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National Review of Nursing Education

Midwifery Education

Literature Review and Additional Material (Revised Edition)

3. Results of the Review

• 3.1 Background

• 3.1.1 Workforce Crisis in Australian Midwifery

• 3.1.2 The Australian Health Workforce Advisory Committee Midwifery AHWAC) Workforce Working Party

• 3.1.3 Inconsistencies Within Midwifery Education in Australia

• 3.1.4 Incompatibility with International Standards

• 3.1.5 Financial Issues

• 3.1.6 Recruitment, Attrition and Retention Rates of Midwives

• 3.1.7 The Transfer of Midwifery Education into Universities

• 3.2 Current Issues

• 3.2.1 Retention of Graduates Through Evidence-based Models of Care

• 3.2.2 Strategies for midwifery educational reform in Australia

• 3.2.3 Flexible Delivery of Midwifery Education

• 3.2.4 Standards

• 3.2.5 Continuing education of midwives in Australia

• 3.2.6 Midwifery Education in Rural Australia

• 3.2.6.1 Western Australia: Rural Midwifery Program

• 3.2.6.2 New South Wales Charles Sturt University: Graduate Diploma in Midwifery

• 3.2.6.3 The University of Southern Queensland

• 3.2.6.4 A personal overview of midwifery education for rural midwifery

• 3.2.7 Continuing Education Needs in Rural Areas

• 3.2.8 Re-Entry

• 3.3 Australian Midwifery Action Project⁶ Education Survey Results

• 3.3.1 Course Details

• 3.3.2 Course Demographics

• 3.3.3 Total number of students

• 3.3.4 Program Details

• 3.3.5 Barriers to providing midwifery education and strategies to overcome these barriers

• 3.3.6 AMAP Practitioner Survey

• 3.4 The Development of 3-Year Bachelor of Midwifery in Australia

• 3.4.1 International Trends in the Last 10-Years

• 3.4.2 The Development of New DEM Courses in the UK: Comparisons with the Situation in Contemporary Australia

• 3.4.3 Evaluation of the New DEM Programs in the UK

• 3.4.4 The Australian Bachelor of Midwifery

‘Unevenness of educational preparation and a projected shortage of midwives together with growing frustration at inadequate recognition of midwives’ distinctive knowledge and skills all pose challenges to policy moves to encourage a greater midwifery role in maternity care’. (Reiger 2000/2001)

3.1 Background

In 1986, Lesley Barclay provided a thorough historical analysis of midwifery education and practice in Australia. She identified issues that hinder Australian midwives from practising fully according to the World Health Organisation’s (WHO) definition of a midwife (WHO 1966). These issues are still relevant in 2001 and can be summarised thus:

• Rules and regulations in most states do not define or describe midwifery and do not set appropriate standards for midwifery education and practice. Regulation is idiosyncratic, inconsistent and often renders midwifery invisible within nursing. This is compounded by the limited view of midwifery demonstrated by some nursing leaders who are in a decision-making capacity on behalf of midwifery;

• Midwifery education is inconsistent between states and needs to be reviewed since reciprocal registration is granted. There is evidence of major differences in the award, and length of programs as well as the theory, practice and assessment elements of midwifery courses across Australia;

• The economic competition of private medicine, elitism, sexism, insurance systems and the alignment of nursing with medicine have all combined to erode the role of the midwife and assert medical dominance;

• A tradition arose in the early 1900s that midwifery was a necessary completion of one’s training as a ‘nurse’, a prerequisite for promotion;

• There is a poor use of midwives’ skills in many hospitals and few opportunities for midwives to practise autonomously;

• The current system of midwifery education is not cost-effective and is wasteful of resources;

• The issue of ‘direct entry’ should be re-examined in light of international developments in midwifery and the ‘dubious cost-effectiveness’ of current midwifery education.

• Since Barclay’s 1986 thesis, these issues have continued to dominate discussions regarding Australian midwifery (Barclay & Jones 1996, Barclay 1995, Barclay 1998, Tracy et al 2000, Bogossian 1998, Brodie & Barclay 2001, Leap 1999, ACMI Victoria).

The situation has become increasingly more acute in the face of a workforce crisis in recent years. Furthermore, in line with international developments, various government documents have identified the need for new models of care where midwives offer continuity of care to women throughout pregnancy, labour and the early postnatal period (Department of Health 1993, NHMRC 1996, NHMRC 1999, Commonwealth Department of Health, Rocking the Cradle 1999). The challenge is to design an appropriate education system to address these issues and build a competent midwifery workforce in the numbers required delivering essential maternity services.

3.1.1 Workforce Crisis in Australian Midwifery

A recent review of midwifery workforce issues in Australia undertaken by Tracy et al (2000) highlights the need for national policy leadership. Their review suggests that there is a crisis of confidence in the education and monitoring of the maternity workforce and that, across Australia, there are concerns about the fact that there is no national planning, monitoring, regulation or quality control of midwifery education in Australia.

Specific areas of concern highlighted by the research carried out by Tracy et al are:

• There is a lack of data and coherent national planning for the maternity services workforce;

• There is little quality control of current midwifery education;

• There is a severe national shortfall in the availability of employable midwives and there are concerns regarding the time it will take to reduce the deficit;

• There is a need to educate midwives for the emerging innovative models of care;

• The needs of Indigenous and remote communities, where there are no local maternity services or personnel, should be addressed as a matter of urgency;

• As midwifery is considered a postgraduate qualification it now attracts full course fees;

• The supernumerary status of midwifery students may lead to a decrease in clinical experience.

Tracy et al (2000) suggest that the short, one year direct entry programs that were phased out thirty years ago in Australia have influenced a negative perception of Direct Entry Midwifery (DEM) that is out of keeping with international trends. They propose that DEM education in the form of three-year undergraduate programs could address the current concerns outlined above. They suggest the following considerations when contemplating such a move:

• It is not cost-effective to educate someone for five years in order for them to become a practitioner in midwifery;

• The current and projected shortage of midwives could be addressed more quickly through DEM programs;

• Government subsidised first degree programs are a more viable proposition than the current expensive post (nursing) graduate programs;

• Appropriate clinical placements need to be developed;

• Support from other professions should be sought;

• There are already overseas DEM educated midwives registering in Australia.

Tracy et al (2000) outline major issues around midwifery labour force and education in Australia. The researchers identify a lack of comprehensive data on midwifery workforce complicated by differences in definition. Where data is available it demonstrates a shortage of midwives, particularly in rural areas, an ageing midwifery labour force and a lack of consistency in education programs for midwives within states and territories and nationally. A rudimentary modeling exercise led the researchers to suggest that we are currently educating less than two-thirds of the number of midwives required to meet the needs of Australian maternity services. This suggestion was borne out by a survey of Area Health Services and universities in New South Wales in 1998 that highlighted a shortfall of student midwives and foreshadowed declining numbers (NSW Health Framework for Maternity Services 2000:14). There is no national monitoring system or reliable data set nationally, to ensure that enough midwives are educated, or to guarantee that comparability and quality are maintained through agreed standards.

3.1.2 The Australian Health Workforce Advisory Committee Midwifery AHWAC) Workforce Working Party

An important committee is currently investigating the workforce needs of Australian Midwifery. The Midwifery Workforce Working Party reports to AHWAC and was formed in late 2000 to assist with the development of a more strategic focus to health workforce planning in Australia. The Working Party comprises a panel of experts from a range of fields, including the midwifery profession, government (both policy development and service delivery) and academia.

AHWAC reports to the Australian Health Ministers’ Advisory Council, which has asked that the ‘specialised nursing workforce’ be considered as a first priority, and in particular the specialty areas of critical care, midwifery, mental health, aged care and emergency nursing. Of these five groups, midwifery and critical care have been identified as the initial priority of AHWAC.

It was in recognition of the need for workforce planning that AHWAC asked the Working Party to provide a report on the number, composition, distribution and workforce characteristics of the current midwifery workforce, and the optimal supply (including the appropriate distribution) of midwives across Australia, including projections for future requirements. The focus of the project is very much about numbers.

The Working Party’s immediate goal is to explore data issues. It will utilise existing data sources, including the nurse labour force information collected at registration, and identify what information is still required. Health departments, registration authorities and professional organisations (and the AMAP researchers) have been approached to assist with this process which is on going and concurrent with the preparation of the Review.

3.1.3 Inconsistencies Within Midwifery Education in Australia

The AMAP Education Survey (Appendix B) confirms concerns expressed by others that there is no overall consistency in the level of award, duration, or design both nationally and within each separate state (Glover 1999, Tracy et al 2000).

A survey of midwifery education programs in Australia in 1992 raised concerns about the disparity between programs both between and within states (Hancock 1992). At this time only 10 tertiary midwifery programs were identified in Australia. Inconsistencies were identified in terms of the level of awards, theory and practice hours, employment/supernumerary status, support for students in clinical areas, full-time/part-time options, entry requirements and arrangements for indemnity insurance for students (Hancock 1992).

The AMAP education survey also confirms that the midwifery practice component of courses varies considerably. In some programs, AMAP data shows the clinical experience undertaken by students is insufficient for licensed midwifery practice and legitimate authority to manage care when compared with the clinical experience that is mandatory in other countries. Chamberlain (1998) in her role as Professor of Midwifery at Sydney University draws attention to the inconsistencies that exist in midwifery education:

The strategies that Chamberlain suggests to address this problem include:

• A standardised objective evaluation of all midwifery programs to ensure all students meet the needs of maternity care today and in the future;

• The implementation and evaluation of a limited number of direct entry midwifery programs in different Australian contexts;

• An annual state registration with evidence of recent clinical practice and ongoing continuing education;

• The incorporation of evidence based approaches to teaching and learning;

• All midwives involved in teaching students should participate in preceptorship training and evaluation and feedback on their techniques for clinical facilitation. (Chamberlain 1998)

3.1.4 Incompatibility with International Standards

In some states, competency based assessment in pre-registration midwifery courses has completely replaced a system that was based on minimum clinical requirements for qualification (AMAP Education Survey 2002). This creates the potential for a situation where a preceptor could determine that a student is competent, even though the student has attended fewer than five births. Other states demand proof of the achievement of both competencies and minimum clinical requirements. Still these assessment regulations fall short of those required by the regulating bodies of other industrialised countries considered by them and the BMid Taskforce as essential to protect women. Australian midwives are seriously disadvantaged when they wish to work abroad and often have to complete further education and training, particularly in community midwifery (Leap 1999).

In reviewing midwifery in Australia, when in her role as Professor of Midwifery at La Trobe University, Waldenstrom (1997) outlines developments, such as continuity of care models and birth centre care, which give cause for optimism about the future. She identifies that the challenge is to change mainstream care in the public sector and that education needs to be expanded to facilitate these changes. She calls for a review of midwifery education with international benchmarking, suggesting countries like New Zealand, the USA, Canada and the European Union. As an illustration she lists the clinical requirements for midwifery qualification of the 15 countries of the European Union where the recommended length of midwifery education for nurses is 18 months, full time. Australian midwifery education programs fall short of these standards in terms of both time allocated to education and the amount of clinical experience that is required.

Waldenstrom suggests that a major barrier to increasing the clinical component of midwifery education programs in Australia is competition with medical and other students but states optimism in finding solutions to this problem, ‘considering that clinical placements is not a problem in many other countries with strong midwifery education’ (Waldenstrom 1997:13).

In a previous paper, Waldenstrom (1996) discussed the future organisation of maternity care in Australia and how midwives could practise in a more effective way. She states that developments in practice should be reflected in midwifery education and makes the following suggestions:

• Midwifery education for nurses is expanded to include a third semester, bringing it in line with the length of many European programs. After the education program there should follow one year’s compulsory, supervised, paid training, with half of the time allocated to a labour ward;

• The midwifery student gains extensive experience of antenatal care, including history taking, assessment of maternal and fetal well-being, emotional support and coordination of one childbirth class, including 4-5 antenatal classes and one postnatal class;

• The student provides continuity of care by supporting one woman through pregnancy, birth and the first postnatal weeks;

• The student obtains extensive experience of monitoring labour, and conducts 50 deliveries and 150 vaginal examinations. The student performs 5 episiotomies and sutures 15 tears and 5 episiotomies. The student also inserts 10 intravenous cannulations;

• The student gains sufficient experience in postnatal care to be able to discharge women with a normal pregnancy and birth, and to see the woman at their last check-up some weeks after the birth.

