Ireland's pre-registration midwifery curriculum was last reviewed 13 years ago (Department of Health and Children, 2012) and the Irish healthcare sector has since undergone significant reform. Reviewing the curriculum enables midwives to see if it remains relevant and continues to reflect the philosophy of the profession, resulting in midwifery students being able to meet the needs of women and their babies when they graduate.
The midwifery profession has undergone substantial changes in response to the increasingly changing needs of the Irish population, which has seen a decrease in the birth rate since 2013. The Central Statistics Office (2023) in Ireland reported a decrease in the number of registered births from 68 930 in 2013 to 54 678 in 2023, which represents an annual birth rate of 10.4 per 1000 of population. Regardless of the decrease, it is important to invest in the provision of midwifery services.
Midwifery education programmes in Ireland are required to focus on woman-centred, community-based healthcare and need to be aligned with national maternity priorities for the development and delivery of healthcare services set out in the national maternity strategy (Department of Health, 2016) and in the wider healthcare system of Sláintecare (Committee on the Future of Healthcare, 2017). There has also been an expansion in the use of digital technology in maternity care to support maternal and fetal health and wellbeing, which has had an impact on midwifery education.
Curricula for midwifery students should be supported by up-to-date evidence guided by national maternity priorities and include a balance of theoretical knowledge and clinical practice. Education programmes need to be high quality, sustainable and innovative to ensure that midwives are able to respond to the changing needs of the women and babies in their care. The aim of this study was to conduct a comprehensive review of the undergraduate midwifery curriculum in Ireland.
Methods
This mixed-methods study was underpinned by a curriculum evaluation framework and the positive philosophy and principles of appreciative inquiry (Watkins and Cooperrider, 2000). The focus was on identifying the positive core strengths of the profession to leverage a more sustainable future for the next decade of midwifery education in Ireland.
An expert advisory group was formed to oversee the project in collaboration with the research team. Two chairpersons were agreed to ensure there was equal oversight from both aspects of the curriculum (academic and clinical). The group consisted of service users, students, midwifery leaders and international experts, and it oversaw the review while being appraised on the progress of the project at regular intervals. The expert group was a source of expertise when required and agreed with the recommendations of the final report.
Design
The study used an appreciative inquiry model to manage positive change (Cooperrider and Whitney, 2005). It was used to focus on what was working well in the current curricula and build on this to plan for the future, using the 5Ds that the model is based on:
Stufflebeam's (1971) context, input, process and product evaluation framework was selected to guide the evaluation project. The framework involved a review of the planning (context), structuring (input), implementing (process) and recycling (product) of the curriculum, which involves determining the degree to which the objectives have been achieved (Stufflebeam, 1971).
The five separate workstreams that were created to complete the research phases were a policy document review, curriculum review, graduate survey, stakeholder focus groups and a scoping review of the literature. The scoping review and curriculum review are not included in this article and will be reported separately.
Participants
Purposeful sampling was used to recruit potential participants for stakeholder engagement (graduate survey and stakeholder focus groups). All midwifery graduates who completed the final year of their undergraduate programme in Ireland in 2022 (approximately 140 graduates) were invited to complete an anonymised online survey. The participants were accessed through the Nursing and Midwifery Board of Ireland (NMBI) via its ezine newsletter, which is emailed to members, social media marketing and graduates when they applied for registration. The email to graduates included an anonymous survey link and a QR code.
An extensive broad-reaching consultation with key stakeholders for undergraduate midwifery education in Ireland was also conducted via peer-to-peer focus groups. Newly graduated midwives were recruited following completion of the survey and were invited to provide their contact details if they wished to participate in focus groups. All other participants in the focus groups were recruited by sending an invitation to the head of the appropriate institution requesting a nomination.
There were five focus groups with a total of 37 participants, comprised of senior stakeholders (n=6), such as the chief directors of nursing and midwifery and representatives from the Irish Association of Directors of Nursing and Midwifery; clinical midwives (n=3); midwifery academic staff (n=5) from each higher education institutes; midwifery preceptors (n=12); service users (n=6); and union representatives (n=5).
