Midwifery education: a cause for concern

Midwifery educators and students meet together this week at the Midwifery education and student festivals. Along with all that is happening in clinical practice, midwifery education is facing its own challenges. Nicky Clark, Freelance Midwife Educationalist, and speaker at the festival, addresses some of the issues and provides a challenge for how midwifery education will look going forward.

---

I have been discussing the issues affecting midwifery education for some time now. Is it just me, or are others equally concerned?

To my mind, there are 3 main areas that are in urgent need of redress:

1. The rising caesarean section rate risking the future of midwifery as a profession;
2. The variation of both theory and assessment of student midwives in both universities and in clinical practice;
3. The quality of midwifery education per se.

I will address these areas as succinctly as possible to put my concerns out there in this article. I feel I must add that I am not advocating for midwives to be “trained” again as opposed to being “educated”. The continuing strength of the midwifery profession is its adaptability to research findings, service user choices, the high level of professionalism, competence and confidence with the midwifery proficiencies and the compassion for all those who access or work within it. With midwifery becoming a degree only profession since the implementation of the NMC (2009) standards for pre-registration midwifery education, critical awareness and higher level thinking are standard practices.

The rising caesarean section rate.

“Normal” implies the usual, typical or expected. Spontaneous vaginal birth was viewed as usual, typical and expected unless complications occurred, and either operative or instrumental births were then undertaken. Previously, it was reported that midwives were the lead professional for 100% of births in a free-standing midwifery unit, 77% in alongside midwifery units and 62% in obstetric units. Workforce planning alongside Birthrate Plus for many maternity units identified a ‘midwife to birth ratio’ to inform appropriate staffing and skill mix (Redshaw et al 2011).

With reported caesarean section rates of more than 50% births now, we are witnessing a new normal, with doctors being the lead professional attending more women in childbirth than midwives.

This will affect staffing and skill mix. It will reduce the number of available spontaneous births that student midwives need to complete their pre-registration programmes; and midwives will no longer be the lead professional attending women during labour and birth.

Currently there is a spiral of intervention, approx. 40% of induction of labour ends in a caesarean section; many women are choosing C/S.

Is replacing labour wards with more theatres too far from reality?

This ‘new normal’ will result in fewer student midwives commencing midwifery pre-registration programmes, and fewer midwives being required to conduct spontaneous vaginal births.

This could herald the beginning of the end for the professional role of the midwife as we know it.

Midwifery is a distinct profession with a protected function and title, preserved in law – “A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth” (Article 45 – The Nursing and Midwifery Order 2001). 

It is, however, well documented and evidenced that a midwife’s role is far more than attendance in childbirth, with undisputed positive impacts on maternal and neonatal outcomes when women are attended by educated, knowledgeable, competent and confident midwives. (Renfrew et al 2014)

The variation of both theory and assessment of student midwives in both universities and clinical practice.

It is my belief that students feel unsupported, unconfident, incompetent as newly qualified midwives (NQM) and express discontentment with midwifery. More students than previously suspend or leave their midwifery programme before completion. Midwives feel unsupported, feel insecure and inadequate, consider or do leave the profession and convey dissatisfaction with being a midwife. Unfortunately we are also seeing NQMs not being recruited at all, which is impacting on student recruitment and programme completion (RCM 2022, RCM press release 2024, The Workers Union 2025)

Why is this happening?

Since the move into higher education in the mid 1990’s, national midwifery programmes became devolved to approved educational institutions (AEI) that provided midwifery education. AEI’s have different regulations surrounding credit values, assessment tariffs and recruitment of both staff and students. Each AEI is approved by the Nursing and Midwifery Council (NMC) which is the regulator for all nursing and midwifery pre-registration programmes and registered nurses, midwives and nursing associates. Approval for AEI’s is measured against the standards set by the NMC, which are outcomes focused. When a comparison across the four countries and individual AEI’s, the main variables appear to be: programme length, assessment tariff, funding, staff to student ratio, staff recruitment, interpretation of the NMC standards and partnership working with the clinical areas etc.

Additionally, most AEI’s are experiencing financial crisis, with swathes of redundancies across all health care programmes.

Practice variability fares no better with different trust/health boards governance and culture, staffing and availability of funded CPD. The preparation and governance of those supervising and assessing students in practice, (which moved from a regulated mentorship programme to the outcomes focused standards for student supervision and assessment), students not receiving equitable experiences in placement settings, such as home birth etc. Additionally, individual midwives experience and expertise vary dependent upon their own knowledge and capabilities, and at such a time of high media scrutiny and negativity, low morale.

With such variables, it is now recognised that for preceptorship programmes, NQM’s are not all at the same level. This is a problem.

Quality of Midwifery Education

The changes to midwifery education have been profound since moving into AEI’s, alongside changes to midwifery regulation. Previously, midwifery training programmes were developed at a national level and externally examined. The national programme was rigidly adhered to by those midwifery schools that provided them, and the national assessment was held at the same time for all those eligible to undertake it. The NQM evidenced the same level of knowledge as all others exiting at that time.

Different AEI’s run separate programmes, with different regulations as described above, equity and parity is assumed by the regulator from programme approval and programme monitoring. The main difference between then and now is that the standards are outcome focused and not process driven. An example of this can be seen with recruitment of midwifery lecturers. It was previously denoted that to be a midwifery lecturer, it was stipulated in the rules and standards for midwifery that you had to have a set number years of midwifery practice, to have undertaken successfully the advanced diploma for midwifery, and you had to have successfully completed an approved teacher training programme as identified by the regulator. This has not been the requirement for many years. It is individual AEI’s who set the criteria, and as the salary pay scale for AEI’s does not compare favourably to that for Agenda for Change, it is predominantly junior midwives who elect to join AEIs, as for the most experienced midwives, it is a significant salary drop. Another example is that midwife teachers had to denote 20% of their time to clinical practice. This fostered close and collaborative partnership working. Unfortunately, this no longer appears as a standard. This has resulted in sporadic links with practice across the different AEIs, despite pre-registration programmes being 50% theory and 50% practice. The outcome is measured by those successfully completing the programme, (attrition is arguably at an all time high), by those retained to the profession (midwives leaving the profession is arguably at an all time high) and by those being referred to fitness to practice panels (with the most being referred within the first two years of qualifying as a midwife). The safety of the maternity services is a current focus, and the culture of labour wards being cited as ‘toxic’. This is not where we want to be.

As previously mentioned, AEIs are experiencing significant financial hardship, with many redundancies being observed across healthcare programmes. Unfortunately, the experienced midwifery lecturers are the most expensive to AEI’s and therefore many are being made redundant. This is leaving a junior teaching team to educate our future midwives, many of whom will have just exited programmes having experienced all the issues and variables raised previously. This is not protecting our future.

We need change and we need it now. The rising caesarean section rate and its increasing popularity as a choice needs urgent remedial action to address the rhetoric. There is a consequence in relation to the neonate and its microbiome, but that is for another time. Where and how student midwives are educated must be revisited, and statutory principles and processes put in place to protect and safeguard the quality and consistency necessary to instill confidence and competence in midwifery again.

Nicky Clark, Freelance Midwife Educationalist 

November 2025