Original Article

Connecting Canadian and Australian Midwifery Students Through a Global Peer-to-Peer Program: A Pilot Project

Établissement de relations entre des étudiantes canadiennes et australiennes en pratique sage-femme grâce à un programme de pair à pair mondial : un projet pilote

Bronte K. Johnston, BHSc[Hon], MSc1,2, Lyn Gum, RM, RN, PhD3,4, Elizabeth Hilsenteger, BHSc[Hon]5, Beth Murray-Davis, RM, PhD1,2*

1Bachelor of Health Sciences (Honours) Program, McMaster University, Hamilton, ON, Canada;

2McMaster Midwifery Research Centre, McMaster Un iversity, Hamilton, ON, Canada;

3Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia;

4College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia;

5Midwifery Education Program, Toronto Metropolitan University, Toronto, ON, Canada

Abstract

Introduction: Pen-pal or peer-to-peer programs involving peer correspondence have been included within health professions education. However, there has been no published program for midwifery students in the literature. The Global Peer-to-Peer (GP2P) Program connected first- and second-year midwifery students in Australia and Canada to foster conversations that expanded socio-cultural knowledge to aid in their overall learning.

Methods: Program evaluations included comparing pre- and post-intervention surveys and midwifery student interviews. The surveys incorporated 5-point Likert scale questions and open-ended responses to assess students’ baseline knowledge and exposure to global health topics and international midwifery practice. Midwifery students were invited to partake in interviews after completing the GP2P program to further discuss their experiences and thoughts about the program.

Results: Ten McMaster University and two Flinders University students completed the GP2P Program. Students commented on how beneficial it was to talk to students with similar interests internationally. The program also improved their understandings of global health topics, and international midwifery scope of practices, such as the similarities and differences between Canadian and Australian midwifery education and clinical practice. Some groups had difficulties communicating with each other and maintaining engagement in the study.

Conclusions: The GP2P Program was well received by midwifery students. Although there were issues with student engagement throughout the program, our pilot project would suggest that pen-pal programs within midwifery education could foster stronger international awareness and collaborations. Implications include further expansion of midwifery students’ knowledge and attitudes, and providing new opportunities for future midwives to support pregnant people on a global scale.

Résumé

Introduction: Des programmes de correspondance ou de pair à pair par correspondance constituent des volets de l’enseignement dans les professions de la santé. Cependant, on ne trouve pas dans la littérature de programme publié pour les étudiantes en pratique sage-femme. Le programme de pair à pair mondial a mis en rapport des étudiantes de première et de deuxième année d’Australie et du Canada afin de favoriser des échanges qui ont élargi les connaissances socioculturelles et ont aidé les participantes dans l’ensemble de leur apprentissage.

Méthodes: Pour évaluer le programme, nous avons réalisé des sondages avant et après l’intervention et des entrevues avec des étudiantes en pratique sage-femme. Les sondages comportaient des questions à échelle de Likert de 5 points et des questions ouvertes pour évaluer les connaissances de base des étudiantes et leur exposition à des sujets relatifs à la santé mondiale et à la pratique sage-femme à l’échelle internationale. Les étudiantes ont été invitées à participer à des entrevues après la fin du programme afin de discuter plus en détail de leur expérience et de leurs réflexions sur l’initiative.

Résultats: Dix étudiantes de l’Université McMaster et deux étudiantes de l’Université Flinders ont pris part au programme de pair à pair mondial. Selon les participantes, les échanges avec des étudiantes étrangères aux intérêts semblables ont été bénéfiques. De plus, le programme a amélioré leur compréhension de sujets relatifs à la santé mondiale et celle des champs d’exercice de la pratique sage-femme à l’échelle internationale, comme les similitudes et les différences entre l’enseignement et la pratique clinique dans ce domaine au Canada et en Australie. Certains groupes ont éprouvé de la difficulté à communiquer entre eux et à maintenir leur participation à l’étude.

Conclusions: Le programme a été apprécié par les étudiantes en pratique sage-femme. Bien qu’il y ait eu des problèmes entourant l’engagement des étudiantes tout au long du programme, notre projet pilote laisse entendre que l’inclusion de programmes de correspondance dans l’enseignement de la pratique sage-femme est susceptible de favoriser une meilleure prise de conscience et des collaborations plus solides au niveau international. Entre autres, un tel programme permettrait d’accroître les connaissances et d’améliorer les attitudes des étudiantes en pratique sage-femme ainsi que d’offrir aux futures sages-femmes de nouvelles possibilités de soutenir des personnes enceintes dans le monde entier.