The target size for focus groups was informed by Polit and Beck's (2022) optimum of 6–12 participants. Consistent with evidence-based practice (Nyumba et al, 2018), participants were invited to a focus group scheduled for a maximum of 2 hours.
Data collection
Policy document review
A desk-based analysis of all Irish health and social care policy documents published since 2012 was completed in September–December 2022. The research team agreed that the purpose of this analysis was to review the health and social care policies that influenced Irish health and social care since the last review of the midwifery curriculum (Department of Health, 2012).
Graduate survey
The graduate survey used all six dimensions from the Course Experience Questionnaire (37 items) (Quality Indicators for Learning and Teaching, 2025) and six items from the UK National Student Survey (2025) related to clinical placements. The dimensions were good teaching, clear goals and standards, generic skills, appropriate workload, assessment and feedback, learning resources, student voice and practice placements. A 5-point Likert scale was incorporated and an open text box was included at the end of each survey, providing students with the opportunity to add additional comments on their experience of their undergraduate midwifery programme.
Stakeholder focus groups
The focus groups were conducted online, which enabled participation from various geographical regions by eliminating the need for participants to travel (Stewart and Shamdasani, 2017). According to Richard et al (2021), online focus groups facilitate a similar quantity and quality of information collection as in-person groups at a much-reduced cost, while continuing to gain a greater depth and breadth of discussion between participants (Hoque, 2017).
A semi-structured interview schedule was used, created from data identified in the scoping review and the survey, which informed the focus group questions. The schedule was based on the philosophy of appreciative inquiry and a protocol was developed to guide facilitators for each focus group. Each group comprised two facilitators from the research team. One facilitator led the group questions and discussions and a co-facilitator provided support to the lead facilitator and participants as required. All focus groups were transcribed verbatim with any identifiable information removed. Transcripts were checked for accuracy by the research team. All focus groups were conducted on Zoom between April and June 2023 and recorded on the registered account of the principal investigator.
Data analysis
Policy document review
A protocol was developed using the READ approach, which is a systematic method of qualitative health policy research that uses four stages: reading the material, data extraction, data analysis and collation of the findings (Dheensa and Feder, 2022). The research team created an Excel spreadsheet where each row represented the health and social care documents and each column represented a category of information. Each document was read by two team members. Data extraction and analysis were iterative as the findings continually informed the researchers as to how to interpret the data. The findings were examined for commonalities, inconsistencies, gaps and ambiguities related to midwifery education and its ability to prepare newly graduated midwives to achieve the professional role requirements.
Graduate survey
Data from the graduate survey were analysed using descriptive statistics. Measures of central tendency included the mean and median, and measures of variability, standard deviation, range, minimum and maximum. Inferential statistics were used to draw conclusions about the population that participated in the online survey in the wider context of the midwifery population.
Stakeholder focus groups
Data were analysed thematically by SG and MC (Braun and Clarke, 2022). Themes were developed individually, then discussed and a consensus reached among the research team. Codes were identified for each focus group and placed within the framework of appreciate inquiry headings, discovery, dream, design and destiny. The authors (MC and SG) developed codes for collective midwifery focus groups.
Ethical considerations
Full ethical review for the two phases of data collection involving participants (the graduate survey and stakeholder focus groups) was granted by University College Dublin's Human Research Ethics Committee (survey reference: LS-C-22-164-Ryder, focus group reference: LS-LR-23-03-Ryder).
All participants were provided with an information sheet outlining the scope of the study, the research team's contact details and the phone number for a helpline if they experienced any emotional discomfort when recalling their experiences. Participants were advised that they were able to withdraw at any time and asked to provide written consent to participate.
Results
Policy document review
Eight health and policy documents pertaining to midwifery were identified and analysed to identify the attributes that graduates were expected to have and whether this was being met in the current midwifery curricula (Table 1). The use of the term ‘nursing and midwifery’ throughout the broader health policy resulted in many documents using the term midwifery when they were not relevant to midwifery practice.
