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What future for midwifery?
Nurse Education in Practice 12 (2012) 297e300
Contents lists available at SciVerse ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
What future for midwifery? Rhona J. McInnes*, Colette Mc Intosh 1 School of Nursing, Midwifery & Health, University of Stirling, FK9 4LA, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 29 April 2012
Safe, effective and high quality maternity care is crucial to the wellbeing of mother and baby and for society as a whole. The midwife is now recognized and recommended as the lead professional and coordinator of care for low risk women and plays a central role in ensuring a safe outcome for mother and newborn. A number of key policy documents, service audits and reviews highlight the essential role of the midwife and the skills and expertise required to provide expert care and make educated decisions about care management. Yet there has been considerable attention and debate in the media, from the public and from the profession itself because of the current shortage of midwives in England. This paper debates some of the implications of the lack of midwives and the need to ensure a commitment to the recruitment and education of midwives who are equipped to deal with the challenges of providing the highest quality woman-centred care which is safe, effective and meets the changing needs of society and the profession. Some of the questions centre around the importance of the availability of midwives to provide midwifery care and support the development of student midwives, as well as the need to ensure continued access to opportunities to maintain and update midwives’ knowledge and skills. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Continuing professional development
The context of midwifery in the UK Government policy based on research evidence emphasises the crucial importance of the early years and early year services, including the unique role of the maternity services, in ensuring longterm health and wellbeing (DoH, 2004; Scottish Government, 2009; Scottish Government, 2011a Welsh Government 2011). Since events in the early years have an influence across the whole life course in terms of health, development and life opportunities investment in this area is essential for reducing inequalities and subsequent burden on health and social services (DoH, 2004; DoH, 2007; Scottish Government, 2009; Scottish Government, 2011a; Welsh Government, 2011; Midwifery 2020). The long-term effects of birth on women’s emotional wellbeing, their relationship with their baby and their approach to parenting are also recognised (HCC, 2008). The UK maternity services aim to provide high quality, safe and effective care with current policy advocating ‘normal birth’ (i.e. no unnecessary medical intervention), women’s involvement and choice, and continuity of care (DoH, 2007; Scottish Government, 2008; Welsh Government, 2011; Scottish Government, 2011a;
* Corresponding author. Tel.: þ44 (0) 1786 466 363. E-mail addresses: [email protected] (R.J. McInnes), [email protected] (C. Mc Intosh). 1 Tel.: þ44 (0) 1786 466 389. 1471-5953/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2012.04.011
Scottish Government, 2011b). In the UK, the midwife is the key professional in the provision of midwifery care (RCOG, 2007a; Hatem et al., 2008; Midwifery, 2020; Scottish Government, 2009; Scottish Government, 2011a; Welsh Government, 2011), is an ‘autonomous practitioner of normal labour and birth’ and has a central role in the multi-disciplinary team in more complex presentations (RCOG, 2007a:1; NMC, 2009; Scottish Government, 2009). Midwife-led care is beneficial for the majority of childbearing women, there is no evidence of harm and it may prove to be a cost effective model (Hatem et al., 2008; Devane et al., 2010). All four UK countries recognise the importance of autonomous midwives and highlight their expanding role and the need for continued learning after graduation (Midwifery, 2020). Midwifery, 2020 also emphasises staffing and expertise stating that the provision of high quality maternity services is contingent on the “availability of a workforce of practising skilled midwives, who can lead and contribute to the care of women as part of the multidisciplinary team” (Midwifery, 2020: 18). However, continued public sector cuts across the UK and growing uncertainty about the structure of the NHS in England are giving increasing cause for concern about the sustainability and safety of maternity services. In the UK there is considerable evidence of poorly staffed maternity services from various sources such as the media (Guardian, 2011; Laurance, 2011), published academic papers (Ashcroft et al., 2003; Ockleford et al., 2004; McInnes and Chambers, 2008), professional bodies (RCOG, 2007a; RCM, 2011a;
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RCM, 2011b; RCM, 2011c) and service audits (HCC 2008) with an estimated 5000 additional midwives required in England (RCM, 2011a). The current pressure on maternity services across the UK was outlined in a recent report (RCM, 2011c), which identified high and increasing birthrates in all four UK countries and specific issues for each individual country. The ‘baby boom’ in England and Wales on top of a pre-existing understaffing has led to a chronic shortage of midwives and although the number of midwives in England has increased since 2002 this has not kept up with the rising birthrate. The current workforce in Ireland and Scotland is considered to be ‘adequate’ but the ageing midwifery population indicates potential future shortages. The report makes a number of recommendations to address the situation including maintaining or increasing student numbers and deployment of appropriately trained and supervised maternity support workers. There are several additional factors that are impacting on maternity services and may have even greater effect in years to come. The ageing childbearing population presents with more complex pregnancies in general (RCOG, 2009; RCM, 2011c) and with additional complications related to assisted conception (RCOG, 2007b). Concurrently the changing clinical profile of childbearing women indicates poorer general health due to unhealthy lifestyles (e.g. smoking, alcohol misuse, recreational drugs and poor diet) (CMACE, 2011a) and increasing global obesity (WHO, 2011). In the UK around 24% of childbearing women were obese in 2007 (CMACE, 2011a) and around 20% of pregnant women were obese in 2008 (National Observatory of Obesity). Obesity is associated with poorer outcomes in pregnancy and clinical complications such as heart disease and diabetes as well as overall challenges to provision of care (Modder and Fitzimmons, 2010). These changes will alter the skill and educational requirements of