Waldenstrom’s recommendations (1996, 1997) are clearly an effort to address the notion that midwives should be competent to work autonomously from day one following graduation. This is the rhetoric described in many Australian midwifery curriculum documents. However, the short length of courses when compared with other countries, the need for graduate midwifery programs and the notion of preparation for a ‘beginning practitioner’ (Glover 1999a) suggest that many Australian midwives may not be adequately prepared to work autonomously, without further education. This is paradoxical and concerning given that midwives are licensed to provide care on graduation. Furthermore, Australian educated midwives, applying to practise in other countries, are required to undertake further education and training before gaining registration and being able to work as a midwife.

In commenting on her impressions of Australian midwifery following a study tour in New Zealand and Australia, Professor Lesley Page (1997) noted that there is evidence of a search for professional autonomy in Australia against considerable difficulties and a great pride in advanced scholarship amongst midwives. In her opinion, the difficulties Australian midwives face include the following situations:

• Australian midwives face an operative delivery rate which is on a par with the USA;

• Although there is a strong will to alter the regulation of midwifery education by nursing and provide direct entry midwifery, change is difficult because of a lack of national opportunities – legislative change only being possible state-by-state;

• Some nursing associations regulate midwifery without any midwifery representation at all;

• There is evidence of a strong movement to alter the maternity services, mainly through team midwifery and the provision of birth centres;

• Although educational provision differs from state to state, in general programs are not as long as in Britain.

3.1.5 Financial Issues

Midwifery in Australia is classified as a postgraduate qualification that builds on a nursing qualification therefore it attracts full course fees in most universities. Financial hardship to students is well described in the AMAP Education Survey (See Section 4). The financial constraints of undertaking midwifery education for most nurses contribute to recruitment and attrition rates. Furthermore, some students are obliged to continue working as nurses throughout the period of undertaking midwifery education, some of them full time, fitting in midwifery placements whenever possible, a factor that is clearly stressful and mitigates against quality midwifery education and a sense of midwifery identity (AMAP Education Survey).

The health system is indirectly suffering through lack of staff produced as hospitals themselves no longer pay for the education of their workforce and therefore less often contribute to competency and retention of students in the workforce.

3.1.6 Recruitment, Attrition and Retention Rates of Midwives

Historically, and until recently in Australia, midwifery was commonly undertaken as a second certificate in nursing by people who did not intend to practise midwifery (Barclay 1995). A recent report on new midwifery graduates in New South Wales (NSW Health 2000b) identified that 30% of newly qualified midwives did not seek midwifery employment on completion of their midwifery education program. Local experience suggests this may be course-specific, not generalisable across the state and the reasons therefore require further investigation. Issues identified for attrition include lack of support, the stressful nature of the course, failure to acknowledge prior experience and horizontal violence (AMAP Education Survey 2002, NSW Health 2000)

Waldenstrom (1997:13) highlights the discrepancy between the number of midwives trained and the numbers who actually practise midwifery and suggests that ‘a better education and a more extended role might limit the numbers who abandon midwifery’. Attrition rates appear to be related to the quality of education and clinical experience received by students. The high attrition rates from programs that are expensive for students to undertake and the fact that attrition rates are not consistent across courses suggest these can be reduced.

The University of Technology, Sydney (UTS) offers a Graduate Diploma that has increased recruitment rates dramatically and has low attrition rates. Information regarding the revision of this program can be seen in Appendix C. When comparing this program with others across Australia, and following informal consultation with students and midwifery educators, it would seem that the success is associated with the following issues:

• Students are employed for one-year on a four-day a week basis at a rate of remuneration compatible with their previous employment as nurses. This has obvious financial benefits for students but also increases their exposure to and sense of ‘belonging’ within a midwifery culture. Midwives in the hospital get to know the students and take an interest in their development;

• Midwifery educators with close links with the university are employed in hospitals to work alongside the students;

• Summer schools on either side of the year of employment enable students to qualify in approximately fourteen months, thus theory and practice can be integrated during this time and the students can concentrate on midwifery practice and developing skills and confidence throughout their education;

• The revised program specifically addresses contemporary developments in midwifery practice, service provision and midwifery teaching and learning.

3.1.7 The Transfer of Midwifery Education into Universities

In Australia, the ‘greatest debate’ in a workshop to discuss the transfer of midwifery education to the university sector in 1992, related to the level of the award. Participants were unable to agree and some advocated strongly for nurses to be able to study to become midwives at both graduate diploma and masters level ‘to allow the Registered Nurse a choice’ (Glover 1992). In reporting on this meeting, Glover (p.9) questions whether the international definition of the midwife is appropriate ‘for the midwife of today and the midwife of tomorrow’ and suggests that the new university curricula ‘must reflect the attitude, knowledge and skills of a beginning level midwifery practitioner’. This view is not reflected in the literature in other countries where the onus is on universities to educate midwives who can practise to the full role and sphere of practice of the midwife on graduation. This arguably has been different within university schools of nursing which have very different outcomes and ongoing systems from those existing in schools of midwifery that were women’s hospital or maternity unit based. While Barclay (1986) showed that those also were problematic in many ways, they had more autonomy and focus than university programs set up in the last decade and more authority over course content and clinical experience.

By contrast, in reporting on the same workshop, Sledzik (1992) identified that there was universal concern for a uniform approach to midwifery education from both a national and a global perspective, that adequate funding for midwifery programs needed to be secured, and that every effort should be made to ensure that theory and practice be integrated in the interest of competence in clinical practice.

In her survey of Australian midwifery education in universities in 1992, Hancock confirms that existing inconsistencies between states regarding registration criteria were exacerbated by the move to universities and the subsequent different levels of academic award. In a later opinion piece, Hancock (1996:7) sees the transfer of midwifery education to the higher education as a ‘challenging but extremely worthwhile process’. She alludes to a process of ‘grieving over the loss of hospital-based training’ but suggests that comparisons are irrelevant given the potential for students to emerge as ‘independent’ practitioners, prepared to…

Hancock describes a curriculum that differs from midwifery curricula in other countries since it includes aspects of women’s health ‘from menarche to menopause… performing Pap smears and associated women’s health assessments’ (ibid:8). Careful consideration should be given to the implications of fitting in this additional area of expertise in programs that are already much shorter than midwifery education programs in other countries.

For teachers of nurses and midwives, the loss of identity with the health service and the difficulty in maintaining links and clinical competence when trying to establish themselves within a university setting have been well described by Barton (1998).

3.2 Current Issues

3.2.1 Retention of Graduates Through Evidence-based Models of Care

National and international research has demonstrated that where midwives are able to respond to the identified needs of women and provide a personal and continuous service through pregnancy, birth and the early weeks thereafter, they report an increased sense of satisfaction and autonomy. Furthermore, the experience of working in such models of care may transform approaches and attitudes to practice (Brodie 1996, Homer et al 2000, Kenny et al 1994, McCourt & Page 1996, Page 1995 & 2000, Rowley et al 1995, Waldenstrom and Turnbull 1998). Midwifery students, who are exposed to this way of working, even if only in theory, find the tensions between such models and the realities of tertiary midwifery services in Australia discouraging (NSW Health 2000a). Any strategies to improve the education of midwives need to be mindful of the risks of retaining graduates exposed to different models where they cannot fulfil the full potential of the role and sphere of practice of the midwife (ACMI Vic 1999).

3.2.2 Strategies for midwifery educational reform in Australia

Tracy et al (2000) suggest strategies for Australian midwifery educational reform in order to address the supply and preparation of midwives. The argument on which this is based is not only because of crisis of supply and cost disincentives to enter programs, but also that midwifery is a new area of study with a separate license, not a postgraduate addition to nursing. This is confirmed by numerous states licensing non-nurse midwives. The strategies Tracy et al (2000) suggest include:

• Removing the postgraduate fee attached to midwifery education;

• Increasing the options of midwifery models of care and birth centres to improve the retention of midwives in the workforce;

• New models of education to enable Indigenous women to become midwives;

• Area Health Services work with universities to ensure that midwifery education programs meet service needs (NSW Health 2000a, 2000b);

• Offering three-year Bachelor of Midwifery programs that would educate midwives to provide a breadth of practice across tertiary, remote and rural areas and assist retain graduates in practice.

3.2.3 Flexible Delivery of Midwifery Education

Glover et al (2001) have described strategies at Flinders University, Adelaide, that enable nurses living in rural areas to undertake midwifery education by distance education at both bachelor and masters level. The paper raises serious issues about competency assessment, as minimum practice requirements are not included in the course. An example is cited of a student not getting employment in her country hospital on completion of her midwifery education ‘as she did not have enough experience as a midwife’ (Glover 2001: 433). The problems associated with students fitting full-time study and midwifery practice placements around continued full-time employment as nurses are alluded to by Glover (2001) and were identified as a major problem in the AMAP Education Survey (2001). This approach contrasts strongly with that developed by Fahy in Queensland and the quality controls applied by the registering authority in that state to monitor their flexible delivery program. This program has been developed with the industry who are active partners and is designed to meet rural needs (see 3.2.6.3).

The Midwifery CD-ROM based units designed by Dr. Kathleen Fahy¹ and colleagues at the University of Southern Queensland (USQ) recently won an award for Excellence in Design and Delivery of Teaching Materials. The four CD ROM based units constitute the majority of the midwifery clinically orientated units in a Masters of Midwifery offered by the university for nurses wishing to gain a midwifery qualification.

The curriculum is designed to develop both individually and socially co-constructed knowledge through the interactive CD-ROM learning experiences supported by books of readings, online discussion groups, interaction with midwifery clinicians and residential schools. For example, over sixty oral stories (with image) from women, their husbands and expert practitioners have been incorporated as a way of situating learning in practice instead of textbooks. In viewing these stories the user is able to use a controller to stop, start and replay these stories and photos of the speaker and other relevant images.

The Midwifery curriculum and the CD ROMs use a model of situated learning, which means using real stories from childbearing women and midwives as the way of anchoring learning and making it meaningful. A situated learning perspective is based on the belief that skill development and knowledge is contextually situated and is fundamentally influenced by the activity, context, and the culture in which it is used. Key attributes of this approach to learning are: cognitive apprenticeship, reflection, coaching, multiple practice and articulation of learning, including linking research evidence to practice, and use of stories from the field.

'Be the Midwife' learning and assessment scenarios are life-like re-enactments of clinical situations, including emergencies, where students are required to respond interactively as if they were the clinician in the situation. In the emergency scenarios students are required to respond within a ten-minute timeframe as if they are the only registered health care practitioner in a rural hospital during an obstetric emergency. Students are required to answer directly into an embedded e-mail so that their answer comes directly to the lecturer's desk. Immediately following the student’s answer being sent they are provided with expert feedback which shows how a practitioner actually responded.

The course has been positively evaluated by both students and professional peers, and has undermined the common assumption that classroom teaching is necessary for training health personnel. A further strength is that the course is based on industry partnership, which means that many students’ learning is happening in the clinical setting, supported by clinicians and clinical educators. This is a cost-effective model for the university whilst providing an excellent combination of theoretical and clinical education for students. [Further information regarding this program can be seen in 3.2.6.3].

3.2.4 Standards

As first identified by Barclay (1985) Australian midwifery practice suffers from a lack of national standards. The uptake of the ACMI Competency Standards for Midwives (ACMI 1998), first developed in 1994 (Glover 1999b) by regulatory authorities has been slow. Concerns that the competencies have not been validated are being addressed in the latest revision of these standards due to be published later in the year alongside a national Code of Professional Conduct (Glover 1999b). The importance of consistent national standards of practice is recognised in all other countries studied for this Review.

3.2.5 Continuing education of midwives in Australia

A survey of 240 practising midwives in Victoria (Watson et al 1999) found that 80% were satisfied with their work, and interactions with women were the most important aspect of this. Satisfaction was associated with working in the labour ward, feeling adequately prepared by midwifery education, nursing for more than 15-years and having continuing education. There was little evidence of increasing autonomy or involvement in change. Few midwives in this survey were university educated. They were more likely to describe their preparation for midwifery practice as ‘adequate in most areas’ than to say it was ‘thorough’ (71% and 24% respectively) but only a few (5%) felt they had been not been very well prepared.

