When student midwives are present during labour and childbirth in a peer-learning model: An interview study of parents in Sweden

Objective: For peer learning to be useful in clinical practice, we need to know how parents experience peer learning during labour and childbirth. This study explored how parents experienced having two students present during labour and childbirth in a peer-learning model. Design: A qualitative approach using individual interviews followed by thematic inductive analysis. Setting: Three hospitals and obstetric units in Stockholm, Sweden. Participants: Eleven women and nine partners. Findings: The overarching theme was that of a fruitful model of health care, in which there were gains for both parents and students. Parents described feeling seen and cared for, being made aware of what was going on, and never being left alone ( subtheme 1, Trustful relationship). Parents appreciated being able to observe student midwives’ attendance to the tasks at hand and that they, the two students, learned from each other (subtheme 2, Advantages for students). Conclusions: The parent couple was able to build a trustful relationship with both students. Furthermore, could parents only see advantages for students in a peer-learning model. Parents reported generous support and were willing to contribute to student education. Parents took advantage of the learning taking place between the two students. The model deserves to be incorporated in the midwifery-student internships to complement more individually assisted births.


Introduction
In recent years, midwife precepting has been put under tremendous pressure because of the shortage of clinical placements combined with an increased number of student midwives admitted to universities ( Barimani et al., 2020 ;McKellar and Graham, 2017).Preceptorship means practical experience and training for a student while being supervised by an expert, in this case, a practicing midwife.Although a requirement of all midwives is to provide teaching and supervision, midwife precepting is challenging and demanding for the midwife preceptors ( Barimani et al., 2020 ).The student midwives, too, are challenged in several ways: by a lack of support from the preceptors ( Davies and Coldridge, 2015 ;Zwedberg et al., 2020 ), by having multiple preceptors ( Gilmour et al., 2013 ;Zwedberg et al., 2020 ), and by learning in stressful environments ( Licqurish and Seibold, 2013 ;Zwedberg et al., 2020 ).One solution could be peer learning, meaning that two students of equal standing, or peers, learn from each other.In this peer-learning model, the same midwife preceptor supervises two students.Previously, we have found studies neither of peer learning for student midwives in obstetric units, nor of how parents experience having two students in the birthing room.
Peer learning has been shown to be beneficial in clinical placements, especially in nursing education ( Tai et al., 2017 ).It is a collaborative learning model, meaning it is based on interactions between equally competent students who use each other as a resource to develop their skills.The model requires that two students jointly prepare and solve activities, discuss, and reflect on patient work in a structured way.The preceptor has a facilitating role, guiding and supporting the students through the exercises.The model stimulates collaboration, reflection, and critical thinking; it promotes communication skills and independent learning; it focuses on collaboration, communication, support, reflection, critical thinking, and feedback ( Boud et al., 1999( Boud et al., , 2001 ) ). Boud https://doi.org/10.1016/j.midw.2021.103173Received 10 May 2021; Received in revised form 17 October 2021; Accepted 18 October 2021 0266-6138/© 2021 The Author(s).Published by Elsevier Ltd.This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ ) defined peer learning as "students learning from and with each other in both formal and informal ways.The emphasis is on the learning process, including the emotional support that learners offer each other, as much as the learning task itself " ( Boud, 2001 , p. 4).However, the most common preceptorship model in midwifery education in Sweden is apprenticeship training models, meaning one preceptor and one student concurrently ( Zwedberg et al., 2020 ).Therefore, a new pedagogical model can also mean a need for training in new precepting skills.
Some studies have investigated how parents responded to having one student midwife present during childbirth, but these studies focused on meeting the same student midwife throughout the entire childbearing period and found that parents highly valued continuous support ( Aune et al., 2012 ;Dahlberg and Aune, 2013 ;Tickle et al., 2016).A study by Barimani et al. (2019) has investigated how parents experience the presence of student midwives and medical students during childbirth when meeting them for the first time (with no earlier contact during pregnancy).The result showed that a student presence was experienced as very supportive and that parents were willing to contribute to student learning.For parents to see student presence as positive, interaction was vital.Some parents reported the presence of students to be a negative experience, mainly as a result of insufficient autonomy, such as being unable to choose whether a student should be present during labour and childbirth or extra vaginal examinations ( Barimani et al., 2019 ).
Despite the lack of studies on peer learning in the context of student midwives, there are many studies supporting peer learning for nursing students in clinical settings.These studies suggest that peer learning promotes independence, knowledge, and security.However, these studies also reported some disadvantages such as limit opportunities to practice hands-on skills and difficulties to cooperate ( Secomb, 2008 ;Stone et al., 2013 ;Stenberg and Carlsson, 2015 ;Pålsson et al., 2017 ).
Clinical practice is central to midwifery education, yet there is no tradition of peer learning in Sweden in the clinical setting ( Zwedberg et al., 2020 ).Before introducing a peer-learning model to obstetric units, we need to know how parents experience having two students present during their labour and birth.In this research project, the purpose was to explore how the birthing woman and her partner experienced the presence of two students.