Key words: midwifery, education, health occupations, pen-pal program, midwifery collaboration, global midwifery, collaborative health professions education

Corresponding author: Beth Murray-Davis: [email protected]

Submitted: 21 January 2023; Accepted: 3 November 2023; Published: 29 November 2023

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

INTRODUCTION

At a global level, midwifery is founded on relationship-based care that emphasizes the partnership between midwife and pregnant person to provide the best care for each client. Midwifery emphasizes “the normal biological, psychological, social, and cultural processes of childbirth and early life of the newborn.”1 The education, scope, and clinical competencies of midwives, although shaped by the International Confederation of Midwives (ICM) standards, may vary by country due to (1) the needs of pregnant people in that jurisdiction, (2) the need to work within the health system, and (3) the historical context of the profession. Specifically, due to the history of regulation and the role of the midwife within the broader health system in any given country, there may be subtle differences in how the role of the midwife is perceived by people in various contexts. These global similarities and differences are important for midwives to understand as they situate themselves within the global landscape of midwifery. For example, Australian midwifery is often framed as as a “calling,” whereas the Canadian Association of Midwives places more emphasis on the concept of “profession.”5,6 The role of the midwife in each of these countries may also influenced by the number of registered midwives and the number of births attended by midwives. By comparison, in 2020 Australia had 35,300 midwives for 294,369 births, while Canada had only 1,875 midwives for 316,667 births.68

Exploring these variations in the profession around the world and encouraging reflection about the differences and similarities could be facilitated through international collaborative programs such as global peer-to-peer partnerships. Often, the overarching aim of global peer programs are to connect people with like-minded individuals who are studying similar content but in a different social and cultural context, such as a different country. It is argued that this educational initiative, by facilitating global connections, will increase students’ sociocultural knowledge, collaboration skills, and cultural awareness, which in turn will promote future transnational relationships in a globalized world as the students enter their professional fields.9

There is no published literature concerned with peer-to-peer or pen-pal programs for midwifery students. However, there are a few publications from other health professions, such as nursing and medicine.10,11 One study connected nursing students from America and the United Kingdom for their ethics courses. Students explored the different ways health practitioners responded to and solved ethical dilemmas in their own countries, through reporting first-hand experiences on an online platform to facilitate reflective educational practice. Their findings suggested that perspectives on clinical practice were shaped by the students’ own social and health systems.10 Another study illustrated the benefits of a specific communication platform (ScribeMD) aimed at connecting medical students through virtual letters. Participation was found to have a positive impact on learners’ professional identity, emotional intelligence, and narrative competence, as writing through the platform encouraged reflection, imagination, and emotion—crucial social skills required for medical students.11

The goal of our research was to explore the impact of a peer-to-peer pilot project, the Global Peer-to-Peer Program, for student midwives. As the term pen pal often refers to letter writing, we used the term peer-to-peer was used for our project, to indicate that students had flexibility in the modalities or means of communication they could use with their peers. We hypothesized that this peer interaction would deepen socio-cultural understanding and improve the scope of global health knowledge among midwifery students in Canada and Australia through reflective educational practice.

METHODS

The pilot Global Peer-to-Peer (GP2P) Program ran from October 2021 to January 2022. Ethical approval was obtained from the research ethics boards of both universities. First- and second-year midwifery students from McMaster University in Canada and Flinders University in Australia were paired through a random number generator. Midwifery faculty from both institutions advertised the study in their classes and on community pages and posters around the schools. Students were also recruited online. To address issues of bias and power imbalances, faculty members, aside from assisting with recruitment by sharing details of the project, were unaware of which students volunteered, and they had no further interactions with participants. Students volunteered on a first-come, first-serve basis. All communication with study participants was done by two research students (Bronte K. Johnston and Elizabeth Hilsenteger) who were not involved with either institutions’ midwifery programs. After pair matching, learners were given the contact information of their peer to begin communication on their own through a platform of their choice. To generate discussion topics and promote interactions between peers, a Facebook group was created. One of the research students acted as a facilitator in the Facebook group to prompt introductions between groups, distribute study information and general reminders, respond to students’ questions, and review posts from participants. Participants were encouraged to share and post to Facebook any articles, news stories, or even health topics that they found interesting or that they would like to discuss with others outside of their group. Students were encouraged to use the GP2P Program in a manner that was student led and best supported them and their interests (such as their personal lives) in addition to midwifery topics.