Rural midwives wrote about their difficulties in accessing continuing education in terms of release from work, expense of travel and distance. Part-time work, night-duty and family responsibilities were all identified as factors contributing to difficulty in accessing continuing education

Continuing professional education opportunities at the workplace or elsewhere were taken up by three-quarters of the respondents (Watson et al 1999). This is a higher rate than has been demonstrated in several British studies (Clarke & Rees 1989, McCrea 1989, Robinson 1994) and is in line with another studies of midwives uptake of continuing education in midwifery (Nursing Board of Tasmania 1997). In the latter study, all midwives eligible to practice were surveyed. Midwives favoured programs conducted in the workplace over study days, self-directed packages and/or distance courses. Full day courses were preferred to half days and weekdays were more than four times more popular than weekends or evenings. Main sources of information about midwifery practice, in order of importance, were in-service sessions at the workplace, colleagues, an Australian Nursing Journal and professional organisation newsletters (Nursing Board of Tasmania 1997).

Price (2001) has suggested that a modified problem based learning approach facilitated by clinically based teachers in the practice setting is an appropriate form of continuing education for midwives.

There is increasing interest in the use of portfolios to demonstrate professional development as evidence in support of annual registration in Australia (Cooper & Emden 2001). This idea was first articulated in the UK (ENB 1991a) where it is now incorporated into statutory regulation. If a similar system for registration is introduced in Australia midwives will have to consider their needs for continuing education and professional development in a more structured way than is required at the moment.

3.2.6 Midwifery Education in Rural Australia

Shortages of midwives are particularly acute in rural and remote areas of Australia and this places pressure on the continued provision of maternity care and obstetric services in these areas (Cullen 1994). Examples of three models of excellence that have addressed these issues somewhat are differently summarised here:

3.2.6.1 Western Australia: Rural Midwifery Program²

An innovative midwifery course has been run in Western Australia (WA) for some years. It began at King Edward Maternity Hospital (KEMH) and aimed to prepare graduates to be more capable of working in rural settings by providing block placements in both rural and urban settings for rural students. Government and local health services sponsored this program with each nurse applying needing the support of the local Health Service Unit in writing. The candidate was expected to make a commitment to ongoing practice as a midwife in rural WA on completion of the course. This course was initially developed in recognition of difficulties with the recruitment and retention of midwives in rural WA and the fact that 30% of all births in WA take place in country hospitals. The Rural Health Development Unit in Western Australia was heavily involved in the development of the program.

The chronic shortage of midwives in some country areas, in the North of the State and the Goldfields in particular, was the subject of a strategic planning meeting called by the Chief Nursing Officer in 1994. The Health Department of Western Australia suggested that the following factors were contributing to recruitment and retention difficulties:

• Expensive living costs in some rural areas;

• Difficult to maintain skills in hospitals with few births;

• Midwives spending more time caring for the elderly extended care patients than practising midwifery;

• Limited number of midwives on staff necessitating extended periods on call when a birth was expected;

• Difficult to access midwifery education, often necessitating relocation to Perth for some or all period of clinical practice;

• Costs associated with education often prohibitive.

A subsequent survey of all registered midwives in Western Australia confirmed many of the previous assumptions:

• The mean age (43.16 years) of midwives is increasing suggesting that less younger nurses are opting to train and/or work in midwifery

• Limited availability of reasonably priced accommodation is seen as a deterrent to recruitment and retention

• Almost one fifth of hospital based midwives work in hospitals that have less than 25 births per year making competency maintenance a concern

• Some midwives felt that working relationships were less than ideal, others were particularly concerned with lack of opportunity for professional development

Strategies suggested in these Health Department documents to address some of the issues highlighted included:

• Providing increased distance learning opportunities for rural students;

• Increased use of rural placements;

• HDWA midwifery education scholarships should target rural nurses.

The planning of the KEMH Rural Midwifery program was also informed by a study by Butt et al in 1997 which used a Delphi technique to seek information from professional colleagues in order to identify appropriate clinical learning opportunities for student midwives. Midwives working in rural hospitals accounted for seven (29%) of responses. The study identified the following issues:

• The need for adequate preparation for rural midwifery;

• Concerns regarding the standards of practice and amount of experience in some rural hospitals;

• Consideration should be given to the need for hospitals to be formally assessed for their suitability to provide experience for students;

• Students should have exposure to "high risk" experience before working in rural areas;

• Rural areas offer experience in clinical decision making in situations where midwives often work without immediate access to medical assistance;

• The vast size of WA and the obvious disparity of maternity services throughout the State makes it highly desirable that students obtain experience in rural locations during their midwifery course;

• Rural placements may assist future midwives to make firm decisions concerning their choice of practice area and overcome some of the initial difficulty experienced by midwives who accept positions in rural areas.

(Burgum, Butt & Cross 1997)

Since the completion of the sponsored program the option for rural midwifery students has been continued through Curtin University of Technology's Postgraduate Diploma in Midwifery. This is available in distance mode. Midwifery students are employed on salary by their sponsoring/employing rural health service, and spend most of the clinical component time at their local hospital. The hospitals that are involved are required to have approximately 200 births per year to be considered appropriate for inclusion in the arrangement. KEMH provides a clinical placement of approximately 12 weeks, which includes free accommodation and continued payment from the rural health service. This enables the student to complete a period of complex midwifery, obstetric and neonatal nursing experience before returning to their rural base.

3.2.6.2 New South Wales Charles Sturt University: Graduate Diploma in Midwifery³

The Graduate Diploma in Midwifery at Charles Sturt University prepares students for practice in both rural and metropolitan settings in Australia and was developed primarily to meet the needs of registered nurses in rural areas who wish to gain a midwifery qualification.

Charles Sturt University first offered a midwifery course in 1990 as a result of requests from local Directors of Nursing who expressed concern about the difficulties they were facing in recruiting sufficient midwives to staff their midwifery units. The course provides a unique opportunity for registered nurses, particularly those in rural areas who do not want to move to large cities, to undertake their midwifery education using a distance education mode. There are two compulsory residential schools per year. The students complete a total of 954 hours of theory and 1536 hours of clinical experience employed in either 0.8 or full time positions.

In order for all students to meet the required clinical hours in the areas where they require specific experience (antenatal, birthing, postnatal and special care nursery) some may be required to work in larger midwifery settings for some periods. Examples include the students at Cowra and Lithgow hospitals who attend Orange Base Hospital and Nepean Hospitals for birthing and antenatal experience and the "New England Rotation" where five hospitals in the area each employ a student who rotates through all hospitals to gain an overall clinical experience and meet their clinical objectives.

The first program commenced with an intake of four student midwives at Griffith Base Hospital into a 'Certificate in Midwifery'. By 2001 there were 33 students employed in maternity units in the 18 hospitals participating in the program. The number of students and participating hospitals has increased each year and to date 198 students have graduated as midwives.

Feedback from students and midwives who participate in the program has been excellent and the advantages of the program that have been highlighted include:

• Being able to stay in the rural area to complete the midwifery program;

• Having twelve months clinical practise as a student;

• Students are a part of the employed workforce for a period of time during their course which improves clinical experience and their financial position;

• Hospitals enjoy participating in the education of future midwives

• Clinical midwives teaching students find it a refreshing challenge to participate in midwifery education - "it keeps them on their toes".

Difficulties expressed by students have included:

• Travelling to Wagga Wagga for residential schools;

• Leaving family if on rotation

• The cost of the course;

• Horizontal violence towards students and midwives

• Full time study and working at the same time.

3.2.6.3 The University of Southern Queensland⁴

The Master of Midwifery (MM) course offered by the University of Southern Queensland (USQ) was designed as a flexible learning course with rural midwifery practice in mind, mindful of the statewide shortage of midwives. The degree has been designed as a twelve-unit Masters degree, of which four units are CD- ROM based. (See Section 3.2.3 for innovative flexible learning strategies employed in the program). The course has over thirty students currently enrolled and seven students have graduated. Both course and CD ROM evaluation has been ongoing and quality improvements have been made on the basis of these evaluations. The Queensland Nursing Council (QNC) has a peer-review committee that oversees the quality assurance project on a regular basis. Students have been evaluated on a semester basis since the beginning of the course and these evaluations indicate continuous quality improvement and high levels of student satisfaction.

The Masters of Midwifery was developed, and is conducted, in a partnership between the USQ, the Cairns District Health Services, The Toowoomba District Health Service and other maternity units within rural Queensland. It is offered part-time (over five semesters). Students are employed by one of the partner hospitals for five shifts per fortnight for three semesters of the course. Residential school is held in two semesters in Cairns and another school is held in Toowoomba. The two major hospitals provide appropriate classroom access for the three weeks of residential study and a dedicated computer with Internet access for the students of this course.

Cairns and Toowoomba District Health Services continue to employ a full time, on-site midwifery educator who has an appointment as an honorary lecturer with the Department of Nursing at USQ. These clinical educators also have a small role in the teaching of the course. The clinical educators support the students in their computer-assisted learning, supervise their clinical placements, support the clinical teaching associates and conduct clinical assessments.

The primary clinical placements are at the Maternity Unit at Cairns Health Services (10 places) Toowoomba Health Service (12) and the maternity units of Innisfail (1) Ingham (1) and Thursday Island hospitals (1 part-time place). Negotiations have commenced with Mt Isa hospital. Rural students have an exchange placement with students who are located in the high-risk maternity services of Cairns and Toowoomba Base Hospitals.

3.2.6.4 A personal overview of midwifery education for rural midwifery

In commenting on midwifery education for rural midwifery for this Review, Pam Shackleton⁵ drew on her extensive experience of midwifery education as well as some informal research she undertook last year to gauge the satisfaction of students and midwives in rural areas. She identifies that there are many positive aspects of being a rural midwife. However there is also much dissatisfaction, which she summarises thus:

• Inadequate funding of midwifery education;

• Poor support from administration and management;

• Lack of support or time release to attend conferences, seminars or in-service education;

• Staff shortages;

• Horizontal and vertical violence;

• Poor support for students from qualified staff;

• Inadequate funding of small hospitals;

• Prioritizing of resources and incentives to medical students.

Pam Shackleton suggests the following strategies for improving midwifery education in rural areas and for increasing the numbers of midwives practising in rural areas:

• Mainstream funding (as opposed to token amounts in the form of scholarships) to encourage nurses to become student midwives; for midwifery refresher courses with adequate midwifery support and supervision; and some form of mentorship for new midwives in rural areas;

• Allocated funding must be targeted at midwifery education and be seen to be used accordingly with no possibility of it being diverted to other costs by hospital financial managers. There must be accountability regarding where the funding is spent.

• All hospitals that use the services of a midwife (including small private, religious,
  and public hospitals) must contribute towards the cost of educating midwives. It is morally unfair for the cash strapped public system to have to pay for preparing midwives for the workforce and then at graduation they are employed by the private (and often much wealthier) sector. If the hospital has too few births to support a student then they should be required to financially contribute to other centres to allow them to do so;

• Managers must be pro-active in dealing with any horizontal violence. They need to appraise their own attitudes and behaviours, have suitable counselling training and take responsibility for the unhealthy behaviours of employees;

• Managers must not leave it up to midwifery staff to decide if they will have a student midwife or not. If the hospital has the resources and employs midwives then they need to share the costs of educating them;

• Financial support to hospitals to employ a midwifery educator would increase the availability of student placements. An example is Wagga Wagga Base Hospital, which has the capacity to educate ten students per year. Currently they employ four students per year because they cannot afford to employ a midwifery educator. That role is now performed by designated clinical midwifery specialists (and any other willing midwife) who already have huge workloads;

• There is a need for real direction from governments via midwifery / nursing authorities to area health services indicating how allocated funds are to be spent. The system of leaving it up to individual Chief Executive Officers and hospital managers is not a way of ensuring money is spent on midwifery. A system should be enforced where each area CEO has to demonstrate their commitment to midwifery education by allocating adequate funds for the education of midwifery students. This must be in direct proportion to the size of the midwifery units, the number of births per year and the number of midwives employed. The outcomes must be transparent to demonstrate active and adequate participation;

• The registering authorities must continue to be flexible in their accreditation of smaller rural hospitals to support student midwives. Student midwives need to be employed by the participating hospital according to the availability of experienced midwives to provide quality learning experiences and mentorship. The availability of an obstetrician should never be the determining factor of whether or not student midwives are employed by a given hospital. In hospitals with limited maternity services the student would need to continue to participate in a rotation to larger centres to gain a variety of experiences.

3.2.7 Continuing Education Needs in Rural Areas

The Centre for Family Health and Midwifery is currently beginning a study of the orientation and continuing education needs for midwives in rural and remote areas in NSW and Northern Territory. The work has a PhD student attached and has a particular focus on effective community engagement (both Indigenous and non-Indigenous) and a public health orientation to midwifery education and services.

3.2.8 Re-Entry

It has proved difficult to establish the details of employment rates of students after completing the larger government sponsored re-entry courses.

