Recruitment and retention of midwives can be problematic and is continually under scrutiny in the media (BBC, 2018; Royal College of Midwives (RCM), 2018). In an attempt to address this, the Chief Nursing Officer for England, Jane Cummings, has recently announced a new campaign aimed at increasing the numbers of nurses and midwives. This is to coincide with the 70th anniversary of the NHS, where she also acknowledges the ‘extraordinary’ people who want to care for others (NHS England, 2018). It is necessary to ensure that both qualified midwives and student midwives remain in the profession for the long-term, so that succession planning can take place and a quality service can be provided by midwives with a wide variety of skills and experience.
Last year, the Nursing and Midwifery Council (NMC) reported that there were more nurses and midwives leaving the profession than joining the register (NMC, 2017). The main reasons given for leaving were Brexit, retirement, staffing levels and personal circumstances (NMC, 2018). Speaking to both newly qualified midwives and student midwives recently, several stated their intention to move and work abroad, while others were considering alternative career options. Some newly qualified midwives choose not to practise at the point of qualification and decided to return to the role at a later date, but there is a real risk that they could lose their passion for midwifery.
Recently, there have been a number of changes that could now affect midwifery recruitment. For example, in September 2017, a new generation of student midwives began midwifery training, funding their studies via the student loans system. An advantage of this is that midwifery places are no longer commissioned, so educational establishments have the freedom to recruit an unspecified number of midwives; however, some limitations, such as clinical placement capacity and mentor availability, could still remain.
‘Introducing and adapting continuity of care models may be beneficial to both service users and midwifery staff; however, this can only be successful with a sufficient number of midwives in-post’
Despite this, earlier in 2018, the NMC and the RCM reported that midwifery registrations were now at their highest level for 4 years with fewer exiting the profession (NMC, 2018), resulting in some stabilisation in workforce numbers. This, alongside the announcement by the Department of Health and Social Care (2018) to train an extra 3000 midwives over the next 4 years while driving forward greater continuity of care, can only be seen as positive. There also appears to be progress in negotiating a pay deal, albeit in principle.
Continuity of care was a key topic in the historical Changing Childbirth report (Department of Health, 1993), and continues to be a recommendation in midwifery today (National Maternity Review, 2016). The benefits of continuity of care include reduced early stillbirths, miscarriages and neonatal deaths (Sandall et al, 2016), in addition to lower burnout rates in midwifery (Sandall, 1998). Introducing and adapting continuity of care models may be beneficial to both service users and midwifery staff; however, this can only be successful with a sufficient number of midwives in-post, and so it is imperative that midwifery staff and students are retained. We know that staffing challenges result in temporary closures of maternity units and the transfer of women to alternative settings (Ewers, 2017). This could be the first time that woman has attended the unit or encountered the midwifery staff, and this affects the continuity of care ideal.
So how can the workforce be maintained and increased? Higher education institutions are no longer limited by the number of students who can be recruited, but it is also important that this new generation is retained. The ‘elephant in the room’ is the financial implications to future student midwives. Midwifery and Nursing students are now required to pay the same fees as students for non-NHS courses, as well as working and studying on full-time basis, which can create financial challenges if the student midwife is working part-time alongside their studies. Since the announcement of the withdrawal of funding, there has been a notable decrease in applications, especially from mature students, who have expressed their concerns over funding childcare and paying mortgages. As a result, there has been a 35% decrease in applications to study midwifery since 2013, most notably among applicants aged over 21, who showed a reduction of more than 45% by 2017 (Ewers, 2018).
Despite the initial anxieties over obtaining a student loan, some students have reported that they were pleasantly surprised to discover that their student maintenance loan was significantly higher than a NHS bursary. Although there has been opposition to the withdrawal of funding, these students stated that they would have struggled to manage financially if they had been reliant on an NHS bursary, especially in relation to childcare, as they received significantly greater funding via their maintenance loan.
A further challenge is ensuring that there are a sufficient number of placement opportunities. It is imperative that mentorship is robust and that the student feels safe and well-supported during their placement with access to learning opportunities wherever possible. The University of Salford is considering several different models of mentorship to accommodate larger student numbers without affecting the student experience.
It has also been recognised that an increase in student numbers could affect students' opportunity to observe complex situations in the clinical setting. To ensure that students can practise their skills in a safe environment, simulation is being increasingly used for learning, as research (Carolan-Olah et al, 2018) found that simulation, rather than observation of real-time events, improved a student's confidence, knowledge and skills. The University has state-of-the-art simulation facilities, where students can practise and develop clinical skills in a safe, non-threatening environment, and student feedback has already reinforced the value of the simulation suite in learning and understanding clinical scenarios. It is hoped that simulation, along with structured debriefing, may reduce the pressure on mentors in the clinical area.
With this shift in midwifery education, it may be necessary to consider different approaches to supporting and retaining students. Many are still experiencing financial difficulties and childcare challenges while attempting to work part-time and study, and therefore it is important that they receive the same compassion and understanding as we would show to women, their families and each other. This new generation of students need to be prepared for the challenges faced by midwives, particularly in the NHS, but should also see the rewards of being a midwife. Midwifery has to be future-proofed and we all have a part to play.