To evaluate the GP2P Program, survey (pre- and post-intervention) and semistructured interview data were collected and analyzed. The nonvalidated surveys were developed by the study team to provide opportunities to reflect and report personal knowledge of global health, midwifery practice, and models of care through 5-point Likert scale questions and open-ended responses. Specifically, the pre-intervention survey focused on understanding students’ baseline global health and midwifery knowledge as well as the variations of midwifery education and health policies across Australia and Canada. The post-intervention survey built upon the pre-intervention surveys and also included questions about students’ experiences with the GP2P Program, including the nature of their group communications (e.g., the topics and frequency of discussion). Midwifery students were invited to complete the pre-intervention survey before the GP2P matching process (September to October 2021), and the post-intervention survey was completed at the end of the program (January 2022). Quantitative results were analyzed using descriptive statistics, and open-ended questions were analyzed through thematic analysis.

To expand on their survey responses, all students were invited to participate in an individual interview after completing the GP2P Program. The study team created the semistructured interview questions to allow participants to discuss their midwifery knowledge and identify areas of growth and possible improvements for the peer-to-peer program to strengthen future cohorts. The interviews were conducted via Zoom and were recorded and transcribed verbatim. Names of interviewees were not included in the transcripts, which were subjected to thematic analysis as described by Braun and Clarke.12,13 Two researchers read the transcripts in full to observe the initial patterns and meanings throughout the data. Initial codes were then created to develop preliminary themes. The two researchers compared their results for consensus to ensure the trustworthiness of the results. The two additional researchers reviewed the transcripts and preliminary themes to ensure their reliability. The research team met to discuss the final themes to ensure they were rooted in the midwifery students’ interview responses.

RESULTS

Students from McMaster University in Canada and Flinders University in Australia were assigned their peer pairings through a random matching process prior to the distribution of the pre-intervention survey. Initially, 20 students in the study (15 McMaster students and 5 Flinders students) completed the pre-intervention survey. However, eight students were lost to follow-up, so only 12 (10 McMaster students and 2 Flinders students) completed the post-intervention survey. Of the final 12 learners, three students (2 from McMaster and 1 from Flinders) participated in individual interviews. The results highlighted three major themes that shed light on how the piloted GP2P Program helped students with (1) comparing midwifery around the globe, (2) facilitating professional growth, and (3) learning collaboratively.

Comparing Midwifery Around the Globe

Participating in the GP2P Program helped students to refine their knowledge of international midwifery practices. The international collaboration within the GP2P Program brought to Canadian and Australian students a fresh and engaging medium for learning internationally relevant practices. For example, one student remarked that they were “constantly told that midwifery practice isn’t the same in other countries, but I guess it really just opened my eyes to how easily it can be different.” Students demonstrated an increase in their knowledge of Canadian and Australian midwifery policies (17% and 5%, respectively). Midwifery students also shared their appreciation of the diversity of the midwifery profession and education throughout the world. This was summarized by one participant, who said, “it's great to see how other countries midwifery programs and professional settings work.” The final survey responses indicated that 36% of students recognized the differences in the profession between Canada and Australia. For example, one student shared the following:

[In] Australia we have MGP [Midwifery Group Practice, where women see the same midwife or team of midwives, but only if they are lucky enough to be accepted. Whereas in Canada, that seems to be how [the]majority of their clinics run normally.

Another student spoke of how their pen pal described the proportion of home births as being less in Australia than in Canada. Students felt that “there were a lot of parallels” in the midwifery profession across the two countries. For example, several students in the survey appreciated how continuity of care was a major pillar of midwifery in both Canada and Australia. Other similarities described by participants included the role of midwifery models of care in providing pregnancy care for low-risk obstetrical patients.

Facilitating Professional Growth

Both Canadian and Australian midwifery students commented on how the GP2P Program helped their professional growth by improving their personal reflective practice. For example, 30% of final survey respondents felt that they learned more about their personal biases throughout the program. At the end of the program there was an 11% increase of students who agreed that they had a well-conceptualized view of their future roles as midwives. Similarly, there was a 12% increased (70% pre-program vs. 82% post-program) agreement that “client-centred care is the forefront of the midwifery profession around the world.” One student stated that the philosophy of midwifery from each country was well aligned: “We both have the same sort of outlook on the profession and overarching mandate of physiological birth is our thing and, I guess, the same beliefs.”

Learners described how the program was an opportunity to facilitate connections and grow their contacts in the midwifery field. One student felt that the program was “a more networking kind of thing, something you would do like a conference kind of situation.” Others articulated how this informed their interests in completing an international placement. One student shared how connecting with Australian students helped figure out how to pursue “midwifery if I was going to travel and do midwifery ethically.”