midwives and affect decisions about care planning and provision. Thus to summarize, in the UK there is currently a shortage of midwives, the experienced workforce is set to shrink further, the birthrate is rising and childbearing is becoming more complex. In this context the role of the midwife is changing with greater autonomy, emphasis on reducing interventions, health promotion and education and more choice for women. The importance of the midwife Globally, 350,000 extra midwives are needed to reduce the incidence of maternal and neonatal mortality and morbidity (SCF, 2011). A lack of midwives and appropriate education opportunities means that around 48 million women give birth each year without a ‘skilled person’ in attendance and 2 million women give birth entirely on their own (SCF, 2011). It has been estimated that 358,000 childbearing women die each year (SCF, 2011) from mainly preventable causes (Islam, undated). In the UK, where maternal deaths are relatively rare (SCF, 2011), around 99% of births are attended by a midwife or doctor. This serves to emphasise the importance of well-educated and skilled midwives and their contribution to safe and effective care. However, even across Europe the distribution of maternal deaths is not random but is linked to differences in obstetric care (Saucedo et al., 2012; Wildman et al., 2004). In the UK, each maternal death is assessed through the Centre for Maternal and Child Enquiries (CMACE) and reported in a Confidential Enquiry into Maternal Deaths. The most recent Enquiry for the period 2006e2008 identified 261 women who died from causes directly or indirectly attributable to pregnancy or birth (CMACE, 2011a). Substandard care was a factor in over 70% of Direct and 55% of Indirect maternal deaths (CMACE, 2011a). Similar enquires conducted for neonatal deaths reported that 6600 babies died during pregnancy or in the first 4 weeks of life in 2009 in the UK (CMACE, 2011b). Furthermore,
the UK stillbirth rate of 3.8/1000 births is also one of the highest among high-income countries but could be reduced by appropriate preconceptual care, parent education and improved antenatal care (Flenady et al., 2011). There are therefore clear indicators that maternal and neonatal outcomes are related to provision of appropriate skilled care even in the modern health care setting. Appropriate skilled care requires midwives who are educated and available but 92% of units audited in 2008 had a shortage of midwives (HCC, 2008). Safer Childbirth (RCOG, 2007a:1) identified a midwifery recruitment and retention crisis and in 2011 a survey of Heads of Midwifery by the RCM indicated that around 60% had insufficient staff to cope (RCM, 2011d). Poor quality care, poorer outcomes and adverse events in maternity units have been attributed to the lack of midwives (Ashcroft et al., 2003; RCOG, 2007a; Gerova et al., 2010; RCM, 2011d). Poor quality care from overworked midwives is evidenced through midwives adopting ‘quick fixes’, poor communication and lacking time to care or listen (Ockleford et al., 2004; McInnes and Chambers, 2008). Furthermore insufficient midwives to support women in normal labour may result in increased intervention and a loss of skill in managing and supporting normal birth (Page, 2003). Staff who are more highly skilled and qualified are known to provide better quality care but inadequate staffing may reduce access to skill updates and training courses (Ashcroft et al., 2003; HCC, 2008; RCM, 2011d). These factors result in maternity care becoming a cycle of increasing intervention and decreasing skills alongside increasingly complex maternity presentations (Smith et al., 2009). This then raises questions about how to promote and protect access to appropriate education and training. Education and continuing professional development Since all for UK countries are experiencing rising birthrates and increasing birth complexity there is an urgent need to increase midwifery provision and the RCM recommend that undergraduate (UG) midwifery education levels should be maintained or even increased in order to provide more, and younger, midwives (RCM, 2011c). In England, which has both a midwife shortage and an ageing workforce, student numbers have increased since a low in 2005 but are currently only just above the level they were at in 2003e2004. In Scotland, where the workforce is ageing, the student numbers have generally decreased from 1999 and from 2012 have been cut dramatically by a further 50%. This is contrary to the RCM recommendation that student numbers are increased in Scotland in order to counteract the implications of an ageing workforce (RCM, 2011c). Wales, which has a younger midwifery workforce, has more than doubled the number of students since 2005/6 and may be better placed to recover from its current shortfall especially given the government’s stated commitment to employing a highly trained workforce (Welsh Government, 2011). However, the ageing midwifery education workforce may restrict UG provision and although rationalisation of UG programmes may off-set education staff shortages and reduce costs, such plans must consider local needs and accessibility for students. In Scotland midwifery education has been rationalised from a six-provider to a three-provider model but with the wide geographical spread of student placements the impact on the student experience and quality of education remains to be seen. The vision for midwifery education (Midwifery, 2020) is to prepare and develop skilled midwives who practise safely and autonomously. UG midwifery education comprises at least 40% theory and at least 50% practice and practice experience must enable students to achieve the NMC standards (NMC, 2009). However, the shortage of midwives may directly affect students’ clinical learning experience through restricting teaching time and lack of qualified mentor support (Begley, 2001; Nettleton and Bray, 2008). Mentors
R.J. McInnes, C. Mc Intosh / Nurse Education in Practice 12 (2012) 297e300