| Year | Policy title | Discipline (times ‘midwife’ mentioned) | Skills/attributes of a newly qualified midwife |
|---|---|---|---|
| 2022 | Department of Health (2022): report of the expert review body on nursing and midwifery | Generic (699) |
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| 2022 | Nursing and Midwifery Board of Ireland (2022): report of the review of undergraduate nursing and midwifery degree programmes | Generic (>700) |
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| 2021 | Health Service Executive (2022): national standards for bereavement care following pregnancy loss and perinatal death | Midwifery (168) |
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| 2017 | Committee on the Future of Healthcare (2017): Sláintecare report | Generic (10) |
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| 2017 | Department of Health (2017): working together for health: a national strategic framework for health and social care workforce planning | Generic (69) |
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| 2016 | Health Information and Quality Authority (2016): national standards for safer better maternity services | Midwifery (69) |
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| 2016 | Department of Health (2016): national maternity strategy | Midwifery (160) |
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| 2012 | Health Information and Quality Authority (2012): national standards for safer better healthcare | Generic (5) |
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Three documents were specifically related to the midwifery profession (Department of Health, 2016; Health Information and Quality Authority, 2016; Health Service Executive, 2022) and these were also well aligned to NMBI requirements and standards for midwife registration. This was demonstrated through the similar use of language such as ‘women-centred care’, ‘advocacy’ and ‘partnership with women’. The remaining policy documents were more likely to describe a service rather than the role of the midwife. This suggested a lack of recognition regarding the importance of the relationship between midwives and women in a service that is philosophically aligned to the midwifery profession.
Graduate survey
There were approximately 140 new graduate midwives who were eligible to complete the survey in September 2022 and 44 responses were completed (response rate: 31%). Most of the graduates accessed the survey through a direct link and took an average of 13 minutes to complete the survey. Over a third (37%, n=44) of midwifery graduates entered the programme as mature students (over 23 years old).
The respondents reported feeling less prepared than their general nurse counterparts (P=0.002) and 89% (n=39) of the respondents agreed or strongly agreed that there was a lot of pressure on them as a student. Of the 44 respondents, 55% (n=24) reported not having adequate supervision during their practice placement and considered the workload too heavy. Over one-third (39%, n=17) did not think their preceptor understood how the placement related to the broader requirements of the course.
Although clinical and academic components were equally valued by midwifery graduates, the open text comments reiterated the lack of support midwifery graduates had in their clinical placements and this was attributed to staffing resources and not being considered part of the team. Respondents suggested that enhanced communication between education and clinical sites and early exposure to the clinical area could help this to improve.
Focus groups
The identified codes from focus groups were applied to an appreciative inquiry model (Table 2). Similarity was noted between midwifery and nursing focus groups, which were being carried out in parallel to assess the nursing curriculum, and this resulted in four themes that encompassed midwifery and nursing: a resourced student-centred learning system, academic entry and access routes, mutual esteem and midwifery as a distinct profession.
| Focus group | Discovery: core values and learning elements | Dream: most engaging component | Design: how to educate for the future | Destiny: what will it look like? |
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| Preceptors |
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| Clinical |
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| Academics |
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| Senior stakeholders |
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A resourced student-centred learning system
The focus groups identified the need for a student-centred approach to the midwifery curriculum that would give increased flexibility and choice for students, such as choice in practice placement sites. It was noted that students were often required to commute large distances without adequate infrastructure, which limited their ability to attend placements.
‘We [had] students travelling daily from Galway and Kerry and they're getting public transport. So, to get to [clinical site] for 9 o'clock is an issue for them. So I do think we may have to be flexible about how we deliver the programme’.
A well-resourced curriculum was described as one with enough layers and staff to ensure that women's care needs and students’ needs could both be met. There was evidence of students being unsupervised, which supported open text comments in the graduate survey responses.
‘I think we need, especially in our hospital, we need more [clinical practice co-ordinator] involvement. More involvement on the wards, they're not there as a support. And because we work in the same area and because we are so heavily understaffed, students are left’.
This affected the experience of the preceptor as well as the student on practice placement.
‘It's so simple, but we don't have it and we're so short-staffed … and we can only do our best’.
All of the focus group participants acknowledged the increased need for practice placements in the community, and this was considered to be a positive and beneficial development for midwifery practice in Ireland.
‘If we were delivering more midwifery antenatal care and postnatal care in the community, which would be fantastic. Well, then, for the students to be a greater part of that as well would be good’.
