Phase 2
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)