identify poor recognition of the role and needs of mentors (Nettleton and Bray, 2008) suggesting that effective mentoring requires both time and adequate staffing (Fisher and Webb, 2008) but that increasing workloads and low staffing often leads to relegation of mentoring (Nettleton and Bray, 2008). Furthermore, as the shortage of employed midwives impacts on the quality of care (Ashcroft et al., 2003; RCOG, 2007a; RCM, 2011d; Gerova et al., 2010), students are likely to be exposed to poor quality care practices (Licqurish and Seibold, 2008), which they may reject or may feel pressured to adopt (Licqurish and Seibold, 2008; Armstrong, 2009). As placement experiences affect student choices of employment following graduation (McCall et al., 2009) the vision of highly skilled workforce providing innovative evidence-based quality care (Midwifery, 2020) starts to seem unattainable. The RCOG (2007a) acknowledges that midwife shortages affect recruitment and retention but doesn’t explore the mechanisms through which this operates. Maintaining a skilled workforce requires continual updating and development to meet the changing needs of the childbearing population. Midwifery 2020 acknowledges that midwives’ learning continues beyond graduation through appropriate continuing professional development (CPD) programmes. However, the reality is that the current general economic situation has reduced opportunities for midwives to maintain and update their skills and has put the onus on staff to attend courses in their own time at their own expense (Ashcroft et al., 2003; HCC, 2008; RCM, 2011d). Munro (2008) uses the charity paradigm to highlight a number of issues around CPD and the learning environment identifying a lack of service provider support for lifelong learning. Although some individuals are personally driven to develop themselves there is little motivation or reward to do so and learning is not valued within health care organisations (Munro, 2008). The NMC states that learning and being up-to-date is the responsibility of the individual student or midwife (NMC, 2011:16; NMC, 2004a) and many education programmes are directed at individuals. There is therefore an urgent need to consider how CPD is offered and ensure access to courses which maintain and update midwives’ skills in the changing context, advance the profession and deliver on various government policies. Skill mix Another strategy to address shortages is to employ maternity support workers (MSWs), also known as midwifery assistants or maternity care assistants, to provide support for midwives. Both the RCM and Midwifery 2020 identify a role for MSWs within the multi-disciplinary team but express concerns about responsibility and accountability, lack of clarity of the role, and the need for high quality training and thoughtful supervision (RCM, 2011c; Midwifery, 2020). The Midwives Rules (NMC, 2004b) clearly state that ‘it is essential that whoever is caring for or advising women in relation to pregnancy, birth or postnatal care has the appropriate skills and knowledge to understand, interpret and manage as appropriate, the complex physiological and social changes a woman or her baby may experience’. A number of studies have explored the role and impact of MSWs (McKenna and Hasson, 2002; Keeney et al., 2005; Ingram and Johnson, 2009) and will not be detailed here but there is a danger that inappropriate deployment of MSWs will affect the quality of care, reduce holistic care, increase ‘task based’ care and add to midwives’ responsibility (Keeney et al., 2005). Furthermore clinical midwives may lack the skills for appropriate and safe delegation and supervision of MSWs. The role and deployment of MSWs must be considered in the planning and development of midwifery education but it is not clear yet where MSWs sit within clinical academic career frameworks and if they have a role in UG midwifery clinical teaching.
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The future Higher Education institutions (HEIs) and their service partners require to collaborate effectively to ensure continued UG provision and to enable clinical midwives to access education opportunities. The goal of UG midwifery education being ‘rooted in normality’ (Midwifery, 2020) is a major challenge in the context of increasing complexities of childbearing and a tendency to locate students in larger teaching hospitals. The increasing focus on communitybased care may require role adjustment, new skills and changes to education programmes. This means that HEIs and maternity services must be creative about how they provide and enable access to UG and CPD opportunities. Rationalisation of UG provision to fewer HEIs may impact on student recruitment, retention and experience and will require new approaches to education to ensure programme quality and effectiveness. The midwifery student profile, which comprises mature students with family commitments, indicates a need to locate education opportunities within practice areas rather than at more distant HEIs (Midwifery, 2020). On-line CPD courses (RCM, 2011d) may be an opportunity for HEIs to work collaboratively to develop innovative on-line modules that advance the profession and practice. Lack of time and support for academic and clinical staff to update and expand skills or to undertake research or scholarly activities (Ashcroft et al., 2003; HCC, 2008; Midwifery, 2020; Fraser et al., 2010; RCM, 2011d) is concerning, particularly for a profession that is striving to develop a unique, innovative and contemporary professional identity (Midwifery, 2020). Providers and educators must accept responsibility for ensuring staff are appropriately skilled, supported and credible to provide or teach safe and effective care and must ensure that students are supported to achieve a positive learning experience in clinical practice. This is crucial for improving recruitment and retention both to UG education and to the midwifery profession. Current emphasis on skills mix alongside budget concerns may result in a choice of offering training opportunities for maternity care assistants or supporting and educating midwives to be effective and creative in how they use their skills and experience to provide high quality women-centred care. Conclusion The UK is experiencing a shortage of midwives and the workforce, especially highly qualified and experienced midwives, is set to shrink further with reduced opportunity to fill these places from the diminished student population. The rising birthrate, more complex childbearing and the changing midwife’s role indicate a need for effective educational opportunities; but these are becoming less accessible. Limited opportunities for midwives to participate in scholarly activities should be of concern for the advancement of the profession and the development of midwifery care. The opportunity to re-design midwifery to be fit for the future exists, but in reality a lack of funding, skill and resources threatens the quality of education. There is therefore an urgent need to safeguard midwifery education to support the future of midwifery and secure the safety and health of women and children in the UK. References Armstrong, N., 2009. Are student midwives influenced by the traditional (non evidence based) practices of their clinical mentor. Evidence Based Midwifery 7 (1), 24e34. Ashcroft, B., Elstein, M., Boreham, N., Holm, S., 2003. Prospective semi-structured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives. British Medical Journal 327 (584). doi:10.1136/bmj.327.7415.584. http://www.telegraph.co.uk/news/uknews/ 1542372/Mothers-are-turned-away-due-to-midwife-shortage.html.