Courses conducted by the NSW Midwives Association, and sponsored by the NSW Health Department, could not be provide information at this time.

The NSW College of Nursing was unable to provide the information and is currently in the process of surveying students having completed re-entry courses.

The Australian College of Midwives (ACMI) was contacted and at the time of production of this report, we still had not received the information requested. The data from the AMAP study showed that one university provides a refresher course to midwives.

Anecdotal reports, however, suggest that some courses have lower employment rates, than others and that this appears to be related to duration of break in practice.

3.3 Australian Midwifery Action Project⁶ Education Survey Results

Summary

The results of the AMAP Education Survey are presented here for the National Review of Nursing Education as part of the researchers’ review of midwifery education. These results will be fully analysed and published elsewhere. The research has successfully described the following factors in relation to current programs offered in Australia for nurses who wish to study midwifery for initial authorisation to practise:

• Course details: name, qualification on completion, entry requirements, modes of study, course costs

• Demographics: numbers of overseas students, age range, male students, Aboriginal and Torres Strait Islander students

• Total numbers of students: current enrolments – full time and part time, projected annual numbers of graduates based on current enrolments, potential places in courses, approximate attrition rates from courses, the employment profile of new graduates, projected numbers from new courses, midwifery courses for qualified midwives,

• Program details: Length of course, subject details, theory and practice hours, clinical placement details including identified difficulties or problems experienced by students, proposed plans to change courses, teaching arrangements

• Barriers and strategies associated with midwifery education as identified by the 27 midwifery course coordinators

In describing all of the above factors, the results raise serious concerns about preparing the midwifery workforce in Australia in terms of costs to students, clinical practice experience, teaching and learning opportunities, collaboration between key stakeholders and most importantly, the workforce crisis associated with the numbers of students who graduate and then practise midwifery. These issues and others raised by the results of the AMAP research are reflected throughout the discussion in this review of midwifery education prepared for the National Review of Nursing Education.

Introduction

Researchers at the Centre for Family Health and Midwifery, University of Technology, Sydney (UTS) undertook a survey of midwifery education as part of the Australian Midwifery Action Project (AMAP). The aim of the study was to describe the current position of midwifery education across Australia as identified by the midwifery course coordinators in each university offering a program for initial authorisation to practise midwifery.

Methodology

Using a structured questionnaire (Appendix A) and undertaken primarily by telephone interview, a survey was carried out of all universities offering a midwifery course leading to authorisation to practise as a midwife. Ethics approval was given for the study in October 2000. The study commenced in May 2001 and data collection was completed in December 2001.

The Questionnaire was designed by two of the researchers and subsequently reviewed by other AMAP researchers and two midwifery course coordinators who also piloted the survey to identify any problems with the questionnaire. The questionnaire was adjusted to take account of all recommendations and perceived omissions.

To identify which universities conducted midwifery programs, the AVCC web page listing all universities in Australia was accessed. From here the researcher identified which universities had midwifery programs. Following this, 30 universities were telephoned to confirm that the university had a midwifery program that led to authorisation to practise as a midwife, as well as to identify the course coordinators and gain contact details. Ultimately, a total of 27 universities were found to be offering midwifery courses leading to authorisation to practise. The final sample included the midwifery course coordinators from all 27 eligible universities.

A letter and the questionnaire were sent in late May to all the identified midwifery course coordinators, informing them of the research and asking them if they would like to participate in the study. In the following weeks the researcher involved in the data collection telephoned the course coordinators to seek consent and to make a time for the interview to be undertaken. All course coordinators gave consent to participate in the study. Four participants chose to complete the questionnaire and return it by mail rather than by telephone interview. These participants agreed to be telephoned if there was a need to clarify any of the answers.

The questionnaire included questions around issues such as the course demographics, prerequisites for the course, minimum theoretical and clinical hours, details on clinical supervision, teaching details, and two questions exploring the barriers affecting midwifery education and the strategies to overcome them.

The data was de-identified and analysed by a second researcher to:

• describe the nature of midwifery education programs⁷ in Australia in terms of level of award, length of course, theory and practice components, assessment for initial registration, workforce data and issues

• elicit information regarding the midwifery education course coordinators’ views on the most pertinent issues affecting contemporary midwifery education in Australia. In line with other research carried out by the AMAP team, participants were asked to identify barriers to midwifery education and strategies to overcome these barriers.

Findings

Twenty-seven universities across Australia were identified as having a midwifery course leading to authorisation to practise as a midwife. All twenty-seven responded to the questionnaire. Data regarding both the double-degree (Nursing/Midwifery) course that commenced in one university in 2001 and the three-year Bachelor of Midwifery courses commencing in 2002 are not included in this survey. Thus data only reflects courses for qualified nurses who wish to become midwives.

3.3.1 Course Details

Name of course and qualification on completion

There are five different names given to the midwifery courses that lead to authorisation to practise as a midwife. These are:

• Graduate Diploma of Midwifery [17]

• Postgraduate Diploma in Midwifery [5]

• Bachelor of Midwifery [2]

• Master of Midwifery [2]

• Master of Science (Midwifery) [1)

One of the courses also indicated it had two exit points, one at Graduate Diploma level and one at Masters level.

The course names reflect the names of the degrees that are awarded on successful completion of the course.

Entry Requirements/prerequisites for course

All 27 courses require that entrants have a registered nurse (RN) qualification and most require some experience in nursing practice and/or a current practising certificate in nursing. One respondent stated that although it is not a requirement of the university per se, some hospitals they use for clinical placements specify that students must have at least one year of postgraduate nursing experience. One university will take candidates immediately following completion of a Bachelor of Nursing if they have worked as an Enrolled Nurse before obtaining a Bachelor of Nursing (BN) degree, otherwise they require a minimum of 12 months of nursing, preferably in an acute setting. Several universities are specific about the type of nursing experience candidates need to have had and specify that their clinical experience needs to have been ‘relevant’ or in ‘acute care nursing’. Some require a degree in nursing or a relevant discipline and some universities require that students without a tertiary qualification complete graduate diplomas, certificates or a course on scholarly studies before undertaking midwifery education. All the courses awarding a Masters degree stated that an undergraduate degree is necessary. One Masters course accepts candidates without an undergraduate degree by considering their previous ‘life long learning’, although they prefer that applicants have a tertiary qualification because they recognise that without this qualification, Masters level study is demanding. This university recommends that students without a tertiary qualification complete a graduate certificate before applying.

The prerequisites for midwifery education programmes vary considerably from university to university as can be seen in the following list:

• RN qualification only [5]

• RN with current registration [2]

• RN with a minimum of 12 months post nursing experience [2]

• RN with at least 12 months recent experience in an acute (medical/surgical) setting [3]

• RN with at least one year of relevant clinical experience [1]

• RN with current practising certificate in relevant state/territory [1]

• RN with degree or diploma and acute clinical experience in the last four years [1]

• Degree in nursing or relevant discipline plus six months nursing experience[1]

• BN plus one year nursing experience [1]

• BN or RN with degree, one year nursing experience and current practising certificate [1]

• BN with mechanism for assessing eligibility if no BN [3]

• BN - mechanism for assessing eligibility if no BN plus current practising certificate[1]

• BN - mechanism for assessing eligibility if no BN plus state practising certificate[1]

• BN - mechanism for assessing eligibility if no BN plus 12 months nursing experience [1]

• BN - mechanism for assessing eligibility if no BN plus current registration plus at least 7 months nursing experience [1]

• Degree in nursing and current registration as a general nurse [1]

• BN with recent (last 2 years) experience plus satisfactory university transcript [1]

Mode of Study

A variety of modes of study were identified with the majority of courses [16] running internally although seven universities offer an external mode of study. Four other universities offer both modes of study. One respondent stated that while their course is identified as internal by university classification, flexible arrangements are made because some students live far from the university campus. In this situation some study days on campus are supplemented by video conferencing as well as linking through email.

Methods identified for external study modes included:

• Email and internet links

• Distance learning/flexible delivery packages by post

• Email/internet talk lines and flexible delivery packages

• CD ROMs

• residential schools

Course Costs

Approximately half of the participants were unsure about actual course costs. What was identified clearly however, was that some courses were covered by HECS, some were fee paying, and some were a combination of fee paying and HECS.

Not all courses were available to overseas students and since the total number of overseas students enrolled in midwifery education courses was estimated at nine, it is unsurprising that several course coordinators reported that their midwifery courses had never attracted overseas students. This may explain why many participants were unable to give information regarding the costs to overseas students and why approximates were used. In the twelve universities where respondents offered a clear or approximate sum, the costs to overseas students ranged between $4,000-$17,000 per year, with the majority charging around $12,000 per year. In line with most university pollicies, costs to overseas students were significantly higher than costs to fee-paying Australian citizens.

3.3.2 Course Demographics

Overseas students

Eight of the respondents identified that they had full-time overseas students in their courses with a total of 9 (one part-time) overseas students counted.

Age range of students

Not all respondents were able to identify the age range of students and generally the answers given were approximations. The majority of students fell within the 21-29 age group. This was relatively consistent in all universities. Four universities had a larger percentage of students in the 30-39 age range and another had an even distribution of students with 50% in the 21-29 age range and 50% in the 30-39 age range. Overall, approximately 40 students were identified as being within the 40+ age group. Since the overall numbers of identified age groups do not in any way tally with the numbers of student enrollments these figures should be treated as an impression on the part of the respondents.

Male students

Eleven male students were enrolled as of April 2001 although one has since withdrawn.

Aboriginal and Torres Strait Islander students

It must be recognized that not all students who are of Aboriginal and Torres Strait Islander descent necessarily identify themselves as such and therefore the nine identified by midwifery course directors in this study may be an underestimation.

3.3.3 Total number of students (see Table: Appendix 1 end of this section)

Summary of current enrolments

The number of overseas full time overseas students: 8
The number of overseas part time overseas students: 1

Excluding overseas students

The number of full time students enrolled: 375
The number of part time students enrolled: 563
(Counted as 281 FTE for university funding purposes)
Total number of students enrolled: 938 (FT + PT)*
Total number of FTE enrolments: 656 (375 + 281 FTE)*

* [+ estimated 18 FT or PT students and 2 unidentified cohorts of approximately 18 FT and 32 PT respectively]

Respondents were asked how many students were enrolled as of April 2001.Twenty-one stated they had full time and part time students, one that they had full time students only and three that they had only part time students. One respondent did not know how many students were enrolled. She estimated the number to be 18 but was unable to get conformation from the university administration department.⁸ These estimated 18 students are identified separately. Twenty students who were not identified as full time or part time by another course coordinator have been counted as part time since the number of potential places was cited as 24 part time equivalent. Two course coordinators only gave numbers (18 FT and 32PT respectively) for one of the two cohorts offered at their university, one stating that she did not know the numbers for the most recent intake. Five other respondents identified that they run two cohorts per year and gave current enrolment numbers for both of these.

Projected annual numbers of graduates based on current enrolments

Estimations of projected annual numbers of graduates based on current enrolments is problematic given the large number of enrolled part-time students (563), who take several years to complete their studies in some cases. This may lead to a significant over-estimation of numbers graduating each year. Although the total number of enrolled students is identified as 938, if the total number of currently enrolled part-time students (563) is halved and added to the total number of currently enrolled full-time students (375) one arrives at a total figure of 656. This calculation presumes that part-time students will complete in two years, which is not the case for many. This method of calculating projected numbers of graduates based on current enrolments should therefore be treated with caution since it may lead to over estimation.

Potential places in courses

Respondents gave a range of potential places from 10 - open. The course that stated ten was however currently over enrolled. The number of potential places on courses was difficult to evaluate, four participants saying that they could not give a number because they are ‘limited by clinical placements’ and one stating that ‘it is open’. Nine of those who did give a number of potential places in their courses also stated that this varied according to the availability of clinical placements. There is confusion about potential and actual places since two part time students can count as one full time place in terms of HECS funding. However, approximately three-quarters of respondents reported under enrollment on courses and at least two course coordinators stated that their numbers are decreasing. The total number of potential places identified added up to 693 FTE (allowing for the fact that 21 courses have full time and part time students, one has only full time students and three have only part time students).

Approximate attrition rates from courses

Three of the course coordinators described new courses that had not previously had graduates so this question was irrelevant in their situation. The total number of graduates from the most recently completed course was 550. Five respondents stated that their attrition rate from the most recent course was 0%. The others had an attrition rate that ranged from 0.06% to 30%. [Some of the answers to this were approximations]. One respondent stated that they only lost one student approximately every two years and another pointed out that the attrition rate in their course was from part-time students only and not related to full-time students.

