National Review of Nursing Education

Midwifery Education

Literature Review and Additional Material (Revised Edition)

Executive Summary

Approach

The reviewers have undertaken a comprehensive literature search on midwifery education in Australia, the United Kingdom, Canada, New Zealand, the Netherlands and the United States of America. We have drawn on databases, policy documents, research and other resources, in collaboration and with assistance from national and international experts.

Additional information has been incorporated from research funded by the Australian Research Council [the Australian Midwifery Action Project (AMAP): research conducted in partnership with key stakeholders from government and the profession].

An analysis of the development of the 3-year Australian Bachelor of Midwifery (BMid) has been undertaken to demonstrate how acceptable national standards and consensus can be established, despite the absence of this in the current education of midwives in Australia.

Findings

This Review also draws on new research that confirms serious inconsistencies across states and territories in the education and regulation of Australian midwifery. There has been a lack of national professional leadership and absence of high quality accountability structures leading to the current situation.

We report, with evidence substantiating this, serious concerns about the standard of midwifery education in Australia, particularly when comparisons are made with midwifery education in other western countries.

The Review demonstrates that concerns raised in a 1985 analysis of midwifery education (Barclay 1985) have remained consistent and been exacerbated by the move to university based education. The reviewers suggest that although there were significant problems with hospital control of education, in particular the theoretical aspect of programs, in many places health industry 'ownership' of midwifery education meant students achieved workforce and clinical competency requirements.

University 'ownership' has not been sufficiently tempered by jurisdictional regulations governing accreditation nor a sufficiently strong professional association until recently. This has meant a decline in the clinical experience and competency of students over all.

Information collected for this review leads the authors to conclude that the lack of accountability and inadequate accreditation mechanisms have led to the following situation:

Industry has lost its influence in relation to the numbers of midwives being educated and clinical practice requirements and frequently feels disempowered and dissatisfied as a consequence. There are notable exceptions to this where industry has remained highly influential and provides a strong clinical presence and teaching in university programs;
There are problems associated with the supernumerary and part time status of students that appear, in many cases, to exacerbate the separation of the program from industry involvement or investment as well as creating economic problems for students;
The midwifery professional body has had little influence on midwifery education standards;
There has been no understanding of the consequences of policy changes regarding the funding of midwifery education or any nationally coherent response to these changes;
Midwifery educators tend to be isolated from practice areas within universities rather than strongly clinically located and 'grounded'. Most work as individuals, and are not sufficiently powerful to 'override' school of nursing priorities in programs or claims on resources. They have lacked strong support from either a national association or strong accreditation requirements from Nurses Boards that could have ameliorated this situation.

Problems of Leadership

An absence of midwifery specific regulation and informed, strong and cohesive representation has led to inconsistencies in the accreditation of programs and standards across Australia. There are currently no nationally agreed and applied standards of midwifery education applied in accreditation mechanisms, although the Australian College of Midwives Inc (ACMI) has recently developed these in relation to the proposed 3-year Bachelor of Midwifery (BMid). The ACMI has brought together expert opinion and facilitated consensus from experienced educators for the first time and the results are under consideration across the country.

Strategies for midwifery educational reform in Australia are originating from the professional body currently (described above), but there are no national or State and Territory jurisdictional commitments, incentives or requirements to comply with these.

The introduction of the post graduate fee for specialist 'nursing' courses have created problems in attracting students into full fee paying programs and financial burdens for midwifery students. These have been exacerbated in supernumerary and part-time courses.

Insufficient professional and industry influence over courses in Australia and the concerns that some programs do not prepare competent or employable graduates appear born out by the very limited clinical experience offered by some programs. Competency standards and assessment are not nationally agreed or applied despite 'mutual recognition' operating across state borders.

There has been insufficient quality control and monitoring of the transfer of midwifery education to universities by the profession and regulating authorities. Regulation for midwifery education and practice is of variable quality and not consistent across the nation.

Nursing education priorities have taken precedence in educational institutions and regulating bodies, therefore decisions and leadership have not necessarily reflected the professional midwifery or maternity services needs as well as is required.

Workforce

Workforce shortage and mal-distribution of age groups in the Australian midwifery workforce are not being addressed by current course enrolments, though the high demand for the BMid has the potential to make a significant improvement to this situation.

Attrition rates in some postgraduate programs for nurses wishing to become midwives are excessive and enrolments are low suggesting problems of quality and credibility in these programs.

There are problems addressing the needs of rural Australia, especially Indigenous communities, within current courses. There are some important exceptions in rural areas, and models that are working well.

Retention strategies for graduates have not been addressed nationally, coherently or at all in some states, therefore they are not well designed or developed to meet Australia�s maternity services.

The continuing education of midwives in Australia remains ad hoc and there are no national policies, incentives or requirements for maintenance by organisations, such as employers, some regulators or individuals.

Education and Learning

Midwifery teaching and learning frameworks have been poorly developed overall, however there are some promising examples of midwifery approaches to evidence based teaching and the flexible delivery of midwifery education. Issues of quality control need careful monitoring

Issues that are shared internationally

The need for support and education for midwives to address new models of care;
Financial support for student midwives and the issue of fees;
Debate and resolution of the supernumerary versus employed status of students in all midwifery education programs leading to authorisation to practise;
Agreed and valid midwifery competency assessment/s;
The attrition and the retention of midwives in practice;
Debate and resolution of the part-time/full-time study issue;
Processes of selection of students.

Models of good practice provided include:

Examples of high quality post (nursing) graduate midwifery programs that meet the needs of the midwifery workforce, including examples of creative teaching and learning methods and an evidence based approach to midwifery education.
The development of the Australian three-year Bachelor of Midwifery program and concurrent developments of national standards for the accreditation of these three-year programs that could also apply to programs for nurses wishing to become midwives.
Examples of high quality education programs from three states that address the needs of rural communities.
International midwifery education developments that can help Australia also identify ways forward in educational service provision and standards.

Lessons for policy identified in this Review

The serious implications involved in imposing postgraduate fees for nurses on entry to a new discipline;
Difficulties establishing national standards associated with the jurisdictional independence of Boards in each State and Territory and no commitment to consistency in the accreditation of midwifery education programs nationally;
The need for policy support for the 'direct entry' option to achieve the same qualification as postgraduate courses for nurses in a shorter time through the Australian Bachelor of Midwifery;
Problems of recruitment and retention issues, that are international as well as local, and require national strategies;
Declining international compatibility of midwifery education in a climate of international 'mutual recognition' policies;
Health services have abdicated or had withdrawn their responsibility for student learning (e.g. providing student placements and clinical teaching in a range of midwifery models as well as in risk-associated maternity care, to ensure the range of skills of graduates). There is a need to support/initiate joint education and health service involvement in programs, for example in setting up joint clinical and teaching posts and education for preceptors/facilitators and clinical mentors for students;
Active support and incentives are required for rural students and Aboriginal and Torres Strait Islander students to enter programs that meet their learning and cultural requirements;
There is an urgent need to specifically regulate midwifery education and practice and for the development and application of national standards for midwifery education and practice within jurisdictions;
National research is needed to investigate, monitor and evaluate the introduction of the Australian Bachelor of Midwifery and to compare and standardise outcomes with a strengthened and improved national approach to include standards for the midwifery education of nurses.

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