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Begley, C.M., 2001. ‘Giving midwifery care’: student midwives’ views of their working role. Midwifery 17, 24e34. Centre for Maternal and Child Enquiries (CMACE), 2011a. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth report on Confidential Enquiries into maternal deaths in the United Kingdom. BJOG 118 (Suppl. 1), 1e203. Centre for Maternal and Child Enquiries (CMACE), 2011b. Perinatal Mortality 2009: United Kingdom. CMACE, London. Devane, D., Brennan, M., Begley, C., Clarke, M., Walsh, D., Sandall, J., Ryan, P., Revill, P., Normand, C., 2010. A Systematic Review, Meta-Analysis, Metasynthesis and Economic Analysis of Midwife-led Models of Care. Royal College of Midwives Trust, London. Department of Health (DoH), 2004. Maternity Standard, National Service Framework for Children, Young People and Maternity Services. Best Practice Guidelines. DoH, London. Department of Health (DoH), 2007. Maternity Matters: Choice, Access and Continuityof Care in a Safe Service. Department of Health, London. Available at: http://www.dh.gov.uk/health/category/publications/reports-publications/ (accessed 11.11.11.). Fisher, M., Webb, C., 2008. What do midwifery mentors need? Priorities and impact of experience and qualification. Learning in Health and Social Care 8 (1), 33e46. Flenady, V., Middleton, P., Smith, G.C., Duke, W., Erwich, J.J., Khong, T.Y., Neilson, J., Ezzati, M., Koopmans, L., Ellwood, D., Fretts, R., Frøen, J.F., for The Lancet’s Stillbirths Series steering committee, 2011. Stillbirths: the way forward in highincome countries. Lancet 377, 1703e1717. Fraser, D.M., Avis, M., et al., 2010. The MINT Project. Midwives in Teaching: Evaluation of whether Midwife Teachers bring a unique contribution particularly in the context of outcomes for women and their families. Final Report to the Nursing and Midwifery Council, November 2010. Gerova, V., Griffiths, P., Jones, S., Bick, D., 2010. The Association between Midwifery Staffing and Outcomes in Maternity Services in England: Observational Study Using Routinely Collected Data. Preliminary report and feasibility assessment. Department of Health, England. Available from: http://www.kcl.ac.uk/schools/ nursing/nnru. Guardian, 2011. Midwife Shortage Dangerously High. http://www.guardian.co.uk/ society/2011/sep/15/midwife-shortagedangerously-high. Hatem, M., Sandall, J., Devane, D., Soltani, H., Gates, S., 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD004667.pub2. Issue 4. Art. No.: CD004667. Health Care Commission (HCC), 2008. Towards Better births A review of Maternity Services in England July 2008 (Commission for Healthcare Audit and Inspection). Ingram, J., Johnson, D., 2009. Using community maternity care assistants to facilitate family-focused breastfeeding support. Maternal and Child Nutrition 5 (3), 276e281. Islam M., undated. The safe motherhood Initiative and beyond. Bulletin of the World Health Organization. Available at: http://www.who.int/bulletin/ volumes/85/10/07-045963/en/ (accessed 11.11.11.). Keeney, S., Hasson, F., McKenna, H., Gillen, P., 2005. Nurses’, midwives’ and patients’ perceptions of trained health care assistants. Journal of Advanced Nursing 50, 345e355. Laurance, J., 2011. British Maternity Wards in Crisis. The Independent 04th April 2011. http://www.independent.co.uk/life-style/health-and-families/healthnews/ british-maternity-wards-in-crisis-2261403.html. Licqurish, S., Seibold, C., 2008. Bachelor of Midwifery students’ experiences of achieving competencies: the role of the midwife preceptor. Midwifery 24, 480e489. McCall, L., Wray, N., McKenna, L., 2009. Influence of clinical placement on undergraduate midwifery students’ career intentions. Midwifery 25 (4), 403e410. McInnes, R.J., Chambers, J.A., 2008. Supporting breastfeeding mothers: a qualitative synthesis. Journal of Advanced Nursing 62 (4), 407e427. doi:10.1111/j.13652648.2008.04618.x. McKenna, H., Hasson, F., 2002. A study of skill mix issues in midwifery: a multimethod approach. Journal of Advanced Nursing 37, 52e61. Midwifery 2020 Programme, 2010. Delivering Expectations (http://midwifery2020.org. uk/documents/M2020Deliveringexpectations-FullReport2.pdf) (accessed 14.11.11.). Modder, J., Fitzimmons, K.J., 2010. Management of Women with Obesity in Pregnancy. CMACE/RCOG Joint Guideline. Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists.
