Carlton, Melbourne; Graduate Clinical School of Midwifery and Women's Health,2 La Trobe University, ..... major colleges of obstetrics and gynaecology support.
3888 Aust N Z J Obstet Gynaecol 2002; 42: 4: 403
Medical and midwifery students: how do they view their respective roles on the labour ward? Julie A Quinlivan,1 Christine M Thompson,2 Kirsten I Black,1 Louise H Kornman1 and Susan J McDonald2 University Department of Obstetrics and Gynaecology,1 The University of Melbourne, Royal Women’s Hospital, Carlton, Melbourne; Graduate Clinical School of Midwifery and Women’s Health,2 La Trobe University, Kathleen Syme Education Centre, Carlton, Victoria, Australia
A B S T R AC T Background It has been suggested that much of the medical and midwifery student curricula on normal pregnancy and birth could be taught as a co-operative effort between obstetric and midwifery staff. One important element of a successful combined teaching strategy would involve a determination of the extent to which the students themselves identify common learning objectives.
Aim The aim of the present study was to survey medical and midwifery students about how they perceived their respective learning roles on the delivery suite.
Methods A descriptive cross-sectional survey study was undertaken. The study venue was an Australian teaching and tertiary referral hospital in obstetrics and gynaecology. Survey participants were medical students who had just completed a 10 week clinical attachment in obstetrics and gynaecology during the 5th year of a six year undergraduate medical curriculum and midwifery students undertaking a
one year full-time (or two year part-time) postgraduate diploma in midwifery.
Results Of 130 and 52 questionnaires distributed to medical and midwifery students, response rates of 72% and 52% were achieved respectively. The key finding was that students reported a lesser role for their professional colleagues than they identified for themselves. Some medical students lacked an understanding of the role of midwives as 8%, 10%, and 23% did not feel that student midwives should observe or perform a normal birth or neonatal assessment respectively. Of equal concern, 7%, 22%, 26% and 85% of student midwives did not identify a role for medical students to observe or perform a normal birth, neonatal assessment or provide advice on breastfeeding respectively.
Summary Medical and midwifery students are placed in a competitive framework and some students may not understand the complementary role of their future colleagues. Interdisciplinary teaching may facilitate co-operation between the professions and improve working relationships.
I N T RO D U C T I O N
Address for correspondence Dr Julie A Quinlivan Senior Lecturer in Obstetrics and Gynaecology The University of Melbourne Royal Women’s Hospital 132 Grattan Street Carlton Victoria 3053 Australia Julie A Quinlivan PhD FRANZCOG MB BS, Christine M Thompson MEd BSc(N Ed) RM, Kirsten I Black MMed MRANZCOG MB BS, Louise H Kornman PhD FRANZCOG MB BS , Susan J McDonald PhD B Appl Sc RM
At most universities, medical and midwifery students receive separate educations, the curriculum of each specific for their future respective roles.1 The medical school curriculum in obstetrics and gynaecology is usually drafted without reference to the midwifery school and vice versa. However, it has been suggested that some components of the obstetrics and gynaecology curriculum for medical students are complementary to those in the midwifery course. It has been proposed that interdisciplinary education and sharing of teaching resources could facilitate co-operation between competing students and improve future working relationships.2
