Working in midwifery, can be (as with many healthcare professions), incredibly hard work. Shifts are typically long and/or anti-social, medicalisation and complexity provide ongoing challenges, the threat of litigation looms and the NHS (where the majority of UK registered midwives work) has been chronically underfunded and under-resourced for the better part of 15 years (Ham, 2023). These issues, alongside an alarming number of serious incidents and investigations over the previous decade, including the recent birth trauma inquiry report (All-Party Parliamentary Group Birth Trauma, 2024), have contributed to a much changing perception of the value and meaning of midwifery in modern UK society.
Against this backdrop, it might seem a peculiar focus to consider the working conditions of midwifery academics, rather than midwives who may be struggling in challenging frontline conditions. What the authors put forward for consideration is that in a workforce with a high turnover of clinical staff and an established shortage of approximately 2500 midwives (Royal College of Midwives (RCM), 2024), midwifery educators are nurturing the next generation of staff who will go some way towards a solution to some of the issues. More staff, who are properly trained, will backfill gaps, improve working conditions and fulfil the goals of the NHS England (2023a) long term workforce plan. As detailed in the RCM (2023) state of midwifery education report, a focus on equitable pay and conditions in higher education are paramount to attract talent; this is needed to increase student places and bolster the workforce, as the NHS future workforce plan demands.
More importantly, conditions must be created for midwifery students to receive a high-quality, safe education and this cannot be reasonably achieved unless educators themselves are also motivated, nurtured and happy. Taking midwifery educators for granted is perilous; poorly educated or poorly treated students do not make safe, compassionate midwives (that is, if they complete their education at all). Midwifery educators are the lynchpin in this process. This article discusses the current working conditions of educators with these points in mind to propose solutions to nurture and support the future profession.
Equal and fair?
The average starting salary for a lecturer in the UK is £34 308 (University and College Union (UCU), 2023). This is less than the £35 392 received at entry step point for Band 6 midwives (NHS Employers, 2023). While many university employers will salary match for new staff, some will not. Additionally, many midwives in clinical practice will likely be in receipt of unsocial hours and overtime payments, alongside recruitment and retention premia (NHS Employers, 2024a). The NHS Employers' (2024a) submission to the NHS England Pay Review Body defines the average additional earnings of midwives at Band 6 as an uplift equating to 22.9% of basic pay. This means that an entry-level full-time Band 6 midwife (perhaps with only one year's clinical experience) would likely be earning in the region of £43 497, over £9000 more than the average salary offered to an entry level lecturer.
As the RCM (2023) report acknowledges, the more experienced the midwife, the more this disparity would inevitably increase. Universities are also unlikely to salary match those on salaries over the top end of an entry-level lecturer banding unless they have relevant education experience or qualifications. As this unfolds, midwifery education becomes further disconnected from an important pool of talent and expertise and students lose out on a crucial source of learning. The salary inequity explains why the education workforce is becoming younger and less experienced, and why some lecturers are returning to practice to earn a higher salary (RCM, 2023). There are few motivating reasons for an experienced midwife to take a substantial pay cut to work in higher education, particularly in the middle of a cost-of-living crisis.
Comparing midwifery with nursing or other allied healthcare professions further highlights this disparity. Professionals in areas such as nursing can often spend many years at agenda for change Band 5 (Stoye and Warner, 2024). For those on Band 5, Band 6 is typically only achieved through specialism, further study or an increase in responsibilities (often managerial or supervisory in nature), and so is achieved later on in careers. For those on Band 5, an entry level lecturer salary is more likely to constitute an income uplift (or at least income parity) and appeal to a greater range of experience levels. Midwives are somewhat unique, in that achievement of Band 6 is expected on completion of preceptorship, which for full time staff usually takes about a year (NHS England, 2023b). This higher banding for midwives is based on assessment of the responsibilities of the role by the NHS Employers' (2024b) job evaluation scheme; midwives are seen to operate with greater autonomy earlier in their careers. Put bluntly, an entry level lecturer salary may have incredibly limited appeal to any Band 6 midwife beyond their very early career years. While this substantial disparity between salaries in clinical practice and education exists, the status quo is unlikely to shift in terms of attracting experienced midwives into the education workforce (or indeed in retaining them) and universities should consider how they are ensuring competitive salary offers for the talent they wish to both attract and keep.