Design
Our qualitative approach, using telephone interviews and thematic inductive analysis, was described by Braun and Clark (2006) .Thematic analysis emphasizes subjectivity in all research steps as a resource and, the analytic process is active and generative.We chose this design because we wanted to obtain in-depth descriptions of the previously unexplored experiences of parents having two students present in the birthing room.

Context
In the Swedish context, the midwifery program is an 18-month postgraduate education, pursued after obtaining a bachelor's degree in nursing.It conforms in length and content with the recommendations of the International Confederation of Midwives (ICM) ( ICM, 2013 ).Half of the education is spent in clinical placement.The student is required to assist at 50 births and take care of 100 women in labour.The registered midwife/preceptor has the ultimate responsibility for the care of birthing women when precepting.

Procedure
There were several steps to initiating this research project.Firstly, all the midwives who were responsible for students in clinical placement at the three hospitals in the study discussed the pedagogical peer-learning model with the responsible teachers at the university that offered the midwifery program.These joint discussions led to the decision that the student midwife should have advanced to the end of the educational program and have assisted forty-five births.Both members of the student pair were allowed to count the five childbirths that they had assisted as a part of a student pair, toward their totals of fifty births.
Secondly, we prepared the students.All students were informed of the peer-learning model at school.They were instructed to share and cooperate and to take different roles when caring for the parents.A foundation of the peer-learning model was that the students would be studying the same course and be able to take turns providing support to the parents and assuming more responsibility in managing the childbirth.Practising midwives paired the students in such a way as to ease the daily schedule.The students shared one preceptor who oversaw the management of the childbirth.All preceptors were voluntary.

Ethics
All parents who were willing to participate in the study and speak English or Swedish were asked if they could relate their experiences of having two students participate in their birth by phone interview some months following the birth and were given information about the pedagogical project.They also signed consent forms and gave their phone numbers.Parents received information about the study from hospital staff who informed them that they could withdraw from the study without affecting continued care.Confidentiality and voluntary participation were assured.The authors had no relation to the parents.The study was approved by the Stockholm regional Ethics Review Board (2017/1326-31/5).

Data collection
Twelve women and eleven partners signed consent forms at three different hospitals in Stockholm, Sweden.Three women and three partners were born outside Europe, and one partner was born in southern Europe.All were sent text messages requesting a day and a time for an interview by telephone.The message repeated information about voluntary participation.One woman and two partners replied that they could not conveniently be interviewed in Swedish or English.Twenty telephone interviews were conducted by the first author between March and April 2019, about four months after the child was born.The interview was in the form of a conversation in which the interviewer asked first openended questions and then follow-up questions to help the parent deepen the answers.The interview focused on parental response to having two students present, the perceived advantages and disadvantages, the relationship with the students and their preceptor, the communication, and their perception of the students' cooperation with each other.The interviews lasted between 25 and 47 min (mean 31 min), were recorded, and transcribed verbatim in Swedish.

Analysis
All interviews were analysed inductively; in other words, we searched for answers in the text without using a predetermined theory ( Braun and Clarke, 2006 ).Firstly, all interviews were read through several times to get a sense of the whole.Secondly, we colour-coded text segments for further comparison of similarities and differences.Thirdly, the codes were sorted and resorted until there emerged two significant themes.Next, these themes were sorted into subthemes.In the fifth step, themes were defined, and an overarching theme was identified in an ongoing parallel process to differentiate the borders between them.At this point, we discussed the results until consensus was reached.The stories were then reread to ensure that the themes were representative of the content and that coding was suitable.The sixth step was writing the report, compiling results and reflecting on the established themes, identifying quotes for trustworthiness, and exemplifying the content.The quotes were then translated into English.These steps initiated in and were inspired by Braun and Clarke's (2006) work on thematic analysis; they were very circular, going back and forth.

Findings
The overarching theme of peer learning, a fruitful model of health care, meaning there were gains to be had by both students and parents, was divided into two themes, one for the students and one for the parents .Parents described feeling seen and cared for, being made aware of what was going on, and never being left alone (subtheme 1, trustful relationship).Parents appreciated being able to observe student midwives' attendance to the tasks at hand and that they, the two students, learned from each other (subtheme 2, advantages for students).These were further divided into subthemes and are presented below in Fig. 1 .