Table 1 Attrition rates in midwifery education

Employment profile in midwifery of graduates from courses

The majority of graduates sought employment in midwifery but many ended up not being employed in midwifery. Twenty graduates have been included in the ‘employed in midwifery’ category since their course coordinator stated that ‘the majority’ of graduates sought employment in midwifery and ‘most’ were successful. Another respondent was unsure how many of the 10 graduates from the course gained employment in midwifery; although local graduates were successful, the respondent did not know how those who left the area fared. The total number of graduates identified as having gained employment in midwifery was 346 [+ 20] and the total number identified as not having gained midwifery employment was 114.

According to one respondent, some of those who are unable to find permanent employment in midwifery may have ‘casual work’ in the field. One course coordinator stated that she had ‘no idea’ as to whether the 57 graduates from the course sought or obtained employment. The same applied to other course coordinators in relation to 14, 11, and 10 graduates, thus the total number of graduates for whom their employment status in midwifery was not known is 92.

Projected numbers from new midwifery education programs

In terms of workforce planning, it is worth bearing in mind that the total number of students enrolled in the 3 new courses from which students have not graduated is identified as 39 FT and 22 PT students (50 FTE). However, these numbers should be viewed with caution, taking into account the large numbers of graduates who did not obtain employment in midwifery on graduating from the last courses.

Course coordinators who identified that there were no difficulties obtaining employment in midwifery for new graduates

There were 10 respondents who identified that all, or almost all, of their students both sought and obtained employment. However, concerns were raised by some about the lack of both new graduate programs and support for new graduates. In some cases, graduates had to wait a while before being offered permanent full time positions. Two respondents identified that there were no difficulties obtaining positions for new graduates but they did not comment on the relatively low number of graduates from their programs seeking and obtaining employment in midwifery (3/4 of 75%, and 55% of 85%). See Table below:

Table 2 Graduates who had no difficulty obtaining employment in midwifery

Course coordinators who identified that there were difficulties obtaining employment in midwifery for new graduates

Eight respondents identified insufficient employment opportunities for graduates. One course coordinator highlighted a situation where graduates were not seeking employment in a particular hospital due to religious objections to abortion. Another identified that in regional areas, employers insist on 5 years of experience in midwifery. Where graduates are unable to obtain employment some respond by working casually or for agencies, others move to another state or country to pursue employment in midwifery and some return to nursing. Figures were not available from one program concerning the large numbers of graduates experiencing difficulty in gaining full time employment in midwifery. Figures demonstrating the numbers of graduates who were unsuccessful in gaining employment in midwifery are demonstrated in the Table below:

Table 3 Graduates who experienced difficulty in obtaining employment in midwifery

Midwifery Courses offered for qualified midwives

Eight universities only offer a course for initial authorisation to practise midwifery.

Other midwifery courses (for qualified midwives) offered by Universities include:

• Master of Midwifery [17]

• Professional Doctorate in Midwifery [1]

• Bachelor of Midwifery for qualified midwives [2]

• Graduate Certificate in Midwifery Continuity of Care [1]

• Graduate Certificate in Risk Associated Pregnancy [1]

• Graduate Certificate in Independent Practice [1]

• Midwifery Re-entry Programmes [2]

• Postgraduate Rural Midwifery program [1]

It is important to differentiate these 26 postgraduate courses for qualified midwives from the 27 courses for initial authorisation to practise midwifery. For example, a previous report prepared for the Department of Education, Training and Youth Affairs, Canberra identifies 53 postgraduate [nursing] courses in midwifery and from this figure projects 772 graduates for the year 2001 (Ogle et al, 2001). This is clearly an overestimation in terms of workforce planning and identifying the number of new midwives entering the workforce which by conservative estimates is likely to be less than 450 per annum (see above). An earlier paper provided by the AMAP researchers (Tracy et al 2000) relied on similar government reports in attempting to profile the midwifery workforce and therefore overestimated the number of midwives being educated for initial authorisation to practise.

In avoiding the tendency to quantify all midwifery courses as postgraduate specialist nursing courses, this survey is the first to differentiate courses providing further education for qualified midwives from courses educating nurses to become midwives. In clarifying this differentiation, this survey highlights the alarming shortfall in actual and projected numbers of new midwives entering the workforce.

3.3.4 Program Details

Length of Course

The length of courses, if completed full-time, ranges from approximately 26 weeks (where an academic year is based on two 13-week semesters) to 64 weeks:

• 12 full months [11]

• One academic year (two 13 week semesters) [9]

• 42 weeks over two years [1]

• 45 weeks [1]

• 3 semesters (46 weeks) [1]

• 3 semesters (39 weeks) [1]

• 48 weeks  [1]

• 64 weeks [1]

• 2 years part time, four semesters, approximately 52 weeks [1]

These course lengths should be viewed in light of the 18-month, full time, 45 weeks per year courses for nurses undertaking midwifery education for authorisation to practise in other comparable countries. There are discussions in these countries about extending these courses to 2 years full time (2 x 45 week years minimum) in order to make sure that nurses are suitably educated to become midwives and work to the full potential of the midwife’s role and sphere of practice.

Subject Details

The subject outlines of each course vary considerably in the use of language and nomenclature. The subject titles describe the areas of learning that might be expected in courses leading to authorisation to practise midwifery in the Australian context. However, the language used in subject nomenclature often suggests varying educational and midwifery approaches in terms of teaching and learning methods, style, philosophy, and ideology, particularly regarding the role of the midwife. It is not the brief of this research project to carry out a discourse analysis of the language used in the subject outlines or to review and compare the curriculum content of courses. The different approaches are undoubtedly also reflecting the disparate nature of Australian midwifery regulation across individual states and territories and the fact that there are no national standards for the accreditation of midwifery education programmes (Brodie & Barclay 2002).

Theory hours: See Appendix 2

There was considerable variation in the number of theory hours identified in each course. One respondent running an external course stated that they could not realistically identify the number of theory hours but suggested a figure (2080) which was considerably larger than theory hours in the majority of other courses. Two other external courses also stated comparatively large theory hours: 2160 hours and 1560 hours with three respondents citing theory hours of 600, 916 and 954. The remaining courses gave a range of theory hours extending from 174-400 hours. As demonstrated in Appendix 2, the course coordinators who estimated large theory hours in their courses were basing this figure on expectations of student study time in courses offered externally.

Table 4 Theory hours in courses

Clinical practice hours

The number of hours allocated to clinical practice⁹ also appears to differ between courses. Some respondents answered this question by stating minimum hours. The range was 500 –1824 hours with the majority in the less than 1000 hours range. One course arranges 700-900 hours of clinical experience, the number of hours determined by individual competency assessment.

Supernumary students undertake fewer hours than students who are salaried to undertake clinical experience. For example in universities that offer a choice between supernumary and salaried clinical experience the following comparisons can be made:

• Example 1: supernumary model – 900 hours, salaried model – 12,121 hours

• Example 2: supernumary model – 440 hours, salaried model – 1, 920 hours *

• Example 2: supernumary model – 1,000 hours, salaried model – 1.450 hours

• Although the supernumary option is offered, it has never been used as students prefer the salaried option.

Clinical placements

All students have placements in midwifery practice areas. Since midwifery practice was referred to by all participants as ‘clinical’ this is the terminology that will be used here. Clinical placements occur in different modes: weekly, block, yearly and sometimes a combination of these.

Thirteen courses combine supernumary and salaried experience, eight offer supernumary experience only and six offer a salaried model only for clinical placements. Rates of pay for those who are in the salaried model vary and respondents identified this as an important issue that needs to be addressed. Students in eight courses are paid as RNs at their level of experience/service in nursing. Examples of other arrangements are listed below:

• Negotiated on an individual basis with the hospitals.

• Paid at level 1 RN regardless of experience (classified as RN Midwifery student).

• Paid at level 1 RN or level 1 midwife.

• Negotiated between student and hospital - maximum level of pay is as a grade 2, year 6 of equivalence, otherwise paid at their RN year level.

• The minimum standard pay - level 1, increment 2 (ANF award) though some hospitals will negotiate with students to pay more.

• Hospitals determine their own employment rate.

• No less than grade 2 and no greater than grade 3 depends on experience.

• 2 days a week salaried and 1 day per week unpaid (0.4 FTE).

• Employed on 0.8 salary or full time throughout the course.

• Students employed one day a week with two days supernumary in first semester, reversed in second semester.

• Students negotiate their own clinical placements in the first year and are salaried in the second year.

• First half of the course students have supernumary status, salaried for 4½ days a week in second half.

Types of facilities used by the students for clinical placements

All but one respondent [26] stated that they use tertiary level hospitals for midwifery clinical placements and with only a few exceptions, most courses use regional or rural hospitals, some specifying that these facilities must have a level 2 nursery. Private hospitals are used by all but three courses but four respondents clarified that they only use private facilities to access experience for students in hospital postnatal areas. Students are required to rotate through hospital areas and in some cases through different types of hospitals in order to meet the course accreditation requirements of the local nursing regulatory authority. As identified by Brodie and Barclay (2001) these requirements will vary considerably from one state/territory to another. Rotation is most often driven by the need for students to have experience in tertiary referral centres and level 2 nurseries. Students placed in private hospitals need to rotate into public hospitals in order to access sufficient experience of attending women labouring and giving birth. One respondent identified that competition between universities for clinical placements in the same facilities forces students to rotate through different hospitals. One respondent identified a system where it is compulsory for students to remain with the hospital to which they are assigned for the total duration of their midwifery education.

Some regulatory authorities do not require midwifery students to engage in community based placements, hence 11 courses do not enable students to have placements in areas other than hospital wards [a source of serious concern given the trend towards seeing midwifery as a public health strategy for health gain]. Of the sixteen courses that use ‘community’ placements, respondents identified the following areas where students may gain experience:

• Elective time with independent midwife/midwives [6]

• Maternal and Child Health Centres/Early Childhood Nurse [5]

• Community midwifery program [3]

• Women’s Health Centre [3]

• Family Planning/Sexual Health Centre [2]

• Community Centre/ Support group [

• Mother and Baby Unit/Residential Care for PND Unit [2]

• Postnatal ‘early discharge’ program [1]

• ‘Urban Community Nurse’ [1]

• Overseas placement [1]

• ‘community placement – eg Birth Centre’ [1]

• Reproductive Medicine Unit [1]

• Medical Practitioner’s Rooms [1]

• Elective in rural hospital [1]

Arrangements for clinical placements, supervision and assessment

In most programs, responsibility for the organisation of clinical placements rests with the education provider in the university. There are however, five examples of a team approach between hospitals and universities to organising clinical placements. In some cases, before commencing their midwifery education program, students work with the university to secure a placement with a hospital and in three instances the students are interviewed by the hospitals of their choice.

Arrangements for supervision, assessment and the organising of clinical placements vary considerably. There are problems in summarising these arrangements arising from nomenclature, the titles ‘university staff’, ‘lecturer’, ‘mentor’, ‘preceptor’, ‘lecturer practitioner’ ‘clinical educator’ and ‘joint university/hospital appointee’ being used interchangeably by some respondents. As can be seen in the Table below, staff based in hospitals carry out most of the supervision and assessment of students:

Table 5: University staff involved in supervision and assessment of students

Professional development opportunities for preceptors/clinical educators

Twenty-three respondents described some system whereby their university provides professional development opportunities for preceptors/clinical educators. In two sites the university is not involved because the hospitals run their own preceptor workshops and in another instance this is provided by the state health services.

Twelve of the universities identified what type of support they gave. Some universities offered more than one type of support and these included:

• Preceptor workshops

• Assessor program

• Seminars for preceptors with other preceptors from other disciplines of nursing (sic)

• Communication workshops

• Evidence based practice workshop

• Ongoing liaison (‘although not a huge amount - usually when issues arise’)

• In-service

• Professional development to ‘buddies’

• The opportunity for all midwives to attend any lectures in a topic that might interest them without charge

• A workshop for clinical educators to explain the course content and structure and student expectations

Although two universities clearly stated that the workshops were not compulsory the researcher who carried out the telephone survey reports that her impression was that this was also the same for a number of other universities.