Temporary, fixed-term and/or zero-hours contracts are also endemic in higher education and this has featured in episodes of industrial action in recent years. The UCU (2021) stated that higher education is the second highest user of casual labour, with one third of all academics employed on fixed-term contracts and 41% on hourly-paid contracts. The degree to which this affects midwifery educators is unclear, although likely significant. More women than men are represented in the casual workforce in higher education (UCU, 2021) and the midwifery education workforce is predominantly female. Casual working may be beneficial for those juggling family or caring responsibilities; however, it is an established barrier to career advancement and does not contribute to equitable working conditions. Casual workers have more limited access to support, mentoring, progression and promotion than those on permanent contracts and report financial difficulties, mental health issues, insecurity and an inability to plan for the future (UCU, 2019). Universities might consider how they support female educators who are balancing family/caring responsibilities; this may positively influence a move away from casual working and thus support better working conditions.
Motivations and expectations
Bearing in mind the apparent lack of financial motivation and/or job security offered by a career in midwifery education, an examination of the motivations of those midwives who do make the transition into education is missing from the literature and sorely needed. A 2012 mixed-methods survey of 146 new nursing, midwifery and allied healthcare lecturers noted that great satisfaction could be gleaned by nurturing new professionals and that the autonomy and flexibility of the education workplace was positively received (Smith and Boyd, 2012). Conversely, new lecturers reported heavy workloads, a ‘re-learning’ of organisational processes and language, learning how to be an educator, struggles finding time for research and maintaining clinical credibility (Smith and Boyd, 2012). This survey is over 12 years old and the data suggest present conditions are probably worse. The study also did not directly address motivations for entry.
There is naturally a concern that midwives may enter education as they are disillusioned with the working conditions in clinical practice, of which stress, burnout, poor staffing and heavy workloads are all factors (Cull et al, 2020). Shift work is hard physical labour and working over a 24-hour, 365-day rota is harder still. This is exacerbated if staff have caring responsibilities and childcare to negotiate, which will be the case for the majority of the female midwifery workforce as it is for women working across the UK (Centre for Progressive Policy, 2022; Nursing and Midwifery Council (NMC), 2024). Midwives may enter higher education roles believing the working conditions might be ‘better’ in all these respects, although the literature does not exist to confirm this.
Anecdotally, colleagues have affirmed to the authors that they had made assumptions regarding easier conditions in higher education, but the transition constituted somewhat of a rude awakening. Education roles are not immediately ‘life or death’, so do not carry the attendant anxieties or stressors, nor the physical burden of long shift work, but can nonetheless become all consuming. There is no handing over after a shift and the responsibilities of pastoral support for personal students can be overwhelming. Students are present for up to 3 years (longer if they intercalate or extend their course). Students may also ask for support at all hours and as they are (at least on direct entry programmes) paying customers, they rightfully demand a response in a timely manner and engagement when they see fit. This can mean working over and above contracted hours, or at the least flexibly, to meet expectations. The lecturers surveyed in Smith and Boyd's (2012) study highlighted this when discussing the time needed to prepare teaching or get to grips with marking, and this is likely to have worsened because of increasing student numbers against stagnant educator recruitment (RCM, 2023). These expectations are different to clinical practice, as are the impacts, but they are not necessarily ‘less’ challenging. This can be a surprise to some.
The transition period
The transition from midwife to educator of student midwives can also be a demanding journey, and this may impact the working conditions experienced by early career academics as they establish new identities. Gray et al (2023) discussed this in their scoping review, where they identified 10 global papers that considered the experiences of midwives transitioning from clinical midwifery practice to higher education teaching roles. The picture they painted from the retrieved studies is one of a crisis of identity (at least for a time), where midwives reported a lack of support, a shift in identity and a fear of losing clinical credibility.
Two personal reflections published by midwives making the transition into higher education reported similar themes (Foster, 2018; Baker, 2019). Foster (2018) described the experience of needing to understand and appropriately support students who are struggling financially as well as the burden of pastoral support. She described being ‘overwhelmed by the sheer volume of challenges presented by some of the more vulnerable students whom I was supporting, and I became quite distressed as a few were experiencing particularly serious difficulties’ (Foster, 2018). Baker (2019) also described the elements of student support needed in the role but also the opportunities of earlier career transition, which led to easier identification with, and empathy for, students. These experiences align with the earlier Smith and Boyd (2012) findings and underscore the importance of supporting early career academics as they make the transition from clinician to educator. Mentorship might be an important element of support for this early-career process and has been identified in similar research in nursing, particularly for global majority staff (Jackson et al, 2015; Iheduru-Anderson and Shingles, 2023).