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One area where the arguments in favour of interdisciplinary teaching are strongest is in respect to education about normal pregnancy care and birth. For example, core components of both medical and midwifery student curricula involve an understanding of normal observations and care in labour, the performance and management of normal birth and performance of a competent neonatal assessment. However, gaining access to patients to achieve these learning goals is proving increasingly difficult. A co-operative teaching approach between obstetric and midwifery staff may be required as trends in consumerism are resulting in women becoming less likely to accept involvement by students of all types in their intrapartum care.3 There is evidence that antenatal patients have a poor understanding of the roles of the different students they encounter in the hospital setting. For example, in two recent surveys, only 51–54% of patients could identify that the term ‘medical student’ referred to ‘a person training to become a doctor’.3,4 Nearly 30% of antenatal patients regarded the term ‘medical student’ to encompass any of ‘a doctor, nurse or midwife
in training.’ Other patients indicated that the term referred exclusively to a ‘nurse’, ‘midwife’ or ‘other hospital personnel such as an orderly or laboratory staff member in training’.3 Furthermore, acceptance rates for student involvement in intrapartum obstetric care are lower than rates reported in other medical settings. Up to 98% of patients will accept medical student involvement in emergency outpatient and general practice settings.5,6 In contrast, only 62–75% of patients will accept medical student involvement in their intrapartum care.3,4 In view of the increasing difficulties in gaining access to patients, it is timely to determine to what extent medical and midwifery student teaching of intrapartum aspects of obstetric care might be performed as a co-operative effort between obstetric and midwifery disciplines. One important element of a successful teaching collaboration would involve a determination of the extent to which the students themselves identify common learning objectives in their respective curricula. This would allow appropriate focus for combined teaching opportunity.7 To facilitate this process, we have evaluated the opinions of
Table 1 Medical students’ opinions of whether medical and/or midwifery students should perform specific duties during their clinical attachment Skill to be performed
Medical student n = 93 (%)
Midwifery student n = 93 (%)
p value
Provide support to a woman through her labour
87 (94)
91 (98)
0.27
Perform the regular and required observations throughout a labour
87 (94)
91 (98)
0.27
Discuss options for pain relief with a woman in labour
77 (83)
64 (69)
0.04
Administer pain relief in the form of nitrous oxide or pethidine to a woman in labour
78 (84)
71 (76)
0.27
Perform a blood test if indicated on a woman in labour
86 (92)
57 (61)
< 0.001 < 0.001
Insert an intravenous cannula if indicated on a woman in labour
83 (89)
46 (49)
Observe a delivery
93 (100)
86 (92)
0.01
Perform a delivery
93 (100)
84 (90)
0.003
Perform a baby check
85 (91)
72 (77)
0.015
Suture a simple tear
64 (69)
29 (31)
< 0.001
Suture an episiotomy
47 (50)
16 (17)
< 0.001
Provide advice on breastfeeding technique and attachment
66 (71)
80 (86)
0.02
Table 2 Medical students’ opinion of whether it is reasonable for medical and/or midwifery students to be involved in the intrapartum care of women in various clinical scenarios Clinical scenario
Medical student n = 93 (%)
Midwifery student n = 93 (%)
p-value
A 25 year old woman in her first pregnancy who presents in early labour at term, with no antenatal problems
92 (99)
81 (87)
0.004
A 25 year old woman in her first pregnancy who presents in early labour at term with an uncomplicated twin pregnancy
82 (88)
71 (76)
0.05
A 25 year old woman in her first pregnancy who requires a forceps delivery for delay in the second stage of labour and with whom the student has been present in early labour
79 (85)
57 (61)
0.0005
A 25 year old woman in her first pregnancy who presents at term, and in whom an elective caesarean section is planned in view of breech presentation of the fetus
85 (91)
46 (49)
< 0.001
A 25 year old woman in her first pregnancy who presents in early labour at term with severe proteinuric pre-eclampsia, oliguria and clonus
68 (73)
39 (42)
< 0.001
A 25 year old woman in her first pregnancy who presents in early labour at term and the fetal heart is found to be absent
47 (51)
33 (35)
0.05
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JULIE A QUINLIVAN ET AL
medical and midwifery students about their respective roles and learning objectives on the labour ward, in order to ascertain whether students identify common or divergent learning roles.
