Midwives must provide individualised, culturally sensitive care to women seeking abortion in relation to decision making, eligibility for abortion, process, risks and ethical issues (International Confederation of Midwives, 2019). However, in Europe, the requirement to deliver safe practice prior to registration as a midwife does not specifically refer to abortion (EU, 2005). Nationally, standards explain there should be a focus around, ‘contraception, unintended pregnancy, and abortion’ (Nursing and Midwifery Council [NMC], 2019). Therefore, there is an element of discretion where midwifery programmes are left to decide how to include the topic in their curricula.
Midwives' practice-based experience around abortion varies and it is unknown how many student midwives in the UK are involved in that care (Klingberg-Allvin et al, 2007; Paul et al, 2014). Lukasse et al (2017) recognise that 50% of midwifery education takes place in practice and the experience has a substantial impact on student learning. However, it is difficult to align every aspect of exposure in practice to concurrent theoretical content. Therefore, midwifery programmes of education need to make judgment calls about when to place theory into the curricula to meet the developmental needs of the student midwife.
In the present study, the 3-year modular midwifery programme was based over three trimesters per year. There was a maximum of 23 undergraduate midwifery students that could be recruited to the programme each year. The curriculum was underpinned by a values-based approach to care, where theory about abortion was threaded throughout the programme. The authors recognised that specific information about how to care for women who opt for an abortion was important for student midwives to understand.
The importance of recognising how to care for women during termination was highlighted by Wellings et al (2013), who suggested that from a sample of 5 686 women of childbearing age (16–44 years), 4 in 10 pregnancies terminated in the UK were associated with a planned or a neutral maternal response to being pregnant. Therefore, abortion is not synonymous with unplanned pregnancy and the argument further illustrates the need for midwives to have additional skills for supporting women to make genuine choice around abortion, which is a process advocated by the British Society of Abortion Care (2020) providers.
Supporting women to make informed choices when providing holistic, woman-centred care is an important aspect of the role of a midwife (Sandall, 2012). It is essential that student midwives are exposed to in-depth, relevant and current education around the subject of abortion and the care women require when this choice is made. Therefore, this study aimed to explore the perceptions of student midwives about education on abortion care within the midwifery curriculum at a university in the north west of England. The intent was to understand more about theoretical and clinical need aligned to experience.
Methods
A qualitative exploratory survey design was used to capture the perceptions of undergraduate student midwives on the topic of abortion related to their programme of midwifery education. Robson and McCartan (2016) suggest the design permits the collection of a relatively small amount of data in a standardised format and helps to identify an overview of opinion.
Opportunistic sampling included all student midwives present on one day in March 2017. A total of 60 student midwives were invited to participate from a potential total sample of 66, as six were not present on the day. All three years of the undergraduate programme were included. The survey approach used a specifically designed, anonymised questionnaire. There were three demographic quantitative questions, which progressed to sensitive content that involved free text, and helped contextualise responses. The questionnaire could be completed within 2 weeks and return boxes were made available in two locations: one in the actual classroom and another at a faculty desk, where discrete posting of completed questionnaires was possible. The boxes were checked every day for 2 weeks.
The Standards for Reporting Qualitative Research guideline was used to underpin the standard of reporting for qualitative research (O'Brien et al, 2014). Data were analysed using IBM SPSS statistical package (version 23, 2015) to generate frequency and distribution (Greasley, 2008). Framework analysis provided a structured approach to synthesising data (Ritchie and Spencer, 1994; Srivastava and Thompson, 2009; Gale et al, 2013) and by using the five analytical steps to familiarise, map and interpret findings, the framework allowed for the extrapolation and identification of themes.
Ethical considerations
Ethical approval was granted by the University Ethics Committee (Reference FOHS 164). As a result of the sensitive nature of this study, anonymised questionnaires provided an opportunity to express opinions without fear of judgement (Lee, 1999). Students understood that they could take the questionnaire away to complete. Information sheets were provided to all participants at the same time as the distribution of the questionnaires (Richie and Lewis, 2003). The provision of information recognised that the participants may need further information because of the sensitivity of the topic. Therefore, a distress policy informed all involved about how best to provide additional support.