Munro, K.M., 2008. Continuing professional development and the charity paradigm: Interrelated, individual, collective and organisational issues about continuing professional development. Nurse Education Today 28 (8), 953e961. National Observatory of Obesity. Epidemiology of Maternal Obesity. http://www. noo.org.uk/NOO_about_obesity/maternal_obesity/epidemiology Nettleton, P., Bray, L., 2008. Current mentorship schemes might be doing our students a disservice. Nurse Education in Practice 8, 205e212. Nursing and Midwifery Council (NMC), 2004a. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. Available at: www.nmc-uk.org. NMC, 2011. Guidance on Professional Conduct for Nursing and Midwifery Students. NMC, London. Available at: www.nmc-uk.org. Nursing and Midwifery Council (NMC), 2004b. Midwives Rules and Standards. Available at: www.nmc-uk.org. Nursing and Midwifery Council (NMC), 2009. Standards for Pre-registration Midwifery Education. NMC, London. Available at: www.nmc-uk.org. Ockleford, E.M., Berryman, J.C., Hsu, R., 2004. Postnatal care: what new mothers say. British Journal of Midwifery 12 (3), 166e170. Page, L., 2003. ’When normal birth is in the minority’. British Journal of Midwifery 11 (6), 356. Royal College of Midwives (RCM), 2011a. Rocketing birthrate fuels English regional midwife shortages. Available at: http://www.rcm.org.uk/college/about/mediacentre/press-releases/rocketing-birthrate-fuels-english-regional-midwifeshortages-15-09-11/. Royal College of Midwives (RCM), 2011b. Wales needs more midwives says RCM. Available at: http://www.rcm.org.uk/college/about/media-centre/ press-releases/wales-faces-midwife-shortage-19-09-11/. Royal College of Midwives (RCM), 2011c. State of maternity services report 2011. Available at: http://www.rcm.org.uk/college/policy-practice/governmentpolicy/ state-of-maternity-services/?locale¼en (accessed 02.04.12.). Royal College of Midwives (RCM), 2011d. Royal College of Midwives Submission to NHS Pay Review Body. September 2011. Available at: http://www.rcm.org.uk/ college/support-at-work/pay/ (accessed 02.04.12.). Royal College of Obstetricians and Gynaecologists (RCOG), 2007a. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. RCOG Press, London. Royal College of Obstetricians and Gynaecologists (RCOG), 2007b. Perinatal Risks Associated with IVF (SAC Opinion Paper 8). Available at: http://www.rcog.org. uk/womens-health/clinical-guidance/perinatal-risksassociated-ivf (accessed 15.11.11.). Royal College of Obstetricians and Gynaecologists (RCOG), 2009. RCOG Statement on Later Maternal Age. Available at: http://www.rcog.org.uk/what-we-do/ campaigning-and-opinions/statement/rcog-statement-later-maternal-age (accessed 15.11.11.). Saucedo, M., Deneux-Tharaux, C., Bouvier-Colle, M.H., 2012. Understanding regional differences in maternal mortality: a national caseecontrol study in France. BJOG: An International Journal of Obstetrics & Gynaecology 119, 573e581. Save the Children (SCF), 2011. Missing Midwives. SCF April. Available at: http:// www.savethechildren.org.uk/resources/online-library/missing-midwives (accessed 14.11.11.). Scottish Government, 2011a. The Refreshed Framework for Maternity Care. Available at: http://www.scotland.gov.uk/Resource/Doc/337644/0110854.pdf (accessed 15.11.11.). Scottish Government, 2011b. Reducing Antenatal Health Inequalities: Outcome Focused Evidence into Action Guidance. Available at: http://www.scotland.gov. uk/Resource/Doc/337678/0110857.pdf (accessed 15.11.11.). Scottish Government (SG), 2008. Keeping Childbirth Natural and Dynamic (KCND). http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/nursing/ naturalchildbirth (accessed 02.04.12.). Scottish Government (SG), 2009. Early Years Framework. Available at: http://www. scotland.gov.uk/Publications/2009/01/13095148/1 (accessed 02.04.12.). Smith, A.H.K., Dixon, A.L., Page, L.A., 2009. Health-care professionals’ views about safety in maternity services: a qualitative study. Midwifery 25 (1), 21e31. Welsh Government, 2011. A Strategic Vision for Maternity Services in Wales September 2011. Available at: http://www.wales.nhs.uk/news/20265 (accessed 19.03.12.). World Health Organization (WHO), 2011. Obesity and Overweight. Fact Sheet No 311 Available at: http://www.who.int/mediacentre/factsheets/fs311/en/index.html. Wildman, K., Bouvier-Colle, M.H., the MOMS group, 2004. Maternal mortality as an indicator of obstetric care in Europe. BJOG: an International Journal of Obstetrics and Gynaecology 111, 164e169.