Trustful relationship Feeling seen and cared for
Birthing is a situation of vulnerability; therefore, you need to trust the people around you.The parents wanted to understand the students' roles in the birthing room and their levels of competence, yet it took only a few minutes to build a relationship with both students.The reason for this was that the students showed an open-minded approach and a willingness to care for the parents.
The way they presented themselves, how they behaved, and how they showed consideration -it kind of made me feel really safe.During this time, there must be someone to take care of me, and for me, it's quite sensitive, but their behaviour made it feel perfectly OK .(Multipara 5) The parents described how having two students meant there were more eyes watching them and more arms able to assist, accompanied by willingness to care for the birthing parent.Even the birthing woman's partner felt involved and got tips from the students about what to do to make it more bearable, for example, during severe contractions.
Yes, they were good at involving me, such as during the contractions.Then I had to stand and press against her knees so that the pressure there would make the pains not hurt as much as they would otherwise.(Firsttime partner 10) The relationship with the students was of great importance; the parents needed to trust both.This trust was based upon the student providing the best care.
One of them was going to do the stitching.If I had not felt trust in them [the students], if they had not been so active during the birth, … then maybe I would have opposed it.(Primipara 16) When parents were asked if they thought there were too many people in the birthing room, they all answered no.The parent couple was able to build a trustful relationship with both students, and it was convenient to have them around.
I think of them as warm and very sweet, and I know exactly how each of them was, how they felt and how they acted, and that they were there for my sake, both of them, and I remember them fondly.(Multipara 9) In some cases, one of the students was more prominent.This student was often the student who supported the mother during birth and was closer to her head.
I got more contact with one of the students.…She was so very forward and happy.… You kind of felt confidence in her at once.…I remember that she was a bit everywhere and helped, and she was by my head when the baby was born.(Multipara 17) At the moment of birth, the preceptor was always present.Sometimes the preceptor stood behind and oversaw the moment, and sometimes the preceptor intervened.The parents were very pleased with that arrangement; for them, it felt significantly safe to know there was an experienced midwife in the room.
My wife was bleeding after the baby was born, and I was very pleased they all were there [preceptor and students], and that the more experienced midwife took over the helm in that specific situation.(First-time partner 22)

Knowing what is going on
When the students were present, they talked to each other, and the parents could overhear their conversation.This was experienced as pleasant and calming -having the students around, even hearing their conversation.When the students talked to each other, the parents could follow every step; it was calming and relaxing.The parents felt nothing was hidden and that they could hear the thoughts and ideas they usually wouldn't hear.It allowed them to ask questions or intervene if they wished.It gave them a sense of being in control and participating in the birth process.
I like to be in control, so it was nice to hear how they went through and reasoned to reach the best option.It was calming.(Primipara 4) Both parents could ask questions, and the students were consistently meticulous in explaining and answering their questions.If they didn't have an answer for the parents, they asked the preceptor.One couple described an episode in which both students were surprised by the situation, yet the couple felt very safe when the students asked the preceptor to join immediately.
Then there was a bit of chaos when the students looked and examined me; they saw that the head was on its way out.They were a little shocked that it had gone so fast.I had electrodes on me, and they had to be removed.Then the students did not know what to do, but they called their supervisor, and she quickly entered the room.… When the supervisor entered the room, which happened very quickly, however, it was calm.(Multipara 6) The parents also described the students as always explaining their plan and next step, inviting them to take part in all decisions.For example, a woman getting stitches was very nervous and described the student as ensuring that she understood the information and waiting for her to be ready.
And they were careful that I would know all the time, especially afterwards when they were stitching and so on, so they were conscientious that I would know what happened and so on.So it was very respectful, and it felt good.(Primipara 14)

Never being alone
One advantage of having two students is that there is always someone present in the room.The partners said it was calming and allowed them to concentrate on their birthing partner; they could ignore all signals from the technical equipment.
I want to say that since they [the students] were there, I could concentrate on my partner.I felt pretty confident that they were in control of everything else, that they would react if there were something.(Experienced partner 3) When the couple had to stay for many hours, and when the woman experienced the contractions were under control, the students took turns being in the room.This arrangement made it easier for the partner to take short breaks for food or a telephone call.At night it was especially appreciated, since the woman wished her partner to get some sleep.The participants reported hearing stories from other childbearing couples of loneliness during the opening stage of labour.This was never the case in their own childbirth experience.On the contrary, one father mentioned students might want to be more sensitive to couples who wanted private time, even if it wasn't the case for him and his wife.
We would probably have been more alone if they [the students] had not been involved.Because from the time they were with us, … I and S did not have as much alone time as we had before.… It was positive.If I had to do it again, I would have… kept them [the students] in the room.I thought they did a great job.We both felt so.But I can imagine that … some would say that you do not get the alone time, that it is something negative.(First-time partner 19)

