Supporting Innovations in Midwifery Education


The past 10 to 20 years have been marked by tremendous growth in innovative options in midwifery education. In the 1980s, there were few routes to become a certified midwife. If you were a registered nurse, you could attend a full-time certificate or master's education program in your community, if one was available, or relocate for full-time study. If you weren't a nurse but had a bachelor's degree, you could attend Yale's 3-year educational track and obtain a nursing credential as part of the nurse-midwifery master's in nursing curriculum. If you weren't a nurse and didn't have a bachelor's degree or couldn't go to Yale for any reason, you could attend nursing school first and then enter a midwifery certificate or master's program. This last option usually necessitated a year or more of clinical experience as a nurse before starting the midwifery component of the educational process. There were few, if any, part-time programs, no community-based programs, and no programs for persons who did not aspire to a nursing degree.

Yet, as so often happens, necessity fosters change. The necessity came during the late 1980s. Decreasing applications to midwifery education programs, during a time when the profession was promoting strategies to increase the visibility and acceptance of midwifery, marked these years. In 1989, Lily Hsia wrote in this journal, “… nurse-midwifery educational programs have an obligation to become innovative in reconsidering our education program, format, use of alternative locations, and timing of instruction…. “1 She called on programs to do this “with great care, thought and soundness.” Her rationale for this call for innovation was to increase the “accessibility and responsiveness” of educational programs.

Approximately a year later, the Education Committee publicly voiced its support for educational innovation, also in an editorial in this journal.2 The committee called for “the coexistence of a variety of educational offerings.”2 Suggestions were made to expand the number of programs providing challenge mechanisms for nurse practitioners, part-time study, and community-based learning; to develop educational models for students without nursing licensure in states where such licensure is not required to practice midwifery; and to create accelerated programs for other health care providers. In the early 1990s, these were radical proposals.

In fact, most of the suggestions made in 1989 and 1990 have been implemented, and innovations have far exceeded expectations. Many ACNM-accredited programs offer distance education, some as their only educational modality, others incorporating distance or web-enhanced curriculum into their otherwise more traditional programs. Part-time study is widespread, and options are now available for other health providers and individuals without health care experience to become certified midwives (CMs). Educators no longer refer to these students as “non-nurses.”

As these changes have taken place, the reliance on midwifery clinicians to teach students in the clinical area has grown. Clinical preceptors are key players in providing midwifery education and must be full partners in the innovative options conceived and developed by midwifery academic programs. Without the opportunity to practice clinically, students would graduate with knowledge but without application or skill, with theory but without demonstrated efficacy, with problem-solving techniques but without the ability to make real-life, real-time decisions.

As midwifery education programs have grown in scope and depth, we have learned that although clinical skills are necessary, they are not the only skills needed to be a competent clinical educator. Even the best clinicians may not know how to impart their knowledge or, more important, how to help students develop their own knowledge base. They may not know how to assess the ways a particular student learns best or may be unable to recognize the learning styles of different students. Some may not have experience in adjusting his or her teaching style accordingly. The clinician as teacher may find it difficult to relinquish decision making when options exist, even when the student's choice of management plan does not compromise safety.

Fortunately, these are learnable skills, just as the management process is learnable or the steps for managing shoulder dystocia are learnable. But the opportunities must exist for teaching skills to be learned. Most midwives in practice are busy, working long or irregular hours; many take call. Exhaustion is common after seeing 20 or 30 patients in the antepartum or family-planning clinic. Indeed, the job can be overwhelming at times! But there is satisfaction in watching a student develop expertise and confidence.

This issue of the Journal of Midwifery and Women's Health is an exploration, analysis, and celebration of the growth and innovation of midwifery clinical and didactic education. It chronicles the history and implementation of new types of education programs. The article by Katherine Camacho Carr documents the ways technology has changed curriculum delivery, and the article by Deborah Walker and Joanne M. Pohl describes a pilot study using technology to document clinical data. The articles by Linda Walsh and Cindy Farley illustrate service learning—a curricular innovation that has strengthened the teaching of the midwifery model of care. Jeanne Raisler, Michelle O'Grady, and Jodi Lori have written an article that offers theoretical and practical information for clinical educators on ways to teach and ways to best allow students to learn.

The goal of this issue is to provide a resource for all midwives. Of course, one issue can only highlight midwifery innovations. Many innovations not covered here are worth noting. Education programs have seamlessly integrated students with education and backgrounds outside of nursing into their education programs. Dual certification programs that prepare graduates to practice as midwives and/or nurse practitioners have emerged. In the last several years, most midwifery education programs have expanded emphasis on primary care and increased content on the business aspects of practice. Many have incorporated creative ways to continue to ground students' educational experiences in the midwifery model of care, despite changes in the health care system that often seem to undermine this model.

As we learn about what we have done to expand our profession, to enrich it through diversity, and to maintain and strengthen the focus on the midwifery model of care within a rapidly changing health care system, we can only imagine what the future might hold. For sure, it will involve increasing use of technology—the extent of which could only be vaguely imagined in 1989. Perhaps there will be increased collaboration among education programs so that some courses could be offered more efficiently. The Internet is a perfect resource for instituting such sharing in ways that would not have been possible before its widespread use. Possibly palm pilot or pocket PC technology will allow for increased communication between academic and clinical faculty and between students in the clinical setting with their academic instructors on campus, allowing for interactive discussion about case studies and types of clinical experiences as they occur. This would allow both clinical preceptors and academic faculty immediate input into the student's clinical learning.

As midwives become more comfortable with educational innovation and change, the options become potentially endless. Yet, in addition to being creative responses to immediate challenges, innovations must be research based. The examples of innovative educational practices in this issue highlight the need for creating a science of midwifery education on which all educators can draw. Systematic research is needed to document best practices in teaching and learning and to determine the efficacy of various approaches beyond the anecdotal.

There are a number of ways to support the creation of a research base for midwifery education. Midwives in doctoral programs should consider researching educational practices. All midwives should support funding to facilitate sophisticated and complex multisite studies to guide and extend continued reform and innovation across midwifery education. Academic faculty must urge tenure committees to accept the value of educational research so that educators do not find themselves in the impossible situation in which the expectations of their positions are not the same as the expectations for promotion and tenure.

The midwifery profession clearly values support for the education of future midwives. The profession must then ask who will develop the science of midwifery education over the next decades? We must be proactive in ensuring that this science is developed through commitment and funding. We live in an age in which evidence guides clinical practice. It should guide, not stymie, educational innovation as well.

“Don't suture yourself into trouble.”