METHODS A descriptive cross-sectional survey study was undertaken. The study venue was an Australian teaching and tertiary referral hospital in obstetrics and gynaecology. Two groups of participants were surveyed: medical students who had just completed a ten-week clinical attachment in obstetrics and gynaecology during the fifth year of a six-year undergraduate medical curriculum, and midwifery students undertaking a one year full-time (or two year part-time) postgraduate diploma in midwifery, having previously completed a Bachelor of Nursing degree. The questionnaires completed by the medical and midwifery students were complementary and asked parallel questions about learning objectives and opportunities. The questionnaires were designed with input from staff involved in the education of both
medical and midwifery students and the postgraduate education of midwives and medical staff. Once the questionnaires were drafted, they were circulated to 10 members of staff for feedback. The amended questionnaires were then piloted on a focus group that included qualified doctors, midwives and students. Pilot questionnaires are not included in the final results as changes were made to the questionnaire as a result of feedback. Relevant questions are listed in Tables 1–4. Questionnaires were distributed to medical students with a covering letter inviting their participation in the study during the last week of their clinical attachment in obstetrics and gynaecology. Questionnaires for the midwifery students were distributed after a lecture half way through their course. Students were informed of the nature of the survey and invited to participate. As there were limited occasions in the year when the respective students were together as a group, and as responses were confidential, it was not possible to improve the response rate by multiple re-submission of the questionnaires to the students.
Table 3 Midwifery students’ opinions of whether medical and/or midwifery students should perform specific duties during their clinical attachment Skill to be performed
Medical student n = 27 (%)
Midwifery student n = 27 (%)
p value
Provide support to a woman through her labour
19 (70)
27 (100)
0.002
Perform the regular and required observations throughout a labour
16 (59)
27 (100)
< 0.001
Discuss options for pain relief with a woman in labour
18 (67)
27 (100)
0.001
Administer pain relief in the form of nitrous oxide or pethidine to a woman in labour
14 (52)
27 (100)
< 0.001
Perform a blood test if indicated on a woman in labour
18 (67)
27 (100)
0.001
Insert an intravenous cannulae if indicated on a woman in labour
18 (67)
17 (63)
1.0
Observe a delivery
25 (93)
27 (100)
0.49
Perform a delivery
21 (78)
27 (100)
0.023
Perform a baby check
20 (74)
27 (100)
0.01
Suture a simple tear
8 (30)
3 (11)
0.18
Suture an episiotomy
8 (30)
2 (7)
0.08
Provide advice on breastfeeding technique and attachment
4 (15)
27 (100)
< 0.001
Table 4 Midwifery students’ opinions of whether it is reasonable for medical and/or midwifery students to be involved in the intrapartum care of women in various clinical scenarios Clinical scenario
Medical student n = 27 (%)
Midwifery student n = 27 (%)
p value
A 25-year-old woman in her first pregnancy who presents in early labour at term, with no antenatal problems
17 (63)
27 (100)
0.001
A 25-year-old woman in her first pregnancy who presents in early labour at term with an uncomplicated twin pregnancy
18 (67)
24 (89)
0.1
5 (19)
23 (85)
< 0.001
A 25-year-old woman in her first pregnancy who requires a forceps delivery for delay in the second stage of labour and with whom the student has been present in early labour A 25-year-old woman in her first pregnancy who presents at term, and in whom an elective caesarean section is planned in view of breech presentation of the fetus
16 (59)
21 (78)
0.2
A 25-year-old woman in her first pregnancy who presents in early labour at term with severe proteinuric pre-eclampsia, oliguria and clonus
17 (63) 1
9 (70)
0.77
A 25-year-old woman in her first pregnancy who presents in early labour at term and the fetal heart is found to be absent
13 (48)
16 (59)
0.58
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ANZJOG
Departmental and hospital approvals were obtained to undertake the project. After consultation with key members of the Institutional Ethics Committee, approval was not sought as the project was considered to represent audit under committee guidelines. However, return of the completed survey was considered to represent consent to participation. Data were entered onto a database and analysed using SPSS Version 10. Descriptive statistics were performed to determine the proportion of respondents who selected specific options. Discrete data were compared using either chi-squareed test or Fisher’s Exact test according to cell size. A p-value of 0.05 was considered significant.