Contents lists available at SciVerse ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
What future for midwifery? Rhona J. McInnes*, Colette Mc Intosh 1 School of Nursing, Midwifery & Health, University of Stirling, FK9 4LA, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 29 April 2012
Safe, effective and high quality maternity care is crucial to the wellbeing of mother and baby and for society as a whole. The midwife is now recognized and recommended as the lead professional and coordinator of care for low risk women and plays a central role in ensuring a safe outcome for mother and newborn. A number of key policy documents, service audits and reviews highlight the essential role of the midwife and the skills and expertise required to provide expert care and make educated decisions about care management. Yet there has been considerable attention and debate in the media, from the public and from the profession itself because of the current shortage of midwives in England. This paper debates some of the implications of the lack of midwives and the need to ensure a commitment to the recruitment and education of midwives who are equipped to deal with the challenges of providing the highest quality woman-centred care which is safe, effective and meets the changing needs of society and the profession. Some of the questions centre around the importance of the availability of midwives to provide midwifery care and support the development of student midwives, as well as the need to ensure continued access to opportunities to maintain and update midwives’ knowledge and skills. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Continuing professional development
The context of midwifery in the UK Government policy based on research evidence emphasises the crucial importance of the early years and early year services, including the unique role of the maternity services, in ensuring longterm health and wellbeing (DoH, 2004; Scottish Government, 2009; Scottish Government, 2011a Welsh Government 2011). Since events in the early years have an influence across the whole life course in terms of health, development and life opportunities investment in this area is essential for reducing inequalities and subsequent burden on health and social services (DoH, 2004; DoH, 2007; Scottish Government, 2009; Scottish Government, 2011a; Welsh Government, 2011; Midwifery 2020). The long-term effects of birth on women’s emotional wellbeing, their relationship with their baby and their approach to parenting are also recognised (HCC, 2008). The UK maternity services aim to provide high quality, safe and effective care with current policy advocating ‘normal birth’ (i.e. no unnecessary medical intervention), women’s involvement and choice, and continuity of care (DoH, 2007; Scottish Government, 2008; Welsh Government, 2011; Scottish Government, 2011a;
* Corresponding author. Tel.: þ44 (0) 1786 466 363. E-mail addresses: [email protected] (R.J. McInnes), [email protected] (C. Mc Intosh). 1 Tel.: þ44 (0) 1786 466 389. 1471-5953/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2012.04.011
Scottish Government, 2011b). In the UK, the midwife is the key professional in the provision of midwifery care (RCOG, 2007a; Hatem et al., 2008; Midwifery, 2020; Scottish Government, 2009; Scottish Government, 2011a; Welsh Government, 2011), is an ‘autonomous practitioner of normal labour and birth’ and has a central role in the multi-disciplinary team in more complex presentations (RCOG, 2007a:1; NMC, 2009; Scottish Government, 2009). Midwife-led care is beneficial for the majority of childbearing women, there is no evidence of harm and it may prove to be a cost effective model (Hatem et al., 2008; Devane et al., 2010). All four UK countries recognise the importance of autonomous midwives and highlight their expanding role and the need for continued learning after graduation (Midwifery, 2020). Midwifery, 2020 also emphasises staffing and expertise stating that the provision of high quality maternity services is contingent on the “availability of a workforce of practising skilled midwives, who can lead and contribute to the care of women as part of the multidisciplinary team” (Midwifery, 2020: 18). However, continued public sector cuts across the UK and growing uncertainty about the structure of the NHS in England are giving increasing cause for concern about the sustainability and safety of maternity services. In the UK there is considerable evidence of poorly staffed maternity services from various sources such as the media (Guardian, 2011; Laurance, 2011), published academic papers (Ashcroft et al., 2003; Ockleford et al., 2004; McInnes and Chambers, 2008), professional bodies (RCOG, 2007a; RCM, 2011a;
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RCM, 2011b; RCM, 2011c) and service audits (HCC 2008) with an estimated 5000 additional midwives required in England (RCM, 2011a). The current pressure on maternity services across the UK was outlined in a recent report (RCM, 2011c), which identified high and increasing birthrates in all four UK countries and specific issues for each individual country. The ‘baby boom’ in England and Wales on top of a pre-existing understaffing has led to a chronic shortage of midwives and although the number of midwives in England has increased since 2002 this has not kept up with the rising birthrate. The current workforce in Ireland and Scotland is considered to be ‘adequate’ but the ageing midwifery population indicates potential future shortages. The report makes a number of recommendations to address the situation including maintaining or increasing student numbers and deployment of appropriately trained and supervised maternity support workers. There are several additional factors that are impacting on maternity services and may have even greater effect in years to come. The ageing childbearing population presents with more complex pregnancies in general (RCOG, 2009; RCM, 2011c) and with additional complications related to assisted conception (RCOG, 2007b). Concurrently the changing clinical profile of childbearing women indicates poorer general health due to unhealthy lifestyles (e.g. smoking, alcohol misuse, recreational drugs and poor diet) (CMACE, 2011a) and increasing global obesity (WHO, 2011). In the UK around 24% of childbearing women were obese in 2007 (CMACE, 2011a) and around 20% of pregnant women were obese in 2008 (National Observatory of Obesity). Obesity is associated with poorer outcomes in pregnancy and clinical complications such as heart disease and diabetes as well as overall challenges to provision of care (Modder and Fitzimmons, 2010). These changes will alter the skill and educational requirements of midwives and affect decisions about care planning and provision. Thus to summarize, in the UK