence can be helpful to support confidence in teaching (Gray et al, 2023). While some academic midwives worked clinically, maintaining this was cited as problematic because of the competing pressures of academic work, such as teaching, marking, grant writing and studying. Gray et al (2023) suggested that this is only necessary until academic confidence is developed.
When reflecting on the authors' own transition, we agree that having clinical experiences to use in teaching is essential. It is the learning from these experiences that can be drawn out and explained to students, making both theory and research come alive and more memorable for the learner (Griew et al, 2023). It is in the storytelling of these examples that nuances in care, decision making, interactions with women and their families and more can be illuminated and meaning made. This way students see lecturers as credible and this, along with reading and master's level study of the reflexive art of teaching, contributes to the development of academic confidence.
The future
The NHS long-term workforce plan published in June 2023 offers some hope for the future of midwifery. Two of its three priority actions, to train and retain, relate well to the discussion outlined in this article. On the training front, midwifery student numbers grew by 650 in 2019 and 1000 in 2020, 2021 and 2022, leading to the 68% increase seen in the RCM (2023) report. Over the next 15 years of the long-term workforce plan, solid growth of 1.8–1.9% per year is promised using traditional, shortened and apprenticeship routes. There is recognition that midwifery (and nursing) professions have a high proportion of women who may need more flexible working, which will be addressed further in a future article in this series. A national preceptorship framework will be adopted to provide a structured start for newly qualified midwives. However, it is worth noting that this will not address the number of graduates who choose not to join the NMC register on completion of their studies, which equates to 1 in 9 for midwifery, compared to 1 in 14 for nursing (Palmer et al, 2023). Greater support for this transition is clearly needed to retain midwifery graduates; perhaps greater collaboration with practice partners in the final modules will make this transition more seamless and reduce this additional loss.
The long-term workforce plan recognises the need for continued professional development for staff to meet their potential and that of the profession. The commitment to fund continued professional development via employers' equivalent to £1000 per person over 3 years was introduced in 2020. As yet, there has not been an increase in uptake of credit-bearing academic modules. Although it is hoped that this increase will come, as stated by Greatbatch (2016), once expertise is lost, it is hard to reinvigorate. Given too that there are fewer midwifery academics with master's and doctorates (RCM, 2023), progress to reinstate these specialised modules and courses may be slow. Acknowledgement that the midwifery workforce needs to be more research active, and that there are strategic plans for this, is somewhat reassuring (Chief Midwifery Officer, 2023).
Conclusions
Nationally the demographics of midwifery educators (and students) have changed. The increase in midwifery students required to meet the needs of the population and vacancies in midwifery is welcome. However, universities need to recruit to an equivalent increase in its establishment to meet the educational needs of learners. There is a younger demographic of midwives applying for and being successful in their academic careers. However, nationally, a loss of expertise in the academic qualifications of midwifery educators (master's and doctorates) has been reported. To reverse this loss of expertise, universities will have to support their staff and practitioners to gain these awards in addition to educating students.
This article has presented the evidence base for a smooth transition to academia for staff, recognising that it takes time for this new identity to be assimilated. It has considered the implications of this for the midwifery profession using functionalist and interactionist theory. Interactionism is particularly relevant, as students need time and positive support to learn, transition and stay in the midwifery profession, yet similarly it is essential to advance midwifery knowledge and research. It is hoped that there will be a reversal of recent trends in continued professional development funding for midwives and the profession with the NHS long-term workforce plan. The recognition that we need to train midwives and, importantly, retain staff in clinical and academic roles, ensuring that their professional knowledge and skills are developed, is paramount to change outcomes for the women we care for.
Key points
- The qualificatory level of midwifery academics has decreased over the last 5 years.
- Midwifery academics are younger than they were a decade ago, and student numbers have also increased.
- Universities need to support midwives' transition to academia and their professional development to meet the ongoing needs of students and the profession.
CPD reflective questions
- Reflect on your recent professional development; was this in the form of study days or a module/academic award?
- Do you have a good understanding of qualitative research and interactions in clinical practice?
- Would you like to deepen your professional knowledge?
- Do you know who to talk to in your organisation to access funding to support this?