Midwifery education in COVID-19- time: Challenges and opportunities.

Introduction

As with all sectors of education, midwifery has been greatly affected by the lockdown measures imposed by governments throughout Europe. Despite the COVID-19 period, all students were expected to acquire professional midwifery competencies, according to the European Union (EU) Directive ("Directive 2005/36/EC," 2005), the European Qualifications Framework ("The Council of the European Union," 2017), as well as the International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education ("International Confederation of Midwives," 2013). This Directive aims to ensure that midwifery education attains minimum standards and provides a European framework for midwifery education (Vermeulen et al., 2018) and practice including a quantitative description of the tasks the midwife should carry out (Fleming et al., 2011). One of the biggest challenges has been how to continue to provide the hours required under the EU Directive 2005/36/EC so that students may transition to midwives without penalty. However there are equally difficult but less obvious hurdles to overcome. This article provides a reflective account from three experienced midwives in different European countries, one working in education, one in clinical practice and one in research as to some of the major issues that are emerging in undergraduate midwifery education programmes.

The theoretical component

The most profound changes occurred in midwifery education as national lockdowns saw the closure of universities with staff and students working from home (Antonakou, 2020). Initially some institutions considered postponing all their programmes, but many came round to offering the theoretical component of their teaching via online platforms. As up until this point most education had taken place face-to-face this change meant that rapid digitalisation of the curriculum and teaching had to take place. For some lecturers this represented a huge challenge, while others with prior experience managed the transition easily. Thus, the disruptions caused by COVID-19 have had more impact on digitalisation of midwifery education than some educational advisors had during the last decades. A few students, however, were without the necessary hardware, and university libraries had to remain open, reopen, or provide additional support to provide the workspaces and equipment for those who did not have their own.

While a positive development in many ways, the transition to distance learning was being achieved concurrently with timetable changes as clinical areas were struggling to deal with the crisis and to cope with the added burden of students. Some institutions, such as those of one of the authors, had to move theory blocks from the next semester, taking students out of practice altogether, while others have made minor adjustments.

The organisation of assessing students has also been challenging to educators. Diverse approaches have been utilised, with officials in some countries deciding to use an aggregate system based on previous marks and clinical practice, but some moved to an on-line approach when exams rather than essays or short answers are required. Such formats of exams were suitable for some required competencies, such as analysis, critical thinking, or synthesis, but less so for scenarios that involve clinical skills. This is addressed below.

The practice component

In an initial flurry of activity some students working clinically were sent home from practice areas. In some cases clinical managers suggested that educators behave irresponsibly towards the student by sending them in practice, and increasing their exposure to the virus ("Health Education England," 2020). However, in some countries, clinical placements and teaching in practice have gone on as usual. In others, clinical placements were put on hold, with no prospect of when they can be resumed (Furuta, 2020). All international placements were cancelled, which not only cause financial losses for students, but also lead to missed opportunities of acquiring additional competencies gained in an foreign health-care system (Ahmed et al., 2020).

Once things began to settle, a number of models have emerged regarding placing students in practice. In some countries, midwifery students have been recruited to support clinical staff in practice, upon agreement of both institutions. In others, even after the initial flurry of activity, midwifery students have not been allowed to continue their clinical placements during the COVID-19 pandemic. Others still have contracts for final year students to work as health care assistants ("Nursing and Midwifery Council," 2020). A positive development is that some students have been able to work more clinically, in interprofessional teams, and gaining an experience that they previously would not have (Walton, 2020).

Completing the programme and becoming midwives

Obviously anxiety amongst final year students as to when they can complete their programmes has been to the fore. In some countries this is only after they have passed a final examination, which is subject to the constraints outlined above. In others a sign off is required by a clinical mentor and/or a senior member of the academic staff. Yet others require a clinically based examination. What is common to all is the EU Directive's requirement for certain tasks and the required number of hours to be completed. In some areas this has led to students completing their programmes before their expected dates as the EU Directive had been reinterpreted allowing completion after three academic, rather than calendar, years if all other targets had been achieved. In such cases midwives were thus able to enter the workforce early. Others, conversely, have been held back, as placements were suspended and students were not able to acquire the professional midwifery competencies, which might lead to students’ graduation being postponed.

Challenges for the near future and longer term

The teaching of specific midwifery skills remains a clear challenge. Universities are beginning to open up again across Europe and the important question arises as how to guarantee contact-free education and social distancing, while educating midwifery students. One common theme is the need for personal protective equipment for staff and students as social distancing is mainly not possible in midwifery work. Another highly relevant question is whether or not to replace real clinical learning with simulation with some arguing that some components of the EU Directive might partially be replaced by simulation (for example replacing 100 effective antenatal examinations with 90 and 10 simulated). The degree to which simulation can replace the genuine situation, however, will be affected by a number of variables, such as the skill level already achieved by individual students, the quality of the simulation experience available and the history crafted around each simulation experience. In the short term it may be used without such attention to detail but if it were to become a permanent feature, the burden on the academic stuff needs to be considered as well as the experience of the students.

One of the biggest remaining challenges is the mental health of students and academic staff, now and in the near future. What is the impact of the lockdown, the social distancing, staying at home or working with potentially infected women on students? Some have suggested that about one in five students feel more anxious or depressed than in the period before COVID-19 ("University Ghent," 2020). The digitalisation, which is an obvious necessity at this time, may create a loss of collaborative experiences that has the potential to be a significant detriment to education (Rose, 2020). Many may be missing their social network, and have lost the connection with their peers and lecturers, despite on-line encounters. Some may also have difficulties in balancing tasks for the university with additional tasks, including educating their own children at home. Both students and lecturers are processing the new situation, while searching for a new normality.

Conclusion

The prescribed national lockdowns in most European countries has led to a disruption that caused rapid, dramatic changes in the nature of midwifery education. In the short term different approaches have been adopted to mitigate the impact on current midwifery students’ theoretical and clinical education and seek the best approaches for both midwifery students and lecturers during the COVID-19 pandemic (Furuta, 2020).

Some challenges, however, have emerged as chances to be grasped in taking midwifery education forward for the next cohorts of students. Throughout Europe, the changes of increased digitalisation and distance learning can definitely be highlighted as opportunities to improve the current ways of delivering midwifery education. These changes might also extend to a diverse population, such as potential students who are looking for part-time education.

Lots of challenges however also remain. As Bick noticed, “life during the pandemic is on hold, the things we all took for granted, no longer an option”- and comfort zones had to be left (Bick, 2020). Many of these challenges are still ahead of us. We still have only a limited overview of what students have experienced and what directions the virus is taking us in as policy makers grapple with decisions that will affect us all. Despite the pandemic however, as always, midwifery educators will do their utmost to guarantee that the competencies needed and skill acquired will be achieved at the same level as before the disruption.

Ethical approval

N/A

Funding sources

None declared

Declaration of Competing Interest

None declared.