The breadth and depth of the education role
The last article in this series touched on the broad and intensive nature of the midwifery education role, to highlight that this contributes to inequalities and barriers to progression for the largely female workforce (Chenery-Morris and Divers, 2024). It noted the longer teaching year, less time for research or scholarly activity, the multiple roles midwifery educators embody to cover ‘academic assessor’ and/or ‘link lecturer’ roles and the emotional labour of nurturing students who are requiring increasing support (Chenery-Morris and Divers, 2024). This has equally not been aided by regulatory change in 2018 (NMC, 2023), when the ‘practice supervisor’ and ‘practice assessor’ roles were introduced and the requirement for students to spend 40% of their time with one ‘mentor’ was removed. This has led to academics picking up a great deal of the responsibility for supporting, nurturing and guiding students in both practice and university settings.
The need to keep NMC registration current remains when working in education, with 3-yearly revalidation and related continuous professional development still necessary. This is in addition to the ‘standard’ work of education in preparing teaching materials, teaching, marking and moderation, personal tutoring, outreach, admissions and recruitment. Higher education is also a competitive industry where advancement is only possible if substantial personal development is evidenced in the form of such things as research, further study, publications and conference presentations. This is already a large remit before considering the staff/student teaching time.
The ‘staff–student ratio’ reflects the number of students each academic may be working with. Typically, this is an indicator of academic quality, used by university league tables to rate courses and not dissimilar to the staff–patient ratios used to guide resourcing in clinical practice. A lower ratio is assumed to be better, as logic would lead to an assumption that this equates to greater student time and contact. However, midwifery ratios are variable, dependent on the demographics of the women cared for, models of care and community case mix, and often are calculated using complex algorithms or software such as Birthrate Plus (Griffiths et al, 2024). Meanwhile, higher education staff-student ratios are less clearly defined. Unlike some healthcare disciplines (the RCM (2023) report highlighted physiotherapy, which has a recommended ratio of 1:15), there is no ideal staff–student ratio for midwifery, nor direction on this from the regulator.
The national average midwifery staff–student ratio for 2022/23 was 1:19, and this has been increasing year on year since 2010 from 1:14 (RCM, 2023). The authors' direct experience also reflects this rise; when Sam joined their current university in 2006, there were five midwifery educators (4.6 whole time equivalents) and 14–16 students per cohort. This gave a ratio of approximately 1 staff member to 10 students, although the midwifery team also taught part-time post-registration courses too. At present, the staff–student ratio for the direct entry 3-year degree where the authors work sits around 1:17, although it is better for the shortened 2-year programme for qualified nurses at 1:14. Of course, staff can (and do) work interchangeably across midwifery programmes, which makes for an overall ratio of approximately 1:16.
These are relatively high numbers. A brief look at The Guardian (2024) university league tables for 2024 shows that only 26.2% of ranked institutions (n=32) had an overall staff–student ratio of 18:1 or above. When narrowing this to midwifery courses, this figure leaps to 46.2% (24 of 52 ranked courses). This may be in part because of increasing student numbers against static recruitment to education posts (RCM, 2023). It may also not paint a complete picture, as not all academics teaching on midwifery programmes may be midwives and so, depending on how the ratio is calculated, the picture may be better or worse than indicated. It does suggest that midwifery educators are more thinly distributed in comparison to other subjects when they are teaching a longer academic year and have a greater number of responsibilities to assure regulatory demands (Chenery-Morris and Divers, 2024). This does not equate to a necessarily ‘easy’ job that supports mental health nor one that can always be fulfilled within contracted working hours. Overtime is, in general, a problem for the sector, with university staff working two unpaid days of work every week (UCU, 2022). It could be assumed that this too might be higher for those working in midwifery education based on staff–student ratios. There is an urgent need to increase recruitment to assure both the working conditions of staff and the quality of education that student midwives are receiving.
Conclusions
There is much in the working conditions of midwifery education to recommend it; staff generally find working with students rewarding and the limited evidence suggests that they enjoy the autonomy and flexibility of the role. However, overall, midwifery education pay and working conditions are challenging and solutions can only be implemented if the problem itself is clearly outlined.
Ultimately, experienced and passionate midwives need to be encouraged into higher education by way of proper salary matching. The easy way to do this is to raise entry level lecturer wages to mirror the pay of staff from Band 6 and above. As the RCM (2023) report suggests, it would also be beneficial to provide better opportunities for midwives to engage with higher education throughout their careers. Allied healthcare professionals have done good work here recently that we can learn from (Council of Deans of Health and NHS, 2023), and there is interesting new work afoot to develop an educator's career framework for nurses and midwives, which may more clearly articulate the pathways to entry (Skills for Health, 2024).
A better understanding of the motivations of midwives entering higher education is also much needed both to further develop pathways to entry and increase recruitment, as well as to ensure the right staff are recruited for the role. Finally, some acknowledgement of the increased workload, teaching year, regulatory ‘extra’ requirements and increased pastoral burden of midwifery education is overdue; this will require much-needed investment in staff to balance student–staff ratios.