Of the four universities who stated that they do not provide professional development opportunities, three gave reasons to justify this situation:

‘No we have had no reason to do this as each clinical unit runs their own preceptor course’

‘No the state health service provides this. They declined the offer from the university’

‘No the hospital does this the university doesn’t’

Identified difficulties or problems experienced by students in clinical placements

Participants were asked to list the difficulties or problems experienced by their students on clinical placement. While it was recognised that not all students experienced problems the following nine themes were identified as causing problems for students:

• lack of support /supervision

• unrealistic expectations of students

• horizontal violence

• rostering

• learning needs of the students secondary to the hospitals needs

• staffing issues

• a philosophy conflict

• competing demands

• placement difficulties

A full analysis of the course coordinators’ comments on these themes will be published elsewhere.

Minimum clinical practice requirements to gain the award

The course coordinators generally referred the researcher to their local regulatory authority, usually referred to as the ‘Nurses Board’. Those that offered a full explanation highlighted the differences that exist between state and territory standards in relation to the minimum practice requirements of midwifery education program:

Table 6 Examples of minimum practice requirements in courses

Payment and qualifications of midwifery educators/preceptors in the clinical area

Whilst some preceptors are paid in 3 programs, and all preceptors are paid in 4 programs, preceptors are not paid in the majority [20] of programs. In 9 programs, people referred to as either: clinical lecturers, instructors, joint uni/hospital appointees, or midwifery educators are paid. Three examples were given of health facilities, as opposed to individuals, being funded for clinical preceptorship:

Most public hospitals are given $3,000 - $8,000 per student for funding of clinical preceptorship – this comes through DEST and is separate to university funding

The uni makes a contribution to the health facility, it normally goes to the midwifery unit.

Some hospitals charge $30 per hour for each student. If the faculty doesn’t go to supervise they are charged $30 per hour for the student.

When asked if there are any educational or experience requirements for those who supervise students in the clinical areas a variety of criteria were described. In some cases respondents described what they thought should happen rather than the reality in their courses. The criteria described included:

• Hospital or university preceptorship programs

• Recognised current clinical competence

• Senior midwife

• At least 2-5 years experience in midwifery

• Tertiary qualifications, in some places a Master of Midwifery

• Designated commitment to teaching

• Hospitals decide on the criteria, university has no control

• Teaching, communication and leadership skills

• Interest in teaching, students and participation in preceptorship programs

• Ability to assess/plan/implement and evaluate education

• No requirements, all midwives should supervise students

• Completion of a practice portfolio demonstrating ACMI Competencies

• Fulfill Regulatory authority’s requirements for supervision

• Volunteers

• Need to be willing and keen, like students

Use of ACMI Competency Standards for Midwives for assessment

With 4 exceptions, all programs use the ACMI Competency Standards for Midwives or a set of competencies that include these, for assessment. In the 4 programs where the ACMI competencies are not used, the registering authority dictates the competency standards.

Course curriculum issues and specific placements

All respondents identified that their curriculum addresses the following issues:

• Rural and remote maternity services

• Aboriginal and Torres Strait Islander health

• Cultural diversity in midwifery care

• Continuity of care models

• Following women through pregnancy, birth and the early postnatal period

• Birth centre care

• Home birth

Placements that enable students to gain experience in these areas were identified as problematic. On the whole placements in such areas were electives that the students had to organise and fund themselves, particularly where experience of midwifery in home birth settings was concerned:

The opportunity is available for the students to do these options as an elective if they have a passion. However there is a cost involved that needs to be met by the student which would make it prohibitive for some.

Birth Centre Care and Home birth [placements] are difficult to provide mostly. Rural and remote [placements] are the same. It’s about the students’ choice and availability. The students don’t follow women through. They used to do this but it became overwhelmingly difficult.

It’s not for want of trying but there are very few models of care to match theory and practice.

Difficulties identified with placing students in rural and remote maternity services included the following practicalities:

• The pressure to meet clinical requirements in areas where maternity service provision is occasional or low volume.

• Students are encouraged to choose rural placements but are unable to due to ‘their other obligations’.

• In one state the Registering Authority has to approve each facility.

Table 7: Opportunities for placements within the curriculum

* Elective option includes where course coordinators identified that it depends on whether the hospital the student is placed in offers this experience. It also includes situations where the student organises this experience (as opposed to the education provider).

# Placements with midwives providing home birth services were identified as rare, and almost always organised and funded by the student.

Extra information about courses

In response to the question, ‘Is there anything else you would like to tell us about your course?’ 6 respondents declined to offer any extra information and one identified that their program had only just started and had not been evaluated yet. Other comments were:

• Going for 5 years, fewer people applying, difficult to find out why

• Have chosen to concentrate on the normal process, only a small amount of deviation from normal taught

• No doctors or obstetricians in the course, only taught by midwives

• They have a theoretical grounding before they go into clinical, follows the sequential nature of birth

• The course has a good retention rate

• Applications always exceed the available places

• It’s a great course. It’s designed for remote and rural people who need to travel a long distance. We offer lectures in blocks and placements are made preferably where students are, within reason. They do need to travel for some placements but we’re flexible about where and how they get their hours up. We offer placements with some great agencies. Because of this range the students get to exchange ideas. They speak highly of their placements.

• The course is conducted totally as a collaborative effort between the university and the area health services – this includes writing the curriculum, implementation of subjects, teaching, assessment and marking

• The course provides a good education for nurses predominantly placed in hospital. It’s not for want of trying [other placements] but there are very few midwifery models of care to match theory and practice.

• One of the strengths of this course is the cultural diversity. Because the materials are external, they needed to be good so they were developed by a collaborative team - which shows in the quality.

• Can’t wait for the 3 year BMid course to start next year. One year is not enough. It’s a very flexible program, students can be external anywhere in Australia. It’s supported very well by [university] staff, usually by phone or staff try to see the students at least every week.

• The strength of the course lies in the small number of students who can be nurtured into midwifery – they stay in midwifery. Competition for placements is difficult. We have to refuse students because of placement difficulties.

• We work in collaboration with a major clinical industry partner and this links the university and industry. Our Clinical Chair in midwifery was the first in the country. It’s a popular course. There’s a graduate clinical school on a hospital site so there’s not a diverse gap between education and clinical.

• An effort is continually made to liaise with hospitals so that an efficient and relevant course can be offered. There is a rural focus and we hope that they will stay working as midwives in rural areas.

• We have a good relationship with the agencies we use and it’s getting better. We are negotiating with one agency to provide paid places. WE provide inservice for health agencies and help with research activities.

• The course is based on a midwifery model, not a medical model. Students only do 5-10 days in SCN

• We were the first to design a one-year course, which made it popular.

• Students are clinically competent and have a good focus on what woman centred care is. Students are very aware of midwifery models of care.

• I think we’re doing something right. We’re frustrated about having to explain why this is a masters program.

• We offer an employment model. We have taken student and industry preferences and adjusted our course to fit. We offer the opportunity to deliver midwifery education in a variety of settings who have not previously been able to support students such as private Level 2 hospitals and rural hospitals.

• Our course is on line and offered in mixed mode.

Consideration of plans to change courses

Ten Midwifery Course Coordinators described an ongoing process of evaluating and changing their program to reflect the identified needs of students and industry, as well as contemporary midwifery practice:

I want to emphasise that the course is looked at constantly for any possible deficits and positive aspects. We review it for quality assurance and as part of the accreditation process. We want to deliver a course that meets the needs of the students but reflects contemporary midwifery practice.

Currently we are addressing through a curriculum development committee the medicalisation of our course. We’re making changes in subject title and content to reflect a more woman centred approach. Changes to language and a move away form nursing and medical knowledge are also part of this process.

Several respondents identified that their university was changing the length of the course. Examples given were extending the program to a:

• trimester model of 15 months

• 4 term academic year

• 4 ten week terms + a 2 week intensive residential prior to clinical

• 3 semester course with one full day on campus and four days a week in clinical, a minimum of 47 weeks employment

• 3 year Bachelor of Midwifery

• 3-year degree with entry for both RNs and non-RNs

Other projected changes in the way courses are offered included:

• Introducing a paid component to replace or combine with supernumary placements (2)

• Increasing clinical hours

• Rewriting the program

• Collaboration with another university to strengthen the sociological and evidence based practice aspects of the program

• Changing the course from a Masters to a Graduate Diploma

• Running the same curriculum over two campuses with two coordinators

• Changing the content of the course for RNs to ensure that they meet the same standards as the students in the 3 year BMid

• Mixing ‘normal’ and ‘abnormal’

University staff teaching arrangements

The teaching arrangements for university staff are summarised in Table 8:

Table 8: university staff teaching details

Course Coordinators qualifications *

Information about the course coordinators’ qualifications are set out below:

* Information not received for one course coordinator and question not addressed in a program where each subject has a different coordinator

3.3.5 Barriers to providing midwifery education and strategies to overcome these barriers

In line with the major research questions of the Australian Midwifery Action Project (AMAP), the Midwifery Course Coordinators were asked to list what they see as the barriers to providing quality midwifery education and strategies to overcome these barriers. Their main concerns were centred on the difficulties providing appropriate clinical placements, teaching and learning difficulties, financial pressures for students and midwifery professional issues. These issues will be discussed elsewhere using the qualitative data elicited during this research but the following list is strategies that were identified frequently:

• More clinical placements

• Improve collaboration between universities and agencies

• Improve support for preceptors and educators

• Multidisciplinary learning, more collaborative teaching

• Address problems associated with part-time students and short supernumary placements

• Develop 3- year Bachelor of Midwifery programs

• Integrate theory and practice

• University support for educators to be involved in research

• More flexible arrangements for delivery of programs

• National and international exchanges

• Clarification of roles and responsibilities around teaching and learning

• More continuing education programs

• Funding for more joint clinical appointments and recognition of their importance

• Clinical Chairs in Midwifery

• Increase course to 18 months

• Employment model to improve financial situation for students and give them a a sense of belonging in the agencies and in a midwifery culture

• Woman centred, evidence based approaches to midwifery education

• Scholarships, subsidies, HECS, reduced fees, reimbursement of students’ costs, increased funding for placements, fund full time study

• Increase publicly funded midwifery models of care

• Increase workforce numbers

• Raise the profile of the midwife within the community

• Increasing inter-professional collaboration and midwifery autonomy

• More staff improved midwife /client ratio

• More midwifery models of care

• Separation of nursing and midwifery within university and hospital settings to recognise the different philosophy

• A pure midwifery award so that hospitals would be unable to deploy midwives [to nursing areas]. This would increase job satisfaction, increase retention and decrease attrition.

Appendix 1

Total number of graduates currently enrolled, potential number of places in the course, number of graduates from most recent course, approximate attrition rates, percentages seeking and obtaining employment

Summary

Total number of graduates currently enrolled (excluding O/S students): 375 FT + 563 PT (281 FTE for university funding purposes)

Total number of students enrolled: 938 FT+PT = 656 FTE + estimated 18 (+ 2 potential cohorts not included: 18 FT and 32 PT based on current cohort)

Number of overseas students: 8 FT, 1PT

Potential places in courses FTE: 693 identified + 1 open (4 gave no numbers – ‘limited by clinical placements’)

Approximate attrition rates: see Chart in Findings

(3 N/A as new courses – first cohort has not completed yet). Total students enrolled in these new courses = FT 39, PT 22 (50 FTE)

Total number of graduates from last course = 572. Majority of graduates sought employment in midwifery Total number graduates estimated to have gained employment in midwifery = 346 [+ 20 ‘most’ of whom gained employment] 366

Total number estimated to have not gained midwifery employment: 114 (some may have ‘casual work’)

Graduates for whom employment status in midwifery not known: 92.

Appendix 2

Table showing internal, external and mixed mode courses by number of theory hours.

3.3.6 AMAP Practitioner Survey

Analysis of the data is in train and a summary will be provided to the National Review of Nursing Education when this is completed.

We have extracted some typical quotes from the raw data that exemplify concerns practising midwives have about the current education of students:

• ‘Lack of a nationwide standard of midwifery education and registration process (endorsement).’

• ‘It's time to unite the various states' Nursing Councils and have an Australia wide registration process. It would save money both for councils and the nurses. It would also make it easier for midwives/nurses to work anywhere. How many good nurses have we lost because of the mucking around with registration changes to other states when their husband has been posted or moved? We may need to look at bringing back in semi hospital training or a more structured clinical placement with the University based education.’

• ‘Education of midwives/ standardisation of care etc and then development of particular skills for practice in different midwifery settings. So midwives are comfortable to be midwives with women’.

• ‘Some way of checking that remote midwives are required to have ongoing education. Co-ordination of GP management of antenatal women requiring up to date management.’

• ‘Uniform midwifery education.’

• ‘Poor education standards -course too short’.