R E S U LT S Of 130 questionnaires distributed to medical students, 93 were returned, giving a response rate of 72%. Of 52 questionnaires distributed to midwifery students, 27 were returned, giving a response rate of 52%. The demographics of medical and midwifery students were significantly different. Medical students were significantly younger than midwifery students (medical mean = 22.3 years, midwifery mean = 27.5 years; p < 0.0001). Nearly half the medical students were male, whereas there were no male midwifery students (medical: males 49%, midwifery: males 0%, p < 0.0001). There were racial differences in the composition of students with significantly fewer medical students being of Caucasian race and significantly more being of Asian race compared to midwifery students (medical: Caucasian 57% Asian 41% other 2%; midwifery: Caucasian 89% p < 0.0001, Asian 7% p < 0.0001 Other 4% p = NS). Medical students all completed their studies full-time, whereas half the midwifery students were part-time (p < 0.0001). There was limited agreement between students on sharing of clinical responsibilities in the birth suite. Tables 1 and 2 outline the opinions of medical students. Medical students felt that both medical and midwifery students had equal roles in respect to providing support to a woman through her labour, performing regular observations throughout labour and administering pain relief in the form of nitrous oxide or pethidine (all p > 0.05). However, significantly more medical students thought that medical, as compared to midwifery students, should discuss options for pain relief in labour, perform a blood test or intravenous cannulation, observe and perform a normal birth and neonatal assessment, suture a simple tear or episiotomy or provide advice on breastfeeding (all p < 0.03; Table 1). Some medical students did not appreciate the role of student midwives, as 8%, 10% and 23% did not report that it was appropriate for midwifery students to observe or perform a normal birth or neonatal assessment respectively. Of concern, 29% and 14% of medical students did not see a role for either them-
selves or midwifery students to provide advice on breastfeeding technique and attachment. Medical students were given a list of increasingly complex clinical scenarios and were asked if student involvement was appropriate. The results are summarised in Table 2. There was a pattern that as the scenario became more complex, medical students were less likely to identify a student role. However, significantly more medical students identified a role for medical, as opposed to midwifery, students, in all clinical settings (all p < 0.05). The opinions of student midwives were diametrically opposed to those of the medical students. Tables 3 and 4 outline the opinions of midwifery students. Midwifery students felt that both medical and midwifery students had similar roles in respect to inserting an intravenous line, observing a delivery or suturing a simple tear or episiotomy (p > 0.05). However, significantly more midwifery students thought that midwifery, as opposed to medical, students should provide support to a woman in labour and perform her required observations, discuss and administer pain relief, perform any due blood tests, perform a normal birth and neonatal assessment and provide advice on breast feeding and attachment (all p < 0.005; Table 3). Of note, 15% of midwifery students felt that medical students had a role in breastfeeding advice. Midwifery students were given a similar list of increasingly complex clinical scenarios and were asked if student involvement was appropriate. The results are summarised in Table 4. As with the medical students, there was a pattern that as the scenario became more complex, midwifery students were less likely to identify a student role. However, significantly more midwifery students identified a role for midwifery, as opposed to medical, students in the setting of a normal or assisted vaginal birth (p = 0.001). However, they identified a similar role in the setting of twin, caesarean section, severe preeclampsia or fetal death in-utero birth.