Results
There was a 75% (45) response rate involving 16 first year students, 15 second year and 14 third year students from a 3-year Midwifery BSc programme. All three cohorts were female and between the ages of 18–54 years, which reflected the demographic of student midwives at the university.
Figure 1 illustrates that 8 students (3.6%) were exposed to theory around abortion prior to their midwifery programme of education. Only 10 students (4.5%) within the programme declared they had experienced theory during their undergraduate midwifery studies. A total of 31 students (13.95%) prior to and 37 (16.65%) students during their studies had not engaged in education about the topic; 4 (1.8%) student midwives were unsure if they had experienced theoretical input.
Figure 1. Education related to the topic of abortion
Only 5 (2.25%) of the 10 students who declared they had experienced abortion education within the midwifery programme commented that their learning needs had been met, while two students reported their needs were not met and three were unsure. For example, student number 31 elaborated on the education received about abortion within the midwifery curriculum.
‘…[It] discussed women's choices and opinions in relation to abortion [and that information] gave us some insight into abortion before going out on placement.’
(N31)
Student N36 went on to clarify that education in the midwifery curriculum contributed to raised awareness.
‘I am much more aware of different situations that occur in some women's lives now than before I started this course. I feel very open-minded now to everything.’
(N36)
However, student N14 expressed that the information was superficial and ‘was not in-depth, only brief’, and did not meet learning needs.
In consideration of responses aligned to year of study, 5 out of 16 first-(31.2 %), 10 out of 15 second-(66.6%) and 6 out of 14 third-year (42.8%) student midwives experienced provision of abortion care in practice. In practice, 18 (40%) students had cared for women seeking abortion, whereas 27 (60%) had no experience of abortion care, regardless of the amount of abortion education they had received during their midwifery education.
Qualitatively, students reflected that raised awareness in the clinical area created a deeper level of understanding.
‘I observed and understood what an abortion involved [and that the observation was] different to what I expected and had previously perceived.’
(N18)
Clinical practice represented the reality of abortion care and that perspective had the potential to alter pre-conceived ideas. Even though student N18 expressed that they had pre-conceived ideas, all 45 students stated that the concept of including theory related to abortion in midwifery education would not conflict with their personal views. Student N36 commented that education about abortion created a sense of feeling ‘very open-minded’.
Quantitative and qualitative data were set into a framework to help identify synthesis and the process generated two overarching themes which reflected perceptions, namely educational need and values.
Educational need
The use of language around abortion was important to the participants. Student midwives explained that they were confused in relation to abortion and termination of pregnancy terminology.
‘My understanding of termination is the woman choosing to end the pregnancy whereas abortion can be spontaneous or a miscarriage. However, abortion and termination are referred to as the same thing, so I believe there is confusion.’
(N24)
Interchangeable terminology used in different contexts within literature or practice causes confusion. Confusion in rhetoric within literature and practice created a vague understanding about the process attached to abortion.
For student N28, there was a need to understand more about the clinical process involved in abortion care. For this student, a lack of understanding about the process of abortion undermined her ability to support women who were in the decision-making phase related to abortion.
‘It would have been better to have learnt a little more about the different ways/processes for abortion, as we do encounter women who are thinking about it.’
(N28)
The process of abortion was raised again by student N43 who added a need to understand more about legal implications surrounding abortion, to underpin the development of an educated personal view.
‘I think it would be valuable to educate regarding the processes and laws surrounding abortion, which would help to form a more educated personal view.’
(N43)
Developing an educated perspective was important, however. One student perceived education about abortion had been superficial and the content had become diluted via tentatively linked topics within the midwifery curriculum.
‘Not sure we received detailed information about abortion but it has been brought up while learning other themes every now and then.’
(N33)
To enhance education around abortion, it was important for student N7 to see the process from the woman's perspective. Student N7 detailed that they would value a service user's perspective on abortion in addition to learning about termination procedures.
‘[I would like to see] … education regarding the different stages of abortion, the process involved and personal perspectives of women who have experienced abortion.’
