Health promotion is of particular importance to midwives who promote health rather than manage disease and ill health. Although the midwife has always had a role in public health, there is now an explicit need for the profession to direct its attention to teenage pregnancy, smoking cessation, drug awareness and domestic violence. Much of the role of the midwife during pregnancy is in health promotion and a more explicit application of such may carry benefits in meeting Government policy on public health.
Some activities undertaken by midwives may not be identified as health promotion, though there is evidence that the interaction generated by routine examinations is of benefit to the motherís health. Midwives should work in partnership with women and families, facilitating decisions about the care that they feel they may require. Social disadvantage may impede participation where formal education was not valued or ethnic background or language impaired access to traditional childbirth education. Tackling this is at the heart of current public health policy around childbirth and child care.
Education can take place during any interaction and this gives midwives huge scope to provide an educational experience for women each time they meet. For the pregnant teenager the extended family may need to be included in health promotion activities particularly if breastfeeding targets are to be met. A united health and education policy to inform and educate children and teenagers about the benefits of pre-conceptional care and breastfeeding may be needed. In this way young women come into contact with midwives before they are pregnant, before attitudes to breastfeeding are established and before the concept of pre-conceptional care is lost. Although breastfeeding improves health for women and their infants it can become another burden and expectation which they fail to achieve. Professionals need to be sensitive to the possible negative impact on a womanís health, which could be reduced if the emphasis was moved from individual behaviour change to the inequalities within society.
Midwives should seek to respond positively to service changes to achieve the goal of multidisciplinary, non-hierarchical patient-centred services. In facilitating change midwives seek to use their influence to the benefit of the pregnant woman.
Of the sixty institutions identified, 55 were eligible as they currently offered pre registration midwifery education. A total of 29 institutions responded (53%) in relation to 37 programmes (3 year and 18mth programmes), of which 23 were in England, 3 in Scotland, 2 in Wales and 1 in NI. Participants responded in a variety of methods: 15 (52%) replied via survey monkey: 10 (35%) via post: 3 (10%) sent their curriculum documents for completion by the project team and 1 (3%) completed over the phone.
Explicit reference to public health in midwifery curricula
The pre registration survey asked respondents to state how explicit (direct reference) the inclusion of public health was in the curriculum philosophy or programme and module aims/objectives. The results are presented in Figure 1.
Explicit Inclusion of public health/inequalities in pre registration programme documentation.
Public health topics included
Respondents were invited to select from a list of pre defined topics on public health and inequalities and indicate whether they were included in their provision of pre registration education for midwives (Table 1). Participants were invited to indicate the approximate number of hours allocated to the list of topics. Table 1 demonstrates the considerable variation across institutions both in relation to the topics provided and the hours allocated, for example, three institutions stated they did not cover the principles of public health, five reported they did not include epidemiology and the number of hours allocated to perinatal mental health ranged from 1.5 to 14. A number of respondents also reported that several subject areas were not offered, as illustrated in Figure 2.
Pre registration public health and inequalities subject areas
Specific public health and inequality subject areas not offered* pre registration programmes.
Curriculum gaps and limitations
Respondents were asked to identify any gaps or limitations in the current provision of public health education. Twenty five (68%) respondents reported there were no gaps, six (16%) reported they felt there were gaps; and six (16%) did not respond. There was recognition that public health was explicit in institutional programmes, however, it was also reported that more time was needed to explore theoretical models and often learning was solely focused on practical aspects. Some respondents who reported that they felt there were no gaps in the curriculum also commented that the public health elements of their undergraduate curricula depended on good links with practice for example the facilitation of clinical placements which provide exposure to public health roles. It was highlighted that the curriculum needed to be regularly revisited in order to ensure relevance. Specific topic areas where gaps were identified by respondents included perinatal mental health, asylum seekers and homelessness, obesity, nutrition and alcohol.
Public health as core to midwifery
Respondents were asked to rate on a scale of 1–5 (5=essential) how much they thought public health was part of the core role of the midwife. All participants denoted a score of 4 or 5 with the exception of one, indicating the majority considered public health as an essential element of core midwifery practice.