Contribute to students education
Some parents were informed in advance of the possibility of students attending their labour and childbirth.For example, one woman said she had decided and welcomed that students could participate.During an antenatal class, she had been informed that midwifery students were practicing at the birthing clinic and needed all possible experience.The midwife had also told her that a student midwife could spend more time and always had a preceptor on hand for issues and concerns.
During the hospital lecture before delivery, they told us that we might get the question and encouraged us to answer yes.Yes, because they [student midwives] needed their number of births, etc.I was positive about it all the time, so it has not been a big issue.I took a stand there and then.(Primipara 18) Other parents wanted to understand student roles and how they cooperated with the preceptor before labour and childbirth.Sometimes it is too late to get information about the student role when in delivery and pain.It was essential to be involved and allowed to say no to students.
We had no problem saying we didn't want them there, … but a suggestion could be to inform parents earlier, so you have the opportunity to write it down in the birth letter.Then it is settled.(First-time partner 19) Altogether, the participants agreed that they wanted to contribute to midwifery education, while appreciating the possibility of saying no to student attendance.The parents wanted information on student competence levels, if they were at the beginning or end of their education.Therefore, they wanted the preceptor to ask them before they met the students.Their opinion was that the student shouldn't hear from the birthing woman that she didn't want them there; it was perceived as difficult to tell a student.
It would have been tough to say to a student, so you wanted to speak to the midwife.It felt like she might be a bit more used to it being a part of not being able to fit with everyone.You also talk about it when you are pregnant, that you may not be able to work with everyone, so you can probably say that to your midwife, but you would not feel comfortable telling the student.(Experienced partner 20)

Improved learning for students
Parents could only see advantages for the students in a peer-learning model.They thought it must be good to have a peer to discuss with, share events with, and learn from each other.They figured the continual communication between the students was a good learning situation.The parents noted that students helped each other and shared tips.They also noted the students responded to each other and cooperated for the next step in the birthing process.They consistently sought to agree before taking the next step.In cases in which the students were unsure about the next step, they always asked the preceptor.One of the students might take the question outside the room during the opening stage, then return and present a solution for the other student and the parents.
Parents also thought it appropriate for students to discuss with a peer.They saw that students were more independent during periods when they were left without the preceptor in the room.They addressed each other and often found an excellent way to proceed; otherwise, they asked the preceptor to enter the room and explained the situation to get help.The parents also mentioned that the students asked each other about things a preceptor might not notice or believe to be so evident as to not merit clarification.
They must feel much more alone if they cannot discuss with a mate.A preceptor is used to it and may not be able to see their questions in the same way as another student.When the preceptor came in, I noticed that they followed her instructions, so they had to practice in a different way when they were there themselves.I felt like they were competent and in control.(Experienced partner 11) During a birth, it is necessary to make many decisions, and the parents thought it could be nice to discuss with a peer.They said it must be safer and build confidence to be able to share opinions about the next step.
I have my own experience, that is, I work as an assistant nurse, and then we are two in some situations, and then it feels nicer to have someone next to you … as you feel, you feel like, you feel more confident in some way.(Multipara 17) They thought that students present at the same birth can use the case to discuss how to cooperate, what to improve, what they learned from each other, and how to proceed.One participant felt discomfort when the preceptor corrected one of the students in front of the parents and thought it would be better if it could be done more discretely, outside the room, if possible.
Like the lessons, not to take them right there and then.Those feelings are out of place compared to your own, and you are very sensitive when you stand there.(Experienced partner 20)