(N7)
Involving participants in the delivery of midwifery education who have experienced abortion would need to be carefully planned in order to assess the ethical implications when protecting confidentiality or providing subsequent care and support for wellbeing after the educational session was completed.
Values
Students commented that education around abortion helped to develop their ability to empathise, have compassion and become non-judgemental.
‘I think I now have a lot more understanding and empathy for women who have an abortion than I previously had.’
(N42)
Empathy in students enabled them to recognise that the decision to opt for an abortion was an emotional experience for the woman and her family.
‘I felt empathy for the woman and her family as it was a difficult choice to make. It was an emotional experience.’
(N38)
Developing empathy and recognising emotional responses in others assisted in developing a non-judgemental response about abortion. For example, student N33 expressed her appreciation that when women choose abortion, a non-judgemental response was appropriate.
‘It has given me a chance to understand why people opt for abortion and helped to care for them in a non-judgemental manner.’
(N33)
Furthermore, student N32 acknowledged how important it was to separate personal from professional views and went on to identify how mixed feelings can emerge.
‘My personal views must be kept outside all aspects of practice, as caring for women with TOP [termination of pregnancy] – we are unprepared. It is almost opposite to our midwifery ethos of preserving life and can bring up mixed feelings.’
(N32)
Being educationally unprepared erodes students' ability to appreciate wider ethical dilemmas when trying to understand good outcomes related to reproductive health (World Health Organization, 2018). Providing compassionate care is a requirement of enhancing wellbeing for women during their reproductive life and contributes to a good outcome (NMC, 2018).
Student N29 recognised that women who require abortion need compassionate care, and an unexpected consequence to supporting the women was that the experience helped the student to develop a deeper understanding about managing their personal and emotional responses.
‘[It] taught me how to handle my own emotions and care for women compassionately.’
(N29)
Discussion
It was important to explore the perspectives of undergraduate student midwives about abortion education in a university in north west England. The rationale emerged from raised awareness that, globally, abortion care influences poor outcomes for women (Dennis et al, 2017; Singh et al, 2018). Dennis et al (2017) performed a systematic review involving 13 peer-reviewed papers, which identified that a key determinant of quality care was employing ‘an adequate number of staff knowledgeable about and trained in abortion care’. However, there is a lack of clarity on how midwives are educated about the topic, nationally and globally (Fullerton et al, 2018).
Fullerton et al (2018) supports a global commitment by midwives to engage in abortion care, suggesting that midwifery education needs to fully align to the midwife's role. In the present study, students identified that the role of the midwife within abortion care was embedded within multiple aspects of the midwifery curriculum, such as early pregnancy loss or values-based discussions, which subsequently diluted meaning about the consequence of abortion for women and their families.
In this study, it was clear that education about abortion was lacking before and during student midwives' experience of practice settings, which was a similar finding for 90% (n=1 060) of medical students in a study in Malaysia (Tey et al, 2012). The consequence, in the present study, was that students were left questioning the process involved in abortion care. The process that students wanted to know about included developing an awareness of legal aspects associated with abortion, which Tey et al (2012) corroborated.
Establishing law around right to life is contentious, and debate around the topic is evident in policy (Fine et al, 2017). The topic is compounded by the media, which can either illuminate or antagonise perspectives (Purcell et al, 2014). Organisations such as the Royal College of Obstetricians and Gynaecologists, the British Medical Association, and the Royal College of Midwives call for abortion to be decriminalised, suggesting that the 1967 Abortion Act is outdated (Legislation.gov.uk, 1967; Regan and Glasier, 2017). If there is a change in law, it is important to recognise that the ethical dilemmas emerging in law fundamentally inform how people live or care for others (Smyth and Lane, 2016; Marecek et al, 2017).
A lack of understanding about ethical issues in practice is undermined by interchangeable rhetoric. In the present study, terminology overlapped and became interchangeable, which created confusion. This is a similar finding to the concept analysis performed by Tshuma et al (2018), where it was suggested a lack of definition contributed to inadequate clinical management of abortion. Therefore, theory related to abortion needs to be presented as a standalone, sensitive topic with a clear definition. It is reassuring to see abortion identified as a standalone competency in the standards of proficiency for midwives in the UK (NMC, 2019).