Academic entry: access routes
Participants described students who were ‘quick smart’ (very clever), but this did not mean that they were automatically the better candidates for the midwifery profession. A wider system that assessed other qualities beyond exam results was suggested to be a better indicator for a candidate's suitability for a midwifery undergraduate course.
‘The points system is so high to get into it, we are missing out ones who might not be academically inclined but who would make good midwives and really caring people … I think that we are cutting out people who would make good caring nurses and midwives by the points being so high’.
High student saturation in practice placements during the academic year was considered detrimental to students’ learning. The summer months were inaccessible to students and participants suggested that using the academic calendar was not preferable.
‘Can we try and address lengthening the academic year? And I think that's a huge … I think that needs to be looked at’.
Mutual esteem
Focus group participants considered a university degree to be a positive attribute for the midwifery profession. They held the clinical environment in high regard. Some participants expressed the need for ‘early exposure’ (academic midwife) and ‘more exposure’ (clinical midwife) to the clinical environment, but did not always connect learning while on practice placement with learning in the university environment as two parts of a whole.
‘Clinical placements, 100%, you learn so much in the environment of working with other midwives. And exactly like [name] said, you can do so much theory and you can read and you can write things down but until you're actually in the environment … then a lot of students will say they get that click, they get that light bulb of “ok this is what it actually means, I get this now”. Clinical skills and placements are just core’.
The strength of feeling over the need to learn in the clinical environment meant that at times there was a lack of esteem given to university-based learning.
‘I think if I could do one thing it would be more time on clinical placement than in the books’.
This was also visible in the lack of understanding of curriculum design and development, or why being outside of the clinical setting could be beneficial to midwifery student's education. Some participants suggested that practice placements consolidated learning that had been ‘missed’ in the university, suggesting a lack of recognition of the shared responsibility of learning in both the clinical and university environment.
‘We're trying to consolidate an awful lot of the learning that should have occurred in the [higher education institution] and it's not necessarily a criticism per se. It's just the way that the curriculum is really structured. I feel there's a lot of self-directed learning which could be structured, and which might help the students more going forward’.
Learning from practice placements and university were not considered to be well integrated. Some participants wanted to see the university's presence in the clinical environment more directly and being more visible for students would support their practice.
‘I suppose it's bringing, maybe more of a presence from the [higher education institutions] into the maternity units itself. Having that collaboration … that integration … the students, seeing that support there’.
Midwifery as a distinct profession
All four focus groups articulated the importance of midwifery being identified as a separate profession. Some participants did not feel the midwifery profession was acknowledged as separate from nursing.
‘And that happens even within our own profession, we have to say “no, this is what a midwife is”. You know it's different to nursing. And then you get people saying “oh, you're being all that”, and you're like, “no. I'm not trying to make something bigger of myself. I'm just saying it's different”. Midwifery is different and these students are not nurses, and … since the 2011 Act legally they cannot be called nurses. They are midwives … it's like microaggressions. You can't call them nurses. They are midwives, and you have to treat them as midwives’.
Midwives articulated what they perceived to be different about their role when compared to nursing which included ‘autonomy’, ‘decision making’ and ‘advocacy’ (senior stakeholder midwife). It was suggested that separating the education of midwives and nurses would help to prevent midwives ‘getting lost’ in the larger group of the nursing profession.
‘You might have a class of 300 students from five different disciplines. I feel sometimes midwifery is getting lost within that number of students’.
Discussion
One of the main findings of this study was the importance of acknowledging midwifery as a distinct profession in Ireland. Midwifery professionals from the focus groups reported that it was a core value of the profession to be distinct from nursing and expressed a sense of frustration that this lacked acknowledgement. It was felt that midwifery education's move to higher education in 2006 had contributed to midwifery merging with nursing in academia, despite a strong desire from clinicians to separate the two professions. This is consistent with previous literature that identified that the move from hospital-based education to higher education produced a change in how midwifery students received education (Ebert et al, 2020) and began the evolution of midwifery education to where midwifery is required to be a distinct profession from its nursing counterpart (McKellar et al, 2023). In this study, the persistent conjoined use of midwifery with nursing was interpreted as a lack of understanding of the profession, which was worsened by senior midwives not being included in the development of healthcare policy. After more than 100 years of midwives’ determination to obtain professional status (Kirkham, 2020), the midwifery profession in Ireland requires acknowledgement of being interprofessional. Where nurses and midwives are taught together, midwifery students would benefit from having tailored examples from midwifery practice.