there is currently a shortage of midwives, the experienced workforce is set to shrink further, the birthrate is rising and childbearing is becoming more complex. In this context the role of the midwife is changing with greater autonomy, emphasis on reducing interventions, health promotion and education and more choice for women. The importance of the midwife Globally, 350,000 extra midwives are needed to reduce the incidence of maternal and neonatal mortality and morbidity (SCF, 2011). A lack of midwives and appropriate education opportunities means that around 48 million women give birth each year without a ‘skilled person’ in attendance and 2 million women give birth entirely on their own (SCF, 2011). It has been estimated that 358,000 childbearing women die each year (SCF, 2011) from mainly preventable causes (Islam, undated). In the UK, where maternal deaths are relatively rare (SCF, 2011), around 99% of births are attended by a midwife or doctor. This serves to emphasise the importance of well-educated and skilled midwives and their contribution to safe and effective care. However, even across Europe the distribution of maternal deaths is not random but is linked to differences in obstetric care (Saucedo et al., 2012; Wildman et al., 2004). In the UK, each maternal death is assessed through the Centre for Maternal and Child Enquiries (CMACE) and reported in a Confidential Enquiry into Maternal Deaths. The most recent Enquiry for the period 2006e2008 identified 261 women who died from causes directly or indirectly attributable to pregnancy or birth (CMACE, 2011a). Substandard care was a factor in over 70% of Direct and 55% of Indirect maternal deaths (CMACE, 2011a). Similar enquires conducted for neonatal deaths reported that 6600 babies died during pregnancy or in the first 4 weeks of life in 2009 in the UK (CMACE, 2011b). Furthermore,
the UK stillbirth rate of 3.8/1000 births is also one of the highest among high-income countries but could be reduced by appropriate preconceptual care, parent education and improved antenatal care (Flenady et al., 2011). There are therefore clear indicators that maternal and neonatal outcomes are related to provision of appropriate skilled care even in the modern health care setting. Appropriate skilled care requires midwives who are educated and available but 92% of units audited in 2008 had a shortage of midwives (HCC, 2008). Safer Childbirth (RCOG, 2007a:1) identified a midwifery recruitment and retention crisis and in 2011 a survey of Heads of Midwifery by the RCM indicated that around 60% had insufficient staff to cope (RCM, 2011d). Poor quality care, poorer outcomes and adverse events in maternity units have been attributed to the lack of midwives (Ashcroft et al., 2003; RCOG, 2007a; Gerova et al., 2010; RCM, 2011d). Poor quality care from overworked midwives is evidenced through midwives adopting ‘quick fixes’, poor communication and lacking time to care or listen (Ockleford et al., 2004; McInnes and Chambers, 2008). Furthermore insufficient midwives to support women in normal labour may result in increased intervention and a loss of skill in managing and supporting normal birth (Page, 2003). Staff who are more highly skilled and qualified are known to provide better quality care but inadequate staffing may reduce access to skill updates and training courses (Ashcroft et al., 2003; HCC, 2008; RCM, 2011d). These factors result in maternity care becoming a cycle of increasing intervention and decreasing skills alongside increasingly complex maternity presentations (Smith et al., 2009). This then raises questions about how to promote and protect access to appropriate education and training. Education and continuing professional development Since all for UK countries are experiencing rising birthrates and increasing birth complexity there is an urgent need to increase midwifery provision and the RCM recommend that undergraduate (UG) midwifery education levels should be maintained or even increased in order to provide more, and younger, midwives (RCM, 2011c). In England, which has both a midwife shortage and an ageing workforce, student numbers have increased since a low in 2005 but are currently only just above the level they were at in 2003e2004. In Scotland, where the workforce is ageing, the student numbers have generally decreased from 1999 and from 2012 have been cut dramatically by a further 50%. This is contrary to the RCM recommendation that student numbers are increased in Scotland in order to counteract the implications of an ageing workforce (RCM, 2011c). Wales, which has a younger midwifery workforce, has more than doubled the number of students since 2005/6 and may be better placed to recover from its current shortfall especially given the government’s stated commitment to employing a highly trained workforce (Welsh Government, 2011). However, the ageing midwifery education workforce may restrict UG provision and although rationalisation of UG programmes may off-set education staff shortages and reduce costs, such plans must consider local needs and accessibility for students. In Scotland midwifery education has been rationalised from a six-provider to a three-provider model but with the wide geographical spread of student placements the impact on the student experience and quality of education remains to be seen. The vision for midwifery education (Midwifery, 2020) is to prepare and develop skilled midwives who practise safely and autonomously. UG midwifery education comprises at least 40% theory and at least 50% practice and practice experience must enable students to achieve the NMC standards (NMC, 2009). However, the shortage of midwives may directly affect students’ clinical learning experience through restricting teaching time and lack of qualified mentor support (Begley, 2001; Nettleton and Bray, 2008). Mentors
