All midwives are educators. While not all midwives are preceptors (clinical teachers who train students), educating birthing families is an integral part of midwifery care. As such, learning principles of adult education can help midwives become more effective for their clients and also will help those who train students to be better preceptors.
Parents will most often parent their children the way they were parented; our early experiences, good or bad, influence us. It can be the same in clinical midwifery education; we often train midwives the same way we were trained. If weak areas existed in our own clinical training, we have to work hard to improve and create better learning experiences for our own students.
Being a good midwife does not necessarily make one a good teacher. Knowledge of basic educational principles will help a person be a more effective teacher. Theories of education regarding how people learn best are tremendously varied. Some of the early work focused on Bloom’s Taxonomy of Intellectual Behavior (1956), which defines the three overlapping learning domains: cognitive, affective and psychomotor. Further research by Howard Gardner (1983) led to the proposal of the Theory of Multiple Intelligences, using seven styles of learning: verbal/linguistic, logical/mathematical, visual, kinesthetic, musical, interpersonal and intrapersonal. A more modern approach focuses on only four types of learners: visual, aural (hearing), read/write and kinesthetic. Many educators theorize that when students know their learning style and use it to help them study, their learning, will improve. The theory of hemispheric dominance—how the right or left sides of our brains affect learning—is often used in midwifery programs because it emphasizes intuition and empathy.
Midwifery programs are often written using woman-centered learning, which is more empathic and connected. It involves the learner in the process and is less hierarchal. Many of the concepts in woman-centered learning also are present in constructivism (Bruner 1990), which is the belief that people actively construct new knowledge as they interact with their environment. When people take notes or use learned material in a practical way, such as to restate or teach, they learn it better.
Constructivism Promotes Learner Involvement
A constructivist perspective views learners as actively engaged in making meaning based on their prior knowledge and experiences. Teaching with that approach focuses on what students can analyze, investigate, collaborate, share, build and generate, based on what they already know, rather than what facts, skills and processes they can memorize and regurgitate. Some of the ways the tenets of constructivism apply to training midwives are:
- Students’ prior experience and learning is recognized and valued.
- New knowledge is constructed using the individual student’s prior knowledge.
- Students learn from each other as well as from the teacher.
- Students learn better by doing.
- Allowing and creating opportunities for all to have a voice promotes the construction of new ideas.
- Learning is particularly effective when constructing something for others to experience.
Ways to Incorporate Constructivist Learning Principles in Clinical Education:
- Observe students teaching clients.
- Role-play complications. For example, get out the pelvis and baby and have the student show you how to get some pesky shoulders unstuck.
- Ask her, “How would you handle this?” at every opportunity. And listen to the response.
- Provide opportunities for hands-on involvement, early and often.
- If you have more than one student, have the students work together. They can practice clinical skills on each other, do group research projects, etc.
- Recognize that your student has her own world-view; respect it and know that changing it takes work.
Being an effective clinical teacher is important, no matter what type of midwife you are or where you practice. Clinical experience is the core of midwifery education. All midwifery educators can improve in this area.
I was trained much the same way as most direct entry midwives (DEM) in the US in the early seventies: a combination of self-teaching and informal apprenticeship. Many of us started attending births with very little experience and even less training. We learned from experience and shared knowledge with our peers, doctors, chiropractors and anyone else we could. Very soon we had our own students. Our students had advantages we did not, especially more formal one-on-one apprenticeships. Some midwives included classes and directed learning activities. Others focused only on the clinical aspects of training; and their students relied on self-study, distance learning and any related training they could find.
The midwife credentialing process of the North American Registry of Midwives (NARM) was designed to fully incorporate and support the apprenticeship model of training through the Portfolio Evaluation Process (PEP). As direct entry midwifery schools formed, the Midwifery Education Accreditation Council (MEAC) began accrediting schools and NARM included a track for those who graduated from an accredited program. While NARM remains committed to the PEP, the philosophical trend is toward all midwives attending an accredited school, regardless of whether they are direct entry midwives or nurse-midwives.
Some have expressed concern about the loss of the “apprenticeship model” of training. Midwives have been trained throughout the ages using the apprenticeship model. While the science of midwifery is taught in the classroom and in books, the art of midwifery is taught in a one-on-one relationship between preceptor and student. We are fortunate in this country to have such a diverse range of training options for women to become midwives. As long as NARM continues to offer the PEP, the apprenticeship model will remain a viable method of becoming a midwife.
The Midwives Alliance of North America (MANA) created the core competencies, or standards of learning, for direct entry midwives. It also provides clear and written objectives for clinical practice that were written largely by early midwives, most of whom were self-taught and apprenticeship-trained. The values of the apprentice model are built into the system.
One of the drawbacks to the apprentice model has been the reliance on only one midwife for the bulk of a student’s education. Midwifery is so complex, and so many diverse approaches are possible for handling the same situations, that the more places students can learn from the better. Today’s midwifery students have more options. They may get their didactic instruction or academics from one place, their clinical training from a number of places and their one-on-one training with one or two midwives, in a high volume birth center or from working in hospitals in the developing world.
Nurse-midwifery students have long had the advantage, in the clinical part of their training, of clear written objectives, skill check-off sheets and other written guidelines. Now, with NARM and MEAC, direct entry students have the same options. These are important tools for clinical training.
Direct entry midwives in the US face an uphill battle to have our training models recognized with the same validity as the American Council of Nurse Midwives (ACNM) models. American College of Obstetrics and Gynecology (ACOG) recently released a Statement of Position which essentially says that all midwives who do not graduate from a program accredited by ACNM’s agency, the American Midwifery Certification Board, are “lay midwives” and are unsafe and not trained. This is a slap in the face to all the work that direct entry midwives have done with our training models and our credentialing processes.
The MANA study (Johnson and Daviss 2005) was an important step in demonstrating the safety of midwifery care by certified professional midwives (CPMs). More research needs to be done on the effectiveness of various educational models. Since ACOG has recognized that midwives do not need to be trained as nurses first, with the certified midwife (CM) recognized by ACNM, the next step is just a turf battle between accrediting agencies.
Unfortunately, research is limited on midwifery education for direct entry midwives in the US. If our position in relation to out-of-hospital deliveries is that mandatory CPM training is as valid as that required for a certified nurse midwife (CNM), we need to ask whether the evidence supports our assumptions. We do not truthfully know. We can make educated guesses, but we do not have the research to support our position either way.
In my experience as a midwifery educator over the last 30 years, I have witnessed tremendous growth and change in how we train midwives. MEAC and NARM have helped us raise the bar. However, I still see the quality of direct entry midwifery education all over the map, from excellent to poor. This includes those who graduate from MEAC programs and those who don’t. We still need to ask: How do midwives think their training prepared them for practice? Are students learning what they are taught? How do students graduating from self-study and apprenticeship-only models hold up in comparison to graduates from accredited schools? How does distance education compare to onsite programs?
To answer some of these and other questions, I conducted a short, informal study that focused on the clinical aspects of training midwives. However, we still need more formal and detailed research.
- Bloom, B., ed. 1956. Taxonomy of educational objectives: the classification of educational goals. New York: Longmans, Green.
- Bruner, J. 1990. Acts of Meaning. Cambridge, Massachusetts: Harvard University Press. Dougiamas, M. 1998. “A journey into constructivism.”
- http://dougiamas.com/writing/constructivism.html. Accessed 26 Feb 2006.
- Gardner, H. 1983. Frames of Mind. New York: Basic Books.
- Johnson, K., and B. Daviss. 2005. Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ 330:1416.
- Sharif, F., and S. Masoumi. 2005. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4:6.