Learning Collaboratively

Learners expressed excitement that the GP2P Program offered international comradery and the chance to work with more peers in their studies. One student shared how beneficial it was to be “in touch with someone who was in a similar situation as myself…was really helpful, I found because we're kind of almost navigating it [their midwifery education] together.” The similarities of students’ academic experiences shared in the GP2P Program helped them feel more connected to one another despite coming from different countries.

Despite these benefits, some participants had difficulty connecting or conversing with their peers. For example, some peers did not respond to messages after initial conversations or could not be reached, which resulted in some loss to follow-up in the research. It was also mentioned how the school year is structured differently in Canada than in Australia, which made it difficult for students to collaborate and promote engagement. For example, in November, Australian students had a final term examination while the Canadians did not; therefore, those students had less available time to dedicate to the GP2P Program. Some students mentioned that they struggled to connect and create conversations with each other—struggles exacerbated by the uneven balance of Canadian and Australian students (3:1) and the fatigue of online learning during the COVID-19 pandemic. One potential solution shared by learners to improve group collaboration and engagement in the GP2P Program was having students participate in video calls to form stronger personal connections. During the pilot, all communication between peers was written, through applications such as Facebook Messenger or WhatsApp.

Australian and Canadian midwifery students were keen for the program to continue and to expand to provide more opportunities for international collaboration. One student highlighted how this could take a few forms, whether connecting with students from more countries or with domestic midwifery students from different provinces or territories.

Expanding it in a group with people around the world, rather than just even in two countries…and not only even necessary that…but I know that B.C. midwifery is different, practiced differently, etcetera; same with midwifery in Alberta.

Overall, while engagement was sometimes described as difficult, students enjoyed the GP2P Program for its opportunities for collaboration with peers to enhance their global midwifery knowledge and facilitate professional growth. In this pilot project, students felt there was potential for the GP2P Program to continue in midwifery education, by weaving the program into the curriculum and connecting domestic and international students to enhance their training.

DISCUSSION

The GP2P Program provided Canadian and Australian midwifery students opportunities to engage with one another. Our findings shed light on how the program improved their knowledge of global health and midwifery topics, promoted professional growth, and fostered social connectedness. Our findings support earlier research in other health professions that showed how peer-based programs facilitate student reflection and global understanding.9,10,14 The GP2P Program was a beneficial strategy for promoting cultural awareness and improving cultural competence through collaboration. The desire to practice midwifery “ethically” internationally, speaks to the participants’ interest in learning more about global midwifery and increasing their cultural competence in caring for their clients.

Our results indicate that peer-to-peer programs are a feasible way to address educational goals related to collaboration and sustainable midwifery leadership.15 The students suggested that the GP2P Program continue and even expand to national peer groups. Although one of the aims of the GP2P Program was to improve students’ global health knowledge, many Canadian students expressed the desire to connect with students from other provinces and territories. They wanted to raise their awareness of national regulatory and health system differences. This indicates the positive reception from learners and the need to establish larger midwifery student networks both nationally and internationally.

Students have many competing responsibilities, so carving out explicit time for international collaboration could be helpful for improving their global midwifery learning. Advances in the use of technology-mediated education, especially since the COVID-19 pandemic, has meant that students are more accepting of online methodologies to improve their learning.17 In particular, this project has highlighted the vital role communication plays in global collaboration. In the end, written messaging was the method used by all students for communication. This may be due to the time zone differences between Canada and Australia, which may have made it difficult for students to have synchronous communication over video platforms, a problem that will need to be addressed in future offerings.

Due to the difficulties in retaining some students for the entire GP2P Program, it is recommended to incorporate peer connection in the future more formally into the curriculum. The inclusion of the GP2P Program within a compulsory course would help improve engagement, as course topics could be prompted through weekly discussion topics for pairs and the entire class to facilitate stronger community bonds. This would also allow faculty to take a more active role in facilitating discussion among their students by prompting conversation. Consideration would need to be given to the best technology platform to incorporate this, either through the university online platforms or through social networking websites, such as Facebook Messenger, WhatsApp, or Twitter. By connecting classrooms with GP2P programs, instructors would be able to directly match their students based on their personal interests, and there may be more potential for matching an equal number of students from each university. A study of the use of Twitter among college students described the importance of shared interests and found that, once students found they had shared values and interests, they could build strong relationships.16 Another benefit of integrating the GP2P Program into a course is that students could be able to earn marks on their engagement with the program, such as through reflections or discussion posts. However, attaching grades with a GP2P program may also impede the organic nature of conversation. Therefore, we recommended that students receive formative marks as opposed to summative evaluations; this would promote engagement and provide students with more choice in regard to if or how they contribute to the dialogue.