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identify poor recognition of the role and needs of mentors (Nettleton and Bray, 2008) suggesting that effective mentoring requires both time and adequate staffing (Fisher and Webb, 2008) but that increasing workloads and low staffing often leads to relegation of mentoring (Nettleton and Bray, 2008). Furthermore, as the shortage of employed midwives impacts on the quality of care (Ashcroft et al., 2003; RCOG, 2007a; RCM, 2011d; Gerova et al., 2010), students are likely to be exposed to poor quality care practices (Licqurish and Seibold, 2008), which they may reject or may feel pressured to adopt (Licqurish and Seibold, 2008; Armstrong, 2009). As placement experiences affect student choices of employment following graduation (McCall et al., 2009) the vision of highly skilled workforce providing innovative evidence-based quality care (Midwifery, 2020) starts to seem unattainable. The RCOG (2007a) acknowledges that midwife shortages affect recruitment and retention but doesn’t explore the mechanisms through which this operates. Maintaining a skilled workforce requires continual updating and development to meet the changing needs of the childbearing population. Midwifery 2020 acknowledges that midwives’ learning continues beyond graduation through appropriate continuing professional development (CPD) programmes. However, the reality is that the current general economic situation has reduced opportunities for midwives to maintain and update their skills and has put the onus on staff to attend courses in their own time at their own expense (Ashcroft et al., 2003; HCC, 2008; RCM, 2011d). Munro (2008) uses the charity paradigm to highlight a number of issues around CPD and the learning environment identifying a lack of service provider support for lifelong learning. Although some individuals are personally driven to develop themselves there is little motivation or reward to do so and learning is not valued within health care organisations (Munro, 2008). The NMC states that learning and being up-to-date is the responsibility of the individual student or midwife (NMC, 2011:16; NMC, 2004a) and many education programmes are directed at individuals. There is therefore an urgent need to consider how CPD is offered and ensure access to courses which maintain and update midwives’ skills in the changing context, advance the profession and deliver on various government policies. Skill mix Another strategy to address shortages is to employ maternity support workers (MSWs), also known as midwifery assistants or maternity care assistants, to provide support for midwives. Both the RCM and Midwifery 2020 identify a role for MSWs within the multi-disciplinary team but express concerns about responsibility and accountability, lack of clarity of the role, and the need for high quality training and thoughtful supervision (RCM, 2011c; Midwifery, 2020). The Midwives Rules (NMC, 2004b) clearly state that ‘it is essential that whoever is caring for or advising women in relation to pregnancy, birth or postnatal care has the appropriate skills and knowledge to understand, interpret and manage as appropriate, the complex physiological and social changes a woman or her baby may experience’. A number of studies have explored the role and impact of MSWs (McKenna and Hasson, 2002; Keeney et al., 2005; Ingram and Johnson, 2009) and will not be detailed here but there is a danger that inappropriate deployment of MSWs will affect the quality of care, reduce holistic care, increase ‘task based’ care and add to midwives’ responsibility (Keeney et al., 2005). Furthermore clinical midwives may lack the skills for appropriate and safe delegation and supervision of MSWs. The role and deployment of MSWs must be considered in the planning and development of midwifery education but it is not clear yet where MSWs sit within clinical academic career frameworks and if they have a role in UG midwifery clinical teaching.
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The future Higher Education institutions (HEIs) and their service partners require to collaborate effectively to ensure continued UG provision and to enable clinical midwives to access education opportunities. The goal of UG midwifery education being ‘rooted in normality’ (Midwifery, 2020) is a major challenge in the context of increasing complexities of childbearing and a tendency to locate students in larger teaching hospitals. The increasing focus on communitybased care may require role adjustment, new skills and changes to education programmes. This means that HEIs and maternity services must be creative about how they provide and enable access to UG and CPD opportunities. Rationalisation of UG provision to fewer HEIs may impact on student recruitment, retention and experience and will require new approaches to education to ensure programme quality and effectiveness. The midwifery student profile, which comprises mature students with family commitments, indicates a need to locate education opportunities within practice areas rather than at more distant HEIs (Midwifery, 2020). On-line CPD courses (RCM, 2011d) may be an opportunity for HEIs to work collaboratively to develop innovative on-line modules that advance the profession and practice. Lack of time and support for academic and clinical staff to update and expand skills or to undertake research or scholarly activities (Ashcroft et al., 2003; HCC, 2008; Midwifery, 2020; Fraser et al., 2010; RCM, 2011d) is concerning, particularly for a profession that is striving to develop a unique, innovative and contemporary professional identity (Midwifery, 2020). Providers and educators must accept responsibility for ensuring staff are appropriately skilled, supported and credible to provide or teach safe and effective care and must ensure that students are supported to achieve a positive learning experience in clinical practice. This is crucial for improving recruitment and retention both to UG education and to the midwifery profession. Current emphasis on skills mix alongside budget concerns may result in a choice of offering training opportunities for maternity care assistants or supporting and educating midwives to be effective and creative in how they use their skills and experience to provide high quality women-centred care. Conclusion The UK is experiencing a shortage of midwives and the workforce, especially highly qualified and experienced midwives, is set to shrink further with reduced opportunity to fill these places from the diminished student population. The rising birthrate, more complex childbearing and the changing midwife’s role indicate a need for effective educational opportunities; but these are becoming less accessible. Limited opportunities for midwives to participate in scholarly activities should be of concern for the advancement of the profession and the development of midwifery care. The opportunity to re-design midwifery to be fit for the future exists, but in reality a lack of funding, skill and resources threatens the quality of education. There is therefore an urgent need to safeguard midwifery education to support the future of midwifery and secure the safety and health of women and children in the UK. References Armstrong, N., 2009. Are student midwives influenced by the traditional (non evidence based) practices of their clinical mentor. Evidence Based Midwifery 7 (1), 24e34. Ashcroft, B., Elstein, M., Boreham, N., Holm, S., 2003. Prospective semi-structured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives. British Medical Journal 327 (584). doi:10.1136/bmj.327.7415.584. http://www.telegraph.co.uk/news/uknews/ 1542372/Mothers-are-turned-away-due-to-midwife-shortage.html.
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