• ‘Increase in length of education with uniform standards.’

• ‘Better education -i.e. 'national' standard -for education of midwives.’

• ‘Inadequate education of midwives to fulfil expected role. Don't feel competent! Limited experience in all areas’.

• ‘Current midwifery training inadequate.’

• ‘Review current midwifery training. Have national standard midwifery’.

• ‘Standardise clinical and educational requirements across States and territories. Standardise Registration procedure at Federal level. Distribute the saved administrative costs to publishing a book.’

• ‘Evaluate which tertiary course give the best balance of practical and academic grounding in Midwifery knowledge. Make this the Australian Standard required. Be cognisant of the need of the midwife to earn as they learn. And making more manpower available. Perhaps also investigate alternative payment options for tertiary courses’.

3.4 The Development of 3-Year Bachelor of Midwifery in Australia

3.4.1 International Trends in the Last 10-Years

European countries such as France, Germany, Denmark, Belgium, Switzerland and Netherlands have continued to develop three and four-year programs as the route of entry to midwifery ever since midwifery was regulated in those countries during the last century. It seems that, wherever governments enable women to have publicly funded continuity of midwifery care as well as the opportunity to give birth at home, DEM¹⁰ is recognised as the most appropriate form of education for midwives. Study of at least three years duration is seen as the way to prepare beginning practitioners who are autonomous and competent to provide continuity of care to women throughout their experience of childbirth referring to other practitioners only when necessary.

As can be seen in the sections in this document regarding New Zealand and Canada, the development of DEM education programs was chosen following legislation that enabled autonomous, publicly funded midwifery services (Tulley 1999, Houd et al 1993). Evaluations of midwifery education programs in these countries has been encouraging, particularly in terms of recruitment and the education of competent, confident midwives, capable of providing continuity of care in all settings.

In New Zealand, Ontario and European countries, including the UK, there is a move towards competency-based assessment and the opportunity for student midwives to follow women through their experience of childbirth. However, there is still a requirement for students to attend at least 40 births during their education program in order to reach competency. In all of these countries, students have a caseload of women they follow through, particularly in their final year.

3.4.2 The Development of New DEM Courses in the UK: Comparisons with the Situation in Contemporary Australia

Leap (1999a) suggests that comparisons with developments around the development of 3-year midwifery education programs in the UK are useful since many of the issues, concerns and discussions in contemporary Australia are similar to those that precipitated the new wave of DEM courses in the 1990s in the UK. Furthermore, the government funded research that was developed around the development and implementation of the new model of midwifery education was exemplary and worthy of consideration as Australia prepares to commence 3-year programs. No other country offers a model of evaluation of midwifery education on the scale of the studies carried out in the UK.

‘Direct entry’ is now the main route of entry to midwifery in the UK whereas ten years ago, it had almost been discontinued. Following rigorous evaluation (Kent et al 1994, Fraser et al 1998), the English National Board (ENB) recommends this form of education as the major route to initial midwifery registration.

In contemporary Australia, as in the UK ten years ago, there is a recognised drive towards new models of maternity care that are woman-centred and offer continuity of midwifery care (NHMRC 1996, 1999). As in the UK, there is a ground swell of opinion in midwifery circles that DEM would be the most appropriate way to prepare practitioners to work in these new models (ACMI BMid Information Pack, 2001).

Radford and Thompson (1988) present an interesting historical account of the development of DEM in the UK. The series of events they describe leading to the resurgence of DEM are not dissimilar to those described by Barclay in research two decades ago, written as a Masters Thesis (Barclay 1986). In both countries, the demise of DEM courses prior to the 1980s was associated with the professionalisation of nursing. Furthermore, both countries share unfavourable memories of DEM that are associated with one and two year courses deemed inadequate in terms of preparing competent midwifery practitioners (Tracy et al 2000, Radford & Thompson 1988).

Recommendations for the Introduction of DEM Programs in the UK

The recommendation of the report (Radford and Thompson 1988) was that positive action should be taken if the development of direct entry training was to be accelerated along the following lines:

Co-ordination

A liaison group or task force representative of all bodies concerned should be given the responsibility for determining the most effective way forward for direct entry midwifery training coordinating initiatives and maintaining the impetus

Support

• Greater support should be given to those considering the implementation of direct entry courses;

• An organised link should be formed between all those considering or planning a course as well as those who attempted to implement a course and did not succeed;

• A series of study days should be run on course implementation (e.g. selection, curriculum, finance);

• Additional resources should be allocated to enable midwifery education officers to help provide the extra support which direct entry midwifery projects require.

Information

• Information on all aspects of direct entry (eg. potential candidates, costing, curriculum) should be easily available from a central source.

Research

• Evaluation of new and existing courses should be carried out by an independent body and the findings made widely available;

• Each area considering a direct entry project should carry out a local feasibility study

Communication

• Lines of communication between regions, districts and schools should be improved, as should those between them and their statutory bodies;

• The ENB should clarify its role in the changing education environment;

• Each region should appoint midwifery advisers to coordinate initiatives and to liaise between schools, districts, region and the statutory bodies.

Funding

• Further research should be carried out to identify the most appropriate and effective organisation of funding for midwifery education.

Rationalisation

• To ensure a sound base for the development of new courses, rationalisation of the structure and provision of midwifery education is essential.

Strategy

• The agency responsible for strategic planning should be clearly identified, and should control funding.

Statistics

• Statistics on potential candidates for direct entry midwifery training should be gathered nationally in a standard format.

As a consequence of the report by Radford and Thompson (1988), it was agreed that all health authorities in England should develop at least one three-year midwifery diploma or degree program and in 1989, the UK Department of Health provided pump-priming funding to 14 sites for this purpose.

Fraser and colleagues (1998:8) note that, given the enormity of the changes, it is surprising that so many institutions set up three-year midwifery programs without pump-priming funding. Although the intention of the DOH had been to evaluate the 14 programs that they had funded during their first two years before promoting further expansion, and it was expected that DEM education would remain a minority option, by the time the initial evaluation was presented, 35 three-year programs had been validated (Kent et al 1994).

Currently over forty Universities offer programs, some of them alongside shortened programs for registered nurses.

3.4.3 Evaluation of the New DEM Programs in the UK

The government in the UK has shown consistent commitment to the evaluation of midwifery education programs. Two studies were commissioned to evaluate the new DEM programs, one by the Department of Health (Kent et al 1994), and the other by the English National Board (Fraser et al 1998).

The study by Fraser and colleagues (1998) is of international relevance as the most comprehensive research into the effectiveness of three-year midwifery education programs.

The project explored a range of issues that were expected to be of interest to key stakeholders. These included:

• Review of current program curricula;

• Development of a model of midwifery competence;

• Exploration of attrition;

• Evaluation of actual outcomes of the programs;

• Evaluation of current assessment strategies;

• Guidelines for effective assessment and assessment matrix;

• Guidelines for effective assessor preparation;

• Examination of support and learning needs of students following registration;

• Exploration of career patterns and retention rates;

• Difficulties associated with failing students.

The study was divided in to two phases:

• A review of the existing programs;

• A study of a cohort of midwives following completion of their midwifery education into their first year in practice (Fraser et al 1998).

Phase 1 of this three-year study involved participants as students, their teachers, and assessors and focussed mainly on the assessment of competence and student ability to fulfil the role of the midwife at the point of registration. It involved:

• An examination of the philosophy, theoretical framework, design and content of curricula;

• The identification and development, as required, of new tools for the assessment of the outcomes of midwifery programs of education, including a framework, a conceptual model of the competence required of a midwife at the point of registration against which assessment strategies could be evaluated;

• An assessment of the intended and actual outcomes of midwifery programs of education in terms of knowledge, attitudes, competencies and skills.

Phase 2 of the study involved tracking study participants in their first year as midwife practitioners and focused on three areas:

• An evaluation of the effectiveness of the three-year programs in terms of knowledge, attitudes, competencies and skills;

• The identification of continuing professional development needs of midwives qualified through this route;

• Identification of the retention rates, career patterns and career intentions of midwives qualified through the three-year programs since 1992.

The main conclusions of the study are worth noting here, given the imminent introduction of three-year Bachelor of Midwifery programs in Australia.

The overall finding of the project is that the three-year route into midwifery is an effective preparation for contemporary midwifery practice. In spite of initial prejudices among some experienced midwife practitioners and teachers, the commitment and enthusiasm of these students towards woman-centred midwifery practice changed their views. Midwives were particularly impressed by students’ knowledge and understanding of the theory underpinning practice, their reflective and questioning attitudes and wide reading and use of research.

Evidence was abundant that pre-registration students could provide competent, normal, midwifery care to women on a one-to-one basis. There were, however variations, in their ability to make the transition from student to midwife in busy, often short-staffed maternity units. This seemed to have more to do with individual students that with program differences. For example, although one third of study midwives had difficulty with the transition, most coped well but a few needed considerable encouragement and reassurance from their colleagues. On the whole, programs were similar in structure although some included strategies more likely to help weaker students.

The greatest overall weaknesses were in variations in learning opportunities and inadequacies in assessment strategies – many of which were reduced by good liaison between schools and practice placement staff. Maternity units were also generally quite small and dialogue between practitioners about students was for the most part effective. This dialogue and liaison could be attributed to midwifery education and service being inextricably linked in the past, and it is hoped that this will continue as the tripartite relationship between student, teacher and assessor appear vital for program effectiveness.

The literature on professional education suggests that competence is a continuum and we should not expect all students to reach the same point at the same time. However statutory requirements and evidence from this study suggest that all students should be expected to achieve all the components of the model of competence at the point of registration, as midwives, unlike many other professionals, have a license to practise independently…

This study concludes that absolute program effectiveness can only be confirmed when every student who successfully completes the program has the capability to competently and confidently to take on the holistic role of a midwife practitioner. (Fraser et al 1998:111-112)

In ten years in the UK the number of midwives registering to practise for the first time who were not nurses grew from less than 1% to over 50%. This could not have been predicted given the initial resistance to DEM.

3.4.4 The Australian Bachelor of Midwifery

In 2002, over 150 students commenced study in a three-year Bachelor of Midwifery in four universities in South Australia and Victoria. At least four other universities in New South Wales, ACT and Victoria are planning to start a three-year Bachelor of Midwifery (BMid) in 2003. The ACMI has had a policy of supporting ‘direct entry’ midwifery education over the last 10-years and there has been growing enthusiasm for the initiative over that time (Hancock 1992, Game 1998, Owen 2000). The ACMI is in the process of finalising national standards for the accreditation of these programs and hopes to work collaboratively with the registering authorities in the future regarding the implementation and evaluation of these standards.

The Australian Bachelor of Midwifery opens up the possibility of more than one route of entry to the profession of midwifery. In considering the opportunities associated with this innovative development, Leap (1999) has advocated for:

• National standards with international compatibility so that midwives can practise in other countries without having to undertake further education or training;

• A collaborative effort across States and Territories;

• Avoidance of a two-tiered system where nurses who want to become midwives are disadvantaged by having fewer clinical practice opportunities;

• Study at Masters level to be reserved for critical thinking and reflection by experienced midwives.

ACMI has played a major role in the development of the Australian BMid through coordinating the ACMI BMid Taskforce. The following information about this Taskforce has been extracted from an information pack (written by Nicky Leap and other members of the Taskforce) soon to be released by the ACMI (ACMI 2002)¹¹ with permission:

History of the ACMI Bachelor of Midwifery Taskforce

South Australia has led the national development of a BMid program. In 1999, Flinders University and the University of South Australia (SA) were committed to a 3-year Bachelor of Midwifery but decided to delay this until other universities could commence courses at the same time. It was felt that this would maximise support for the students/new graduates, would establish the BMid as a serious mainstream option and prevent marginalisation of the courses in a potentially hostile climate. It was also recognised as important to prepare the way for the introduction of the BMid by raising awareness of the issues. The SA universities employed a Project Officer, Jackie Kitschke, who contacted universities across Australia to establish interested parties. From this list, key midwifery educators from each state and territory were invited to the meeting in Adelaide. The SA universities funded a facilitator and the outcome of the meeting was a commitment to proceeding as an ACMI Taskforce and to develop national Standards for the Accreditation of the BMid so that the development of courses across Australia could address a similar framework and achieve comparable outcomes. Information was distributed widely through the ‘BMid Newsletter’ and a database of potential students was set up. In the interest of promoting an inclusive approach, an advertisement was placed in the ACMI Journal calling on universities to lodge expressions of interest regarding the introduction of a BMid. Attention was drawn to publications that would inform all key stakeholders about the initiative (ACMI -Victorian Branch 1999, Leap 1999, 2000, Radford & Thompson 1988, Fraser et al 1997).