Confused rhetoric associated with the term abortion can be more distressing than the phrase termination of pregnancy and there is a shift to use the latter term in patient discourses (Kavanagh et al, 2017). Confused rhetoric undermines the ability of student midwives to provide appropriate care that would support good maternal outcomes (Keys, 2010; Dennis et al, 2017; Priaulx, 2017). It is important to address confused rhetoric within the midwifery curriculum and to engage students in conversations about crossover in language in order to understand more about the impact this has for patients and practitioners.
In consideration of responses aligned to year of study, 5 out of 16 first years, 10 out of 15 second years and 6 out of 14 third-year student midwives experienced provision of abortion care in practice. Aligning theory to practice experience within midwifery curriculum creates challenges that has the potential to create a theory/practice gap (Lukasse et al, 2017). Therefore, the topic of abortion requires an early and clear introduction within midwifery curricula and there is a need to provide a sustained, continued focus to support experiential learning.
Kolb's (1984) theory involves a cycle of transformative learning, where the individual moves through doing (concrete experience), reviewing (reflection), concluding (learning from abstract thought) and experimentation (applying their learnt behaviour to understand the impact). The cycle then begins again and is based around the experimental phase. In the present study, student midwives explained their concrete experience led to a process of internal reflection, which assisted them in understanding their own emotions or more about how women felt during the process of abortion.
Deep learning (Biggs, 1999) generated a heightened level of empathy. The ability of student midwives to develop empathy subsequently helped the individual to reflect about their response in the care setting. In effect, the topic created the scaffold to teach about professional values and to assist in exploring personal values (Maxwell, 2008; Turner et al, 2008). However, teaching empathy is a difficult concept and Williams et al (2014) involved a cross-discipline sample involving paramedic, nursing and midwifery students to suggest that empathy increases as students progress through their studies.
A similar finding was expressed by McKenna et al (2011) who found that levels of empathy for midwifery students increased over time. Interestingly, a study by Hojat et al (2009) in the US noted a decline in medical students' empathy in their third year when they were more exposed to patient-centred care, reflecting that, over time, everyday practice can lead to a disengaged emotional response (Engel, 1977). Empathy is fundamental to providing compassion in practice, and both qualified (Pezaro et al, 2016) and student midwives (Coldridge and Davies, 2017) require support practically within the curriculum to engage in understanding more about personal emotion management.
Strengths and limitations
This study explored a sensitive, emotive and under-researched topic. The questionnaire design may have been enhanced by face-to-face interviews (Feilzer, 2010). However, to explore the sensitive topic of abortion, the distance between the researcher and the participant was important (Råheim, 2016), and the anonymised questionnaire fulfilled the intent to protect identities (Braun and Clarke, 2006).
The sample for this study was opportunistic and assisted in engaging three year groups. However, opportunist sampling relies on the sample at a particular moment in time, which meant six student midwives did not participate because of their absence at that time. The setting for the study was localised and involved only female student midwives, and it would be interesting to explore other settings with mixed-gendered undergraduate student midwives.
Conclusions
Theory about abortion did not prepare for practice. Standardised midwifery content is required on definition, process and legal aspects of care around abortion, internationally, nationally and locally. Empathy was enhanced by exposure to theory or practice and a safe, reflective, educational space is essential to explore how perceptions change after exposure to the topic.
Building knowledge about abortion via research should be encouraged from an international perspective. Education on abortion can provide the vehicle to teach about complex concepts such as how to develop empathy. Raising the profile of abortion education may directly influence improved outcomes for women.
Key points
- Undergraduate student midwives had experience of caring for women seeking abortion.
- Education provided about abortion did not meet their learning needs.
- There is a need for a clearly defined, core standardised midwifery curricula.
- Empathy was developed by exposure to theory or practice related to abortion.
- A safe, reflective, educational space is required to explore the topic of abortion.