Nine focus groups with 59 participants (34 midwifery students and 25 registered midwives) were conducted. Four focus groups with students were conducted in three participating institutions (England, NI and Scotland) and five focus groups were held with registered midwives; participants included managers, midwives from practice, public health specialists and educationalists in England, NI, Scotland and Wales. Data from the focus groups are presented in relation to three key themes: understanding public health in midwifery; the reality of practice; knowledge and confidence about public health.
Understanding public health in midwifery
Throughout the group discussions it was evident that midwifery students did not have clear understanding of the public health role of midwives. In some groups, initially it was seen as a specialist area and not as core, given that midwives cannot be ‘experts’ in all areas. However, as the discussions continued within groups, there eventually (and usually) was consensus that public health was integral to midwifery practice and input from multidisciplinary teams or specialists could be utilised for additional support.
“I think the role of the midwife is really important but when I was doing my bit of research for my assignment one of the key things that was out there, a lot of midwives don’t accept that they have a role in public health” (Scotland Student Group)
In all of the focus groups with registered midwives the definition of public health relative to midwifery was difficult to pinpoint precisely and generally the question was met by initial silence. One group identified that it was important for midwives to have ‘their’ definition of public health and what it means in midwifery practice as other disciplines have a clearer understanding of what public health is.
“So I think what midwives need to do is (consider) what is our meaning, our understanding, our domain, what is our package of public health? What do we mean by it? What would be our targets? What would we want to see as perhaps, we can’t control the whole population but we can look at the whole of childbirth, say from maybe a little bit of preconception right up to is it midwives’ role up to 28 days after birth? What kind of targets, goals, public health things would fit in?” (England Midwifery Group)
Discussions with registered midwives were generally consensual about public health as an aspect of midwifery practice, although, there was often debate as to the extent of this role and boundaries regarding core or specialist practice. Terminology, such as ‘crucial’, ‘pivotal’, ‘the foundation of it’, ‘significant role’, was used to describe the public health role of the midwife in relation to the core aspect, although, within groups there was confusion relating to if and how midwives viewed themselves as public health practitioners.
‘It’s got to be the core function and then we build on top of that’ (Wales Midwifery Group)
One group discussed how difficult it was to marry the goals of public health and the aim of holistic midwifery care. It was proposed that the goals of public health are overarching and at population level, whereas in midwifery care the aim is more towards an individualised approach tailored to the specific needs of women and their families, and therefore, this may result in conflict (see quote below). This was not discussed voluntarily in subsequent groups, however, the moderator of the final focus group introduced the idea and the concept was generally agreed.
“.....public health tends to take a very global approach and they want everybody vaccinated and everybody to give up smoking and everybody to breast feed. And the reality is that midwives, we’re actually dealing with individuals who are giving us very good reason for why they’re going to continue smoking and why they’re not breastfeeding which may not fit with the public health agenda. I think that there’s a fundamental problem between imposing that perhaps, on a midwife who is actually working with an individual and understands that woman’s context. Yes, she knows it’s not good for her to smoke. Yes, she knows it’s going to give her cancer or whatever in the long term but right now she’s just trying to survive. And I think trying to superimpose this public health practitioner role on a midwife could actually lead to role confusion or completely role rejection”. (Scotland Midwifery Group)
The reality of practice
A general lack of confidence and some anxiety around discussing specific public health related topics with women was reported by midwifery students at various stages of their training e.g. smoking cessation.
“I’ve completely avoided that huge area of public health and midwifery and I feel terrified of it now, you know, if I were to get a woman who was saying, ‘I’m smoking, what can I do about it’... I wouldn’t know”. (England Student Group)
Students were also aware of the impact of busy clinical environments and the subsequent effect on the ability of midwives to address or discuss public health issues.
