Midwifery education in the UK has undertaken many changes in recent years. Nicky Clark, Lead Midwife for Education, University of Hull, reveals her journey of changes and expresses concern for the future.
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I was so proud when I became a qualified midwife teacher at the tender age of 29. I was one of the youngest to hold this position. I had been required to have a minimum of 3 years clinical experience, to have successfully completed my Advanced Diploma in Midwifery (ADM), and to have completed teacher training at one of only 5 English National Board (ENB) approved institutions in England, with only 70 places being available per year between all 5. I did mine at Nottingham University, alongside registered general nurses, children’s nurses, mental health nurses and health visitors. From memory, there were approx. 23 of us – 11 being midwives. It was a fully funded 1-year programme with fees, salary and accommodation all covered. The ADM was also fully funded and was of 6 months duration and residential. This, I completed at Leeds General Infirmary, residing in Woodhouse Hall.
Once appointed as a Midwife Teacher, I was supported for 1 full year as part of the ENB funded offer. My first teaching post in 1990 was in Norwich, at The Norfolk College of Nursing and Midwifery. My second post was at The Mid Trent College of Nursing and Midwifery, which became part of the University of Nottingham in 1995. I finally moved to The University of Hull in 1997 where I have remained.
The main recollections of my earlier career as a midwife teacher are that we were fully integrated into the hospital, as we were still NHS employees. We used to sit in on handovers in the morning, letting students know what was happening in the hospital if they were attending a study day, and kept them informed as events unfolded. We would often take students to visit women on the wards if the women were agreeable to this, to carry out observations, abdominal palpation, postnatal examinations on mothers and babies and other aspects of midwifery practice. There was little, if any, evidence of a theory/practice divide.
Following the merger into universities in the early to mid-90’s, as recommended by Briggs (1972) we were no longer NHS employees but were TUPED into universities which meant transfer of undertakings (protection of Employment), basically preserving some NHS rights, one of which was the right to retire at age 55. We became predominantly lecturers as opposed to midwife teachers. Initially there was little impact – though I did focus my MA dissertation on the merger applying the metaphor of ‘An Arranged Marriage’ as that is what it felt like. Midwifery education became separated from the hospital setting and became housed within universities.
Staff:student ratios (SSR) were introduced by the English National Board in 1993, with a mandated staff student ratio of 1:10 for midwifery lecturers to midwifery students (Nursing was 1:12, health visiting 1:15). The NMC did not set the SSR as a standard when it commenced its regulatory powers in 2002, though it continued to be used as benchmark of quality by lead midwives for education for many years after. Unfortunately, the SSR has been increasing in UK universities due to the loss of teaching staff and the numbers of home students increasing, particularly after the recent drive to increase midwifery places exponentially. The RCM undertook a report, The state of Midwifery Education, published in November 2023, which identified vast differences of the SSR between universities and have quoted 1:19 academic assessor to student midwife as a guide. This has not been adopted nor is it being considered by the NMC at this stage. It has to be said though that 1:19 is almost double the initial standard set in 1993.
With the funding crisis in universities being exacerbated by fewer international students and an exodus of European funded researchers, redundancies, both voluntary and compulsory, have been occurring for some years now. This has seen experienced lecturers leave, with new recruits being relatively inexperienced midwives, with no teaching experience or qualification. These must be gained whilst doing the job, unlike the heady days of when I was learning to become a teacher. The pay scale compares very unfavourably with agenda for change, which means for midwives entering universities as a new lecturer, they must accept a salary drop, whereas when I became a midwife teacher, it was a significant salary increase. This inevitably means that for experienced midwives, the salary difference is too great for a career in education to be considered.
Since the introduction of the SSSA standards (NMC 2018) the recording of teacher training status on the NMC professional register was discontinued, relying on individual universities to set their own requirements for lecturing staff. This is no longer information sought by the NMC, unlike the RCM, who seek this via their freedom of information request to all universities offering pre-registration midwifery programme. Qualified teacher status is an important quality marker, and it is disappointing that this does not appear to be a requirement of the position.
Following an NMC commissioned review of statutory supervision of midwifery, which had been in existence since the 1902 Midwives Act. The Kings Fund (2015) review found that there was an unclear relationship between Statutory supervision in midwifery and the regulatory function of the NMC. The NMC subsequently took the decision to change their legislation by removing this additional tier of regulation. This change was effective in 2017, necessitating the midwife rules and standards to be revoked in view of the rules including statutory supervision within them. This was negatively perceived by many midwives who were used to having a familiar and midwifery-specific resource that captured their scope of practice and regulatory framework.
Midwifery education has experienced significant changes over the years. The expectation from the NMC, and Healthcare governance across the UK (NHSE, HEIW, NIPEC and NHS Scotland) is that education will deliver the future workforce including the ‘future midwife’. The NMC standards of proficiencies for midwives (2019) include significant additions to clinical expertise demanded at the point of registration as a midwife, as well as the additions of leadership, scholarly abilities and pharmacological knowledge to be addressed within the pre-registration programme.
Midwifery education has for some time now felt forgotten. There has been a catalogue of events which has led to the situation we are now facing. There is limited evidence of strategic investment into the education of our midwifery workforce. This is despite the clinical arena being arguably the most challenging yet. There is currently no safety net stipulated by the regulator to protect the quality markers of SSR, teacher requirements etc. behind the education of this future workforce. As such, I believe the question has to be asked – do we have appropriately prepared and remunerated midwifery educationalists that can support the successful recruitment and retention of our future midwives? And if not – what are we going to about it?
Nicky Clark
Lead Midwife for Education, University of Hull
February 2025