The national maternity strategy (Department of Health, 2016) is the maternity services arm of the Sláintecare policy. This strategy promotes caring for women as close to their home as possible. Practice placements in midwifery would benefit from being mapped to the various pathways identified for women in pregnancy, as this would make the learning objectives more transparent. A midwifery community component was identified in the study as demonstrating a separation from the medicalised model of the pathway for women and offering an opportunity to provide more holistic care. The literature has consistently reported that women and midwives expressed higher levels of satisfaction in continuity of care based in community settings compared with women and midwives who experienced a standardised medical model (Gamble et al, 2020; Dharni et al, 2021; Hainsworth et al, 2021). Exposing midwifery students to different models of care provides them with a rich and holistic learning experience and helps them develop a sense of professional identity (Baird et al, 2022).
The academic participants in the focus groups reported that the theory and clinical components of the midwifery courses were engaging, whereas the clinical midwives only reported on the benefits of clinical practice. There was a consensus among the midwife participants that early engagement with clinical practice and longer placements were valuable for student learning. The present study's authors recommend exploring an integration framework that begins with midwifery leaders working together to improve academic/clinical collaborations and partnerships (Mattison et al, 2021).
This finding is not unique to Irish midwifery and it has been noted that these relationships can be misaligned and the partnerships fade after specific collaborative projects are completed (Cazzini et al, 2022; Lloyd et al, 2023). These partnerships are important as midwifery care becomes increasingly complex and care delivery transcends multiple models and locations (Wynne et al, 2021). Failure to establish and build on academic/clinical midwifery partnerships is a missed opportunity for the profession to build a strong workforce for the future.
The curriculum in Ireland is delivered in a split environment that requires strong collaborations. Perhaps there should be representatives from universities in the clinical setting and vice versa rather than midwifery students being the only shared personnel between organisations. Midwifery graduates reported a lack of adequate supervision during clinical placements and that their preceptors did not understand how the placement related to the broader course requirements. It is known that students require an experienced clinical preceptor to be able to impart professional knowledge and skills and that planning and preparation are key elements of successful supervision for students (O'Brien et al, 2019).
It has also been identified that a lack of recognition and incentives for providing supervision were among the main concerns of supervisors and preceptors (McLeod et al, 2021). Internationally, midwifery education sits within higher education and, in Ireland, 50% of the course is covered in practice placements. The international standard is a bachelor's degree award of varied duration and the relevant European Union directive stipulates there should be not less than 4600 contact hours both academically and clinically during training, while Irish standards stipulate 144 weeks. This study identified that more practice placement locations should be identified to support and prepare the workforce for the future and to align with Irish policy for maternity care, which values and promotes an increase in the number of community placements.
The current supervision model in the clinical area in the curricula poses the greatest concern for midwifery. The current model places midwifery students in a vulnerable position, where 50% of their course assessment is being tasked to overworked preceptors or supervisors on placements whose main priority is the delivery of high-quality and safe woman-centred care.
Implications for practice
The findings of this study suggest that the clinical learning environment is challenging for midwifery students in Ireland. This has also been found to be an international concern (Martin et al, 2022). There are many clinical supervision models in existence worldwide in the clinical education of midwives and there is a lack of evidence to support one model over another. Midwifery students’ clinical learning is often completely dependent on an individual whose teaching and assessment role is subject to multiple external factors beyond their control and they are under pressure from conflicting demands. The findings suggest that a clinical supervision model that is supportive to both the student and the clinical environment would have a positive impact on the experiences of students and preceptors in midwifery.
Strengths and limitations
This research was strengthened by using a national sample and multiple methods to triangulate the data. The research does have some limitations, such as a possible participant bias to the graduate survey sample response rate.
Conclusion
This study produced the first review of midwifery curricula in Ireland in 10 years. The development of healthcare policy must ensure that the midwifery profession is properly represented. Further research is required to recognise positive attributes of a clinical learning environment to support learning in practice placements as part of the undergraduate programme.