“I think time’s a big issue with all public health. I think midwives don’t have enough time to deal with all the public health issues that they need to deal with” (NI Student Group)
Although it was generally recognised that public health interventions and addressing inequalities are part of the midwives’ role, barriers in clinical practice were identified as influential on the effectiveness of that role. Barriers discussed included the shortage of time available clinically to care for women, the difficulty of providing copious health promotion messages at the booking interview, the ‘tick box’ approach to care, midwives’ reluctance to develop conversations with women due to a lack of time, continual ‘adding onto’ the midwives’ role, models of care and the lack of vision regarding long term outcomes of care. Additional barriers were identified that focused more generally around professional issues, such as, heavy administration and bureaucracy, work load volume and leadership. However, despite the recognised barriers, groups were unanimous that pregnancy was a time of opportunity for midwives to promote the overarching goals of public health. The recognition of pregnancy as a time of ‘opportunity’ was resonant through all the focus groups and there was unanimous agreement both within and between groups that pregnancy is a time in women’s lives which could be influenced with regard to a public health message.
“You know, I think what we do have as midwives is a captive audience. We have an opportunity. We engage with women, somewhere in and around six to twelve weeks in their pregnancy depending on how early they do their pregnancy test and who they contact first. And we have access to those women who are like sponges for information for at least six months and it is an opportunity” (NI Midwifery Group)
Knowledge and confidence about public health
The majority of students were able to discuss key public health topics relevant to midwifery practice and perceived their level of theoretical knowledge was good; however they reported that practical delivery was difficult. Several groups suggested some additional solutions, such as, motivational interviewing or training in communication skills through role play as highlighted below.
“Participant 1: But it’s hard, I think, for us I think to go out and start telling people this. I think you need more than a, confidence lessons or something...
Participant 2: Or, just different approaches to how you go about health promotion. You know, do you ask how, what the woman knows about it first and getting into like dialogue and conversation as opposed to telling the woman what to do.
Participant 1: Yeah...yeah, so like more of the ‘how to’.
Participant 2: Yeah, definitely. Role play....I think that would be really good” (NI Student Group)
Barriers to increasing knowledge were identified by the focus groups with registered midwives. These related to the availability of training, difficulty releasing staff for training and the type of training that is needed. The majority of groups acknowledged that training exists, however, the topic is often politically motivated or a current hot topic, for example, the focus on obesity and weight management during pregnancy. Another issue raised was the availability of funding for training; funding was prioritised for courses where the aim was to develop skills of direct benefit to practice i.e. medical prescribing or examination of the newborn skills over developing theoretical knowledge, as illustrated by a quote from a NHS midwifery manager, below:
“If a midwife came to me and said I want to go and do a module at (a HEI) or wherever on public health, unless she was doing it as part of a degree I can’t see her coming forward to do it, and I couldn’t support her unless I had a particular role for her” (NI Midwifery Group)
There was a recognition that public health was more prominent on pre registration education curricula and that newly qualified midwives were perceived to be ‘steeped in public health” (Scotland) and ‘more conscious of public health than midwives trained a few years back’ (Wales). However other groups felt that while this may be true, there were concerns around the general lack of midwives’ confidence to discuss many public health issues with women, for example obesity, weight management, and routine enquiry about domestic abuse.
Some of the discussion in the focus groups (registered midwives) outlined potential measures to address the barriers in order to maximise the public health role of the midwife. Recognition of the need for more training was identified and several examples of innovative practice were provided. For example, a NHS service manager gave an example of how funding had been obtained through the British Heart Foundation for a midwife to link into a community based obesity networking and motivational programme.
Several methods of training to address gaps in the effectiveness of a midwifery public health role were suggested. Online training in the form of a toolkit was suggested in one group. This would have the advantage that midwives could access it in their own time. However, another group felt that online learning was problematic in the area of public health, as there was a need for an interactive element and also monitoring compliance with online learning could be difficult if the training was not mandatory. Increased knowledge of interventions that midwives could conduct was discussed as something that would be helpful. Brief intervention training, which has been used effectively in other areas of practice, was also raised as a potential for midwives in the area of public health. Underlying the recognition of training, however, was the need for more emphasis on the application of public health to midwifery and for all midwives to understand better the relationship between public health and midwifery.
“.....so I think the longer term thing would be to change the culture of how midwives see their role in public health and accept that and maybe see that it’s not an add-on to our role” (NI Midwifery Group)
“I think a lot of it too is, [that] you do have to get underneath the midwife’s thought processes as well, in it all..if they’re going to deliver the positive message you’ve got to understand them, haven’t you, as a person and build their confidence” (Wales Midwifery Group)