DISCUSSION The results of the study suggest that medical and midwifery students have large discrepancies in their perception of student roles, with each group perceiving a more dominant role for their own participation in patient care. These attitudes may arise from pressures placed upon students to gain ‘numbers of deliveries’ or ‘procedures’. It may also place medical and midwifery students into a competitive framework in the birth suite at the student level in order to gain access to patients. The stress of competition is rising as birth rates in developed nations fall and the mean age of childbirth rises, limiting the number of ‘normal births’ available for students. The fall in available patients is combined with a rise in consumerism that is seeing increasing numbers of patients ‘opting out’ of student involve-
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ment in their care3 or alternatively electing for interventional delivery.8 The competitive, rather than co-operative approach to education, may be responsible for some of the difficulties encountered in the working relationship between obstetric medical and midwifery staff. It could genuinely retard co-operative approaches to patient care. The survey results suggest that some medical students may not appreciate the role of student midwives, and did not regard their involvement in normal birthing processes as reasonable. It is important that medical students are taught of the pivotal role played by midwives in obstetric care. It was also of concern that 29% and 14% of medical students did not see a role for either themselves or midwifery students to provide advice on breastfeeding technique and attachment. Perhaps even more troubling was the finding that only 15% of midwifery students felt that medical students had a role in breastfeeding advice. One of the leading objectives of the World Health Organisation is the promotion of breastfeeding.9 All major colleges of obstetrics and gynaecology support breastfeeding as the preferred method of infant nutrition.10 There is considerable evidence that medical and midwifery practitioners can facilitate and improve breastfeeding uptake and compliance in their patients.9,10 However, training opportunities to receive practical education and information on the initiation of breastfeeding are limited, and many staff report being feeling under trained in this area.10 As it is now recognised that breastfeeding should ideally be initiated on the birth suite,9 this remains an ideal venue to expose all students to practical experience in breastfeeding. Consequently, one would expect that 100% of medical and midwifery students could identify a complementary role for student participation in this process. Of equal concern, many midwifery students did not feel that medical students had a role in several activities considered basic to the medical school curriculum. These activities included providing support to a woman in labour and during birth (30%), performing the regular and required observations of labour (41%), observing (7%) or performing a normal birth (22%) or neonatal assessment (26%). Furthermore, 81% of student midwives saw no role for medical students to view a forceps delivery for delay in the second stage of labour, even if the medical student had been present with the patient through early labour. Similarly, less than half of midwifery students thought that medical students should attend uncomplicated elective caesarean section deliveries. These opinions prevailed despite the fact that as future general practitioners, medical students may need to look after women who have experienced both normal and operative deliveries. It is possible that some of these attitudes may have
arisen as a result of competition, with midwifery students identifying labour ward as their primary career goal, and regarding medical students as having less need for clinical exposure to the increasingly limited consenting patient population. However, without intervening in these divergent attitudes, future intrapartum obstetric medical education may face an uphill battle, with the midwifery students of today being the midwife preceptors of medical students in the future. Unless attitudes are changed, there may be a progressive trend towards blocking medical student participation in the birth suite. Interdisciplinary teaching has been suggested as a strategy to overcome difficulties in students’ attitudes. Several universities have now developed such an approach. At the University of Dundee, an interdisciplinary educational program centred around labour ward was introduced into the undergraduate medical school and diploma course for midwifery students.7 Review of the program found that students gained a better understanding of each other’s roles in the care of labouring women, with the changes being greatest for medical students. The course was well received by both students and teachers.7 Similar partnership models have been developed in the United States and Italy, with initial results being positive by patients, students and educators.11,12 However, the process is not always straightforward, as there is some evidence that medical and midwifery students learn at different rates and through different processes. In one study involving interdisciplinary teaching in the interpretation of cardiotocographs, medical and midwifery students undertook a computer assisted learning (CAL) session and a subsequent tutorial. Medical, but not midwifery, students significantly increased their knowledge from baseline after the CAL session alone. However, when given both the CAL session and tutorial, the post-test scores for both medical and midwifery students were similar and significantly higher than pre-test scores.13 Current teaching structures may place medical and midwifery students in a competitive framework, with students failing to understand the complementary role of their future colleagues. Failure to address these differences in opinions may be harmful to patient care in the future. Interdisciplinary teaching may facilitate co-operation between the professions and improve working relationships, but further work is required to define specific combined teaching strategies.
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