Universities across Australia began to explore the potential of joining forces and forming a consortium or partnership approach to developing BMid programs. Meanwhile, the ACMI continued raising the issue with relevant organisations across Australia and began to coordinate the ACMI National Bachelor of Midwifery Taskforce.

The ACMI National BMid Taskforce members are:

• Nicky Leap (Coordinator)

• Diane Cutts (Victoria)

• Trish David (Tasmania)

• Jenny Browne (ACT)

• Hilary Hunter (New South Wales)

• Jan Pincombe (South Australia)

• Bev Turnbull (Northern Territory)

• Carol Thorogood (West Australia)

The ACMI BMid Taskforce members made a commitment to representing their states/territories and to ensure that information concerning the BMid was both gathered and disseminated at a local level. This has included holding public forums and engaging with universities, health services regulatory bodies and consumers. The Taskforce have also engaged in a process of consensus decision making in their bi-annual meetings as well as a process of circulating and re-circulating all documents via the Internet for comment and editing until all parties are prepared to sign off on them.

An ACMI BMid Taskforce Reference Group was set up in an advisory capacity:

• Vanessa Owen (ACMI President)

• Sally Tracy (Australian Midwifery Action Project – AMAP)

• Maree Markus (Advisor on Regulatory Issues)

A panel of international midwifery education experts was identified; all of whom have offered support for the introduction of a BMid in Australia. They have shared their countries’ experiences of developing similar programs and will have an ongoing role in reviewing the ACMI Standards for the Accreditation of Bachelor of Midwifery Courses and related policy and curriculum documents. The ACMI BMid Taskforce has a commitment to ensuring international compatibility so that graduates of the Australian BMid courses will be able to register to practise in other countries without having to undergo further training and education as they do now.

The rationale for the introduction of an Australian Bachelor of Midwifery (BMid) has been explored in terms of the overall aim of the ACMI to increase the number of competent midwives and midwifery graduates in all areas of Australia. According to the ACMI, ‘the bottom line for any developments has to be improvements to the services offered to childbearing women, their families and communities’ (ACMI BMid Information Pack). Eventually it is hoped that the ACMI Standards for the Accreditation of Bachelor of Midwifery courses will be the Standards for the Accreditation of all programs in Australia leading to initial authorisation to practise midwifery. Negotiations are in process with relevant regulatory authorities to design an appropriate process for this to happen with the full involvement and participation of the ACMI.

Some of the arguments used by members of the ACMI BMid Taskforce to justify the rationale for the BMid in Australia can be summarised thus:

• International trends in midwifery education and evaluation of programs in the UK;

• Addressing workforce shortages;

• The opportunity to develop national standards for midwifery education;

• Appropriate education to enable midwives to work in continuity of care models according to the international definition of the midwife;

• Currently Australian midwives must complete further studies and/or midwifery practice placements in order to register in other western countries;

• Expressed concerns over the standard of some graduates from midwifery education programs by employers;

• Many students are only experiencing fragmented midwifery practice in their education and are not equipped to work according to the international definition of a midwife;

• Each state and territory has its own midwifery course accreditation processes through Nurses Regulatory Boards. Graduates emerge from midwifery programs with different qualifications, having met different standards;

• Depending on the state or territory, graduates may emerge from programs having attended 20 births, 10 births or fewer than 5 births if the assessment is purely competency based without any repeated practice requirements;

• Midwifery education programs are accredited according to the individual regulatory authority’s nursing standards and often midwifery is invisible in the regulation. For example, courses may have to demonstrate that they have a ‘nursing focus’ and that ‘qualified nurses’ teach them;

• Courses are seen to build on a nursing degree and therefore midwives tend to graduate with a Graduate Diploma or Masters degree, with one state offering a Bachelor program (two-years part-time);

• In many cases, students study midwifery part-time while they work full-time as nurses. Some have clinical placements where they are supernumerary which they fit into annual leave over a prolonged period of time. Clearly this is unsatisfactory in terms of acquiring skills and competency;

• High attrition rates for nurses in midwifery;

• Addressing the current financial pressures associated with midwifery education. All undergraduate health courses are HECS based;

• There is no longer a trend for the ‘double certificate’ nurse/Sister and this has impacted on the number of people entering midwifery;

• Addressing regulatory inconsistencies between states and territories. The regulatory process of ‘mutual recognition’ across states and territories makes this an imperative. Employers need to know that they can rely on the standards of practice and competency of all graduates, regardless of the state or territory in which they qualified;

• The ACMI is particularly anxious to avoid a two-tier system of standards for midwifery courses. All midwifery graduates should emerge from their programs of education having achieved the same level of competency and the same repeated practice requirements regardless of their route of entry to the profession.

Addressing common concerns about DEM in Australia

It may well be that, as in Britain, the climate is ready for Australia to move forward and develop a new midwifery culture with a sound educational base. The first step is possibly to understand some of the resistance and anxiety that still exists around DEM. These common concerns are addressed by Leap and the Australian College of Midwives Incorporated (ACMI) in their ACMI Bachelor of Midwifery Information Pack (2002).¹² In states where the BMid is to be introduced, an extensive process of consultation has taken place with service providers, professional organisations and regulatory authorities. There is support for registering graduates of the courses, for supporting student placements and for employing graduates in all areas where midwives currently practise midwifery.

The most commonly voiced concern regarding the BMid is that concerning the needs of rural communities to have dual trained practitioners. There will always be some remote areas where it is important to employ practitioners who will draw on their skills in both nursing and midwifery. However, there is an increasing trend in rural areas, particularly where General Practitioner obstetricians are no longer practising, to consider re-organisation of services so that midwives in group practices offer continuity of care to women, liaising with obstetricians in regional centres where needed [This may not suit remote areas where a nurse midwife might be the only health worker].¹³

The important point to emphasis here is that ALL health practitioners who go to work in rural and remote areas should address their need for appropriate further education and skills acquisition in order to work in these areas. For some midwives educated through the BMid, this may mean that they decide to undertake a BN and apply for recognition of prior learning for some aspects of the course. For others, courses in areas such as Women’s Health, Child Health and/or Family Planning may be deemed sufficient extra preparation for working in a rural or remote community. Internationally, this is the course of action that midwifery graduates without a nursing qualification have often taken if they want to work in developing countries. Particularly in the remote areas of Australia, there is a need for health practitioners who are midwives as well as nurses.

In order to be able to maximise the potential for attracting and employing BMid graduates and students, some rural areas in Australia are already re-organising services so that midwives work in team or caseload models providing continuity of care. This opens possibilities for student placements. It is hoped that some new graduates will be inspired to return as employees, especially where they can work in innovative midwifery models.

It has also been suggested that the BMid could be the vehicle for preparing Indigenous midwives to work exclusively within their communities. Whilst it is possible that Indigenous women educated through a BMid might choose to work exclusively in Indigenous communities, there is clearly a need to avoid educating midwives who are restricted to practise only in certain settings. (This argument also applies to the suggestion that the BMid could educate midwives to works exclusively in home birth or independent practice.)

Negotiations are taking place with relevant Aboriginal and Torres Strait Islander groups to explore what has been seen to work/not work in other professional education programs - such as nursing, teaching and social work - in terms of support and flexible learning opportunities. Funding may need to ensure that there is a large enough cohort of indigenous students in any one program to promote support and prevent marginalisation and tokenism.

In Canada, there are examples of midwifery graduates working in partnership with Indigenous communities in remote areas. These birthing projects are associated with marked improvements in perinatal outcomes when compared with the previous system of removing women from their homes and flying them out to maternity hospitals to give birth.

Often there is a need for reassurance that graduates of the BMid will be ‘safe’ practitioners able to work in any setting. France, Netherlands, Belgium, Switzerland, Denmark have always had DEM education and all of these countries are recognised as being associated with quality maternity services and excellent perinatal statistics. As in these countries, students will be exposed to all relevant medical and surgical areas in order to be able to practise safely and collaboratively.

Anxiety has been expressed about creating a system where school leavers may enter a three-year Bachelor program in order to become either a nurse or a midwife (Sommerville 1997). The argument is that midwifery requires mature students with life experience. It is worth noting that some midwifery educators in England and New Zealand are challenging this notion providing there are careful selection procedures. Contrary to their expectations, they are impressed by the calibre of those young women who are graduating into their chosen career in midwifery (personal communications).

It is important to clear up the misconception that there is a national curriculum for the BMid.

Individual universities will design their own programs according to their own local needs, ideas and frameworks. Each program will however need to meet the requirements of the ACMI Standards for the Accreditation of BMid courses.

Conclusion

There are many advantages for Australian midwifery in learning from, but not necessarily copying, the New Zealand, Canadian and British experience and developing a Bachelor program that becomes the national route of entry to midwifery. Individual universities should be able to develop their own curricula within an overall framework that would set national standards of the highest quality. Australian midwifery educators could develop courses that would attract the same international acclaim as those degree programs developed by Australian nursing colleagues for entry to the nursing profession.

The introduction of the Bachelor of Midwifery programs in Australia may provide the potential for midwifery to gain control of all processes associated with designing its own education, practice and regulation in the interest of improvements in maternity services.

The experience in New Zealand, Canada and Europe has demonstrated that where midwives are educated to work to the full potential of their role they have every opportunity to negotiate and develop new systems of care. This might include a home birth model within the public health system and appropriate services in collaboration with and for indigenous women.

The ACMI Standards for the Accreditation of Bachelor of Midwifery Programs should enable the education of midwives to respond to women’s needs and who will be able to follow women through their experience of pregnancy, childbirth and the early weeks following birth, regardless of where and how the birth occurs. This will always mean being able to collaborate well with other health professionals in order to optimise quality services for women and their families around childbirth.

Foot Notes:

1.All text has been modified from material supplied to the Review by Dr Kathleen Fahy who has since taken up a position as Professor of Midwifery and Head of the School of Nursing & Midwifery at the University of Newcastle, NSW.

2.This initiative is described using material supplied for this Review by Janice Butt RN, RM, ADM, PGCEA, MA(Ed), Lecturer, Curtin University

3.Information about this program was provided for this Review by Pam Shackleton, Midwifery Course Coordinator, Charles Sturt University

4.Dr Kathleen Fahy, provided information for this Review regarding this initiative. Dr. Fahy has since taken up a position as Professor of Midwifery and Head of the School of Nursing & Midwifery at the University of Newcastle, NSW

5.This section has been drawn from correspondence from Pam Shackleton, Midwifery Course Coordinator, Charles Sturt University 2001

6.The Australian Midwifery Action Project (AMAP) was funded by the Australian Commonwealth Government through the Australian Research Council as part of the then ‘Strategic Partnerships with Industry research and Training’ (SPIRT) program. A three-year project, AMAP was set up in April 1999 to identify and investigate barriers to midwifery within the provision of mainstream maternity services in Australia and strategies to address these barriers. This included studying workforce, regulation, education, practice and service delivery issues across the country.

7.In terms of nomenclature, midwifery education programs are generally referred to as ‘courses’ throughout this document since this was identified as the most common terminology in use when designing the questionnaire and during the telephone interviews. This decision was taken in the interest of clarity and consistency.

8.The researcher was unable to clarify this information despite several telephone calls and the genuine wish of the course coordinator to elicit the information. The difficulty was explained in terms of not knowing how many part time students who take several years to complete were in the course. The administration department eventually informed the course coordinator that the information could only be obtained by the researcher applying for special permission from the University Registrar. A decision was taken not to proceed further.

9.There is a recognised commitment by the Australian College of Midwives Inc. (ACMI) to use the word ‘practice’ instead of ‘clinical’ in midwifery to reflect the role of the midwife (See ACMI Standards for the Accreditation of 3-year Bachelor of Midwifery Programs 2002). In this study, a decision was taken to use the word ‘clinical’ in designing the questionnaire in recognition of its common use and in the interest of clarity and consistency.

10.In order to make international comparisons, the term ‘direct entry’ midwifery (DEM) will be used here. Australian midwives prefer to refer to a ‘Bachelor of Midwifery’ (ACMI Victoria). Since this is not necessarily a recognised term for courses for initial authorisation to practise midwifery in other countries (for example, many of the programs in the UK are Diploma courses) the term DEM will be used to avoid confusion whenever it applies to other countries.

11.Available from the ACMI on request

12.Available from the ACMI on request

13. Review authors comment.

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