While the various topics addressed during peer discussions depended on the participants, one topic that several groups discussed was the lower rate of home births in Australia than the rate in Canada. In reality. approximately 3% of Australian births occurred outside of hospital in 2019;18 the rate in Canada was 1.74%.19 The students’ feeling that there are more home births in Canada than in Australia may be because the number of midwives in Canada is much lower than the number of midwives in Australia, so this represents a higher rate of home birth among midwife-attended births, rather than all the births in the country. People who are seeking midwifery care in Canada may be explicitly interested in a home birth. Given the lower number of practitioners across the country, individual midwives likely have more experiences with home births, which may be why Canadian midwifery students think the proportion of home births is higher than that of Australia. The incorporation of the GP2P Program into curricula may be a way to mitigate any discrepancies of information shared among peers, because midwifery educators could provide background and facilitate student discussions about midwifery in the different countries, thus ensuring that reliable information is passed to the students. There may be an important role for a midwifery educator to facilitate group discussions in addition to peer-led communication,

All students emphasized the importance of client-centred care as a central pillar of global midwifery. This was a crucial “take-away” from the GP2P Program, as all learners could see this similarity between the midwifery profession in Australia and Canada, which helped to solidify their professional identity.

Our project had several limitations. Because this was the first pilot of the GP2P Program and because it was implemented during the COVID-19 pandemic, there were issues recruiting and maintaining students throughout the entire study. Loss to follow-up and uneven matching between countries were barriers to participation and may have affected our interpretation of the results. To incentivize participation, midwifery educators are encouraged to consider how to embed course credit or assessment into this concept of peer connection. Providing formal, explicit class time to the GP2P Program may encourage continuous engagement. Finally, the small number of participants who completed the survey data impacts our ability to draw conclusions of statistical significance; however, it can still point to trends between pre- and post-intervention knowledge and understanding.

While there is currently no additional cohort of the GP2P Program planned, we hope to run this peer collaboration program in the future when it is integrated into the first-year midwifery curriculum. In response to students’ interest in the program and desire to learn more about international midwifery, it is hoped that the GP2P program will expand and include other countries (e.g., European nations or low- and middle-resource countries) in addition to Canada and Australia. Educators are also looking into the potential for a domestic peer-to-peer program throughout Canada for students to learn about how midwifery is approached throughout different provinces and territories.

CONCLUSIONS

This study supports the adoption of a collaborative global initiative in midwifery education. In particular, the GP2P Program helped to promote students’ cultural awareness through learning about international issues and practices, cross-cultural socialization, and personal and professional growth. Although there is a need for further research to better understand the social educational value of international peer programs in midwifery education, the overall positive reception of the program is encouraging and indicates interest in future international peer-collaboration initiatives. In connecting with global communities during midwifery education, practitioners will have a better understanding of the world around them, such as the similarities and differences among cultures, to provide the best pregnancy care for their future clients.

ACKNOWLEDGEMENTS

We would like to thank the midwifery programs at McMaster University and Flinders University for their support in this project. Thank you as well to all the students who participated and shared their experiences about their global peers.

This project received ethics approval from the Hamilton Integrated Research Ethics Board and the Flinders Human Research and Ethics Committee.

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About the Authors

Bronte Johnston completed her BHSc in Health Sciences and MSc in Health Sciences Education at McMaster University. She is currently a PhD student at the University of British Columbia in the School of Population and Public Health.

Lyn Gum, RM, RN, PhD has worked as a midwife and nurse for over 30 years. She has been involved in various teaching and research roles across Flinders University since 2003. Previously at the Flinders University Rural Clinical School, Lyn is now based at Bedford Park in the College of Nursing and Health Sciences as a midwifery lecturer. Her PhD (2017) looked interprofessional education and collaborative practice in the rural setting.

Elizabeth Hilsenteger, BHSc [Hon] is a Bachelor of Health Science (Honours) graduate from McMaster University and now beginning her midwifery studies at Toronto Metropolitan University.

Beth Murray Davis (PhD) is the Scientific Director of the McMaster Midwifery Research Centre and is an Associate Professor in the Department of Obstetrics and Gynecology at McMaster University. She also is a practicing midwife in the Hamilton, Ontario area.