Discussion
We investigated how parents experienced having two students present in a peer-learning model during labour and childbirth.Our results showed the peer-learning model was a fruitful model of health care, meaning there were gains for students and parents.The parent couple was able to build a trustful relationship with both students.Furthermore, could parents only see advantages for students in a peer-learning model.
Our results showed that parents felt seen and cared for; having two students meant there were more eyes watching them and more arms able to assist.The willingness of one student to care for the parents built a trustful relationship for both students.It is consistent with other studies showing a student presence in the birthing room to be very positive ( Barimani et al., 2019 ;Aune et al., 2012 ;Dahlberg and Aune, 2013 ;Tickle et al., 2016).However, this is the first study to explore how parents perceive having two students in the birthing room to the best of our knowledge.
The parents felt they always knew what was going on.The learning situation in the birthing room, such as hearing the conversation between the students, was calming.Hearing thoughts and ideas expressed made it possible to ask questions and intervene.It gave a sense of being in control and participating in the birthing process.The parents also felt safe knowing an experienced midwife was responsible and on hand when needed.We know from one earlier study that an open interaction between the student and the midwife in front of the parents is positive.Parents gained information when the midwife instructed the student ( Barimani et al., 2019 ); our findings show that the interaction between two students is also positive for the parents.
In our results, the parents described never being alone.There was always one student in the birthing room, and the two students could take turns if necessary, which was incredibly convenient for the partner.Other studies have focused on the positive impact of the continuous support of having one student constantly in the birthing room ( Aune et al., 2012 ;Barimani et al., 2019 ;Dahlberg and Aune, 2013 ;Tickle et al., 2016).
The results showed that the parents accepted student attendance, but parents wanted that information in advance.Furthermore, they wanted to be involved in deciding to have a student.In Sweden, information about the possibility of having a student present during childbirth is provided mainly in the antenatal stages of pregnancy.However, our findings align with another study ( Barimani et al., 2019 ) showing that parents need much more information during pregnancy about the rationale behind a student presence and especially the role of the student and the midwife's overall responsibility for student guidance.Then parents could choose whether students should be present.A woman's right to self-determination is a fundamental principle of medical care ethics ( International Confederation of Midwives, 2014 ).In this study, there were two students, so in a peer-learning model, it is vital to explain the students' roles and interaction during labour and childbirth.Also, we found that parents could only see advantages for the students in a peer-learning model.The parents felt it was a good learning situation for the students and that two students generally could reflect more over, for example, what they learned from each other and how to proceed.They also felt that students became more independent from the preceptor.The relationship between the preceptor and students also worked well.More studies are needed regarding the preceptor's role and workload with two students.Our findings seem to indicate that the preceptor needs to step back and give students space to reflect and act; this requires having developed self-confidence in the preceptor role ( Barimani et al., 2020 ).
In line with the findings of Boud et al. (1999Boud et al. ( , 2001 ) ), peer learning has benefits for the student midwives.The students used each other as a resource to develop their skills; they discussed and reflected.Boud et al. (1999) also observed that the preceptor became more facilitating and the student more independent.Earlier research has found that student midwives highly value the hands-on learning situation ( Hughes and Fraser, 2011 ;Licqurish and Seibold, 2008 ).One study found that extra vaginal examinations could be seen as unfavourable when a student is present ( Barimani et al., 2019 ).Our findings did not support this.Parents expressed no bad experience, perhaps because students had clear roles, because one student had a more supportive role, or because the students had advanced to the end of their education.The vaginal examinations did not have to be monitored by the preceptor.On the other hand, we don't believe all women are comfortable with having students present during their childbirth.The birthing pair must decide whether or not to have students present.

Strengths and limitations
One strength is that this study helps to elucidate and develop the clinical environment for student midwives in a new way.Peer learning in the obstetric area has not been previously used in Sweden.Although the study sample was small, it was a strength that we were able to obtain responses from partners.One limitation was that the preceptors were voluntary and very motivated, which could have led to a more positive experience for the students in this peer-learning model than if the preceptorship had been mandatory.Another limitation was that we couldn't ask parents speaking languages other than English or Swedish to participate.In our study, there were no conflicts between the students of the pair, but that can happen, and therefore more studies on the topic are welcome.The authors independently analysed the data in all analysis phases and when interpreting the transcribed text to minimize bias from author presumptions and preconceptions.

Conclusion
The peer-learning model in obstetric units is a fruitful model of health care in that there were gains for both parents and students.Parents reported that they received generous support and were willing to contribute to the students' education.Parents took advantage of the learning situation that occurred between two students.The peerlearning model would be beneficial for further development and further studies.It may add new ways to analyse midwifery-student internships in the obstetrics area as a complement to more individually assisted births.

Contribution
All authors (SZ & MB) have made substantial contributions to the conception and design.SZ did the acquisition of data.Both SZ and MB did the analysis and interpretation of data.MB and SZ have drafted the article and reviewed the article critically for important intellectual content.Finally, we both approved the submitted version.
They talked to each other all the time.First one examined and then said to the other, Now I think it's this way, what do you think about it?Then the other looked, and they discussed with each other.It felt like they had excellent communication with each other all the time.(Multipara 9)