Women and Birth 35 (2022) 87–95

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Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Strengthening midwifery education through clinical experience:

Findings from a qualitative study in Indonesia
Qorinah Estiningtyas Sakilah Adnanib,c,* , Andrea Gilkisona , Judith McAra-Couperb
a
Department of Midwifery, Faculty of Health and Environmental Sciences, Auckland University of Technology, North Campus, Auckland 0627, New Zealand
b
Department of Midwifery, Faculty of Health and Environmental Sciences, Auckland University of Technology, South Campus, Auckland 2104, New Zealand
c
Department of Midwifery, Karya Husada Institute of Health Science, Jl Soekarno Hatta P.O. Box 153, Kediri, East Java 64225, Indonesia

A R T I C L E I N F O A B S T R A C T

Article history: Background: One of the Indonesian Government’s strategies to reduce maternal mortality rates has been
Received 14 December 2020 to place a midwife in every village to provide midwifery care and facilitate essential primary healthcare
Received in revised form 27 February 2021 services. To increase the numbers of midwives, the Indonesian Government began opening midwifery
Accepted 2 March 2021
schools. However, Indonesia’s maternal mortality rates remained high. This raises the question of the
quality of midwifery education in Indonesia and how this education could be strengthened so that
Keywords: midwifery plays a key role in reducing maternal mortality rates.
Clinical experience
Aim of the research: The aim of this study was to identify the barriers and enablers to strengthening
Indonesia
Midwifery education
midwifery education in Indonesia.
Midwifery students Methods: A qualitative descriptive approach and in-depth interviews was the method used with 37
participants from 12 midwifery schools in eight cities situated in six provinces in Indonesia. Indonesian
midwives, midwifery lecturers, midwifery students, newly graduated midwives, and obstetricians were
interviewed in Bahasa Indonesia. Interviews were transcribed, translated, and thematically analysed
following Braun and Clark (2006).
Findings: This article focuses on findings on “midwifery clinical experience”, a theme which contained
four sub-themes: “effective hands-on clinical experience”, “theory-practice gap”, “role of the mentor in
practice”, and “the system in the clinical environment”.
Conclusion: This study highlights barriers to preparing midwifery students for obtaining adequate
midwifery knowledge and skills during clinical placement. Quality clinical experience would improve
knowledge and skills for better preparedness for students to competently meet their role as midwives,
contributing to the strengthening of midwifery education in Indonesia.
© 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

midwives are vital for accelerating progress for maternal and

Statement of significance
Problem or issue
Educating midwives has been one of the strategies used to
address high maternal and neonatal mortality rates. Despite
the proliferation of midwifery schools, and the high numbers
of midwives being registered in Indonesia since 1996,
maternal and neonatal mortality rates remain high.
What is already known?
The global evidence on the importance of skilled midwives
for the wellbeing of women and infants has steadily
developed. It now shows that well prepared and resourced
neonatal health outcomes.
What this paper adds
There is limited research on midwifery education in
Indonesia. This study gives an insight into the experience
of midwifery lecturers, midwifery students, newly graduated
midwives, midwives, and obstetricians. This paper high-
lights barriers to preparing midwifery students for obtaining
adequate midwifery knowledge and skills during clinical
placement. This paper focuses on midwifery students’
clinical experience as one of the vital elements in strength-
ening midwifery education in Indonesia.

* Corresponding author at: Jl Pahlawan IX/24, Ketanon, Kedungwaru, Tulunga-

gung, Jawa Timur 66226, Indonesia.
E-mail address: qorinahestiningtyas@yahoo.co.id (Q.E.S. Adnani).
@QorinAdnani (Q.E.S. Adnani)

http://dx.doi.org/10.1016/j.wombi.2021.03.002
1871-5192/© 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Q.E.S. Adnani et al.
1. Introduction
In 2019, the World Health Organization (WHO) reported that Sub-
Saharan Africa and Southern Asia together contributed to around
86% global maternal mortality rates [1]. Indonesia is a country of
approximately 270 million inhabitants, and the government has
significantly reduced maternal and neonatal mortality rates from
390 per 100,000 live births in 1991 to 305 in 2015 [2]. However, the
rate was still higher than the other Southeast Asian countries;
Indonesia failed to reach the Millennium Development Goals
(MDGs) target of 102 per 100,000 live births in 2015 and is not on
track to meet Sustainable Development Goals (SDGs) [3–5]. One of
the SDGs targets is reducing maternal mortality rate to less than 70
per 100,000 live births, with no country, exceeding 140 maternal
deaths per 100,000 live births by 2030 [4,5]. Most causes of maternal
mortality, ranging from bleeding, hypertension, and sepsis [6], are
preventable or treatable by skilled birth attendants, including
midwives. Empirical evidence shows that having well-educated and
resourced midwives can make a difference in preventing these
causes of maternal mortality, and improving maternal and neonatal
health outcomes [7–9].
In Indonesia, midwifery education has a long history. In June
1850, the first midwifery schools established by the Dutch
Government were associated with the reduction of the high
maternal and neonatal mortality rate in Java Island. Indonesia
gained independence on August 17, 1945, and between 1945 and
the 1990s, the Indonesian Government took the initiative of
building a system of midwifery schools which would educate more
midwives in an effort to address the consistently high maternal
and neonatal mortality rate [10–12]. Since 1996, midwifery
education in Indonesia has had a three-year direct-entry pathway
leading to a graduate level. A direct-entry midwifery programme
recognises midwifery as a separate profession from nursing, and it
is the educational pathway which brings students to train to be
midwives, so all students come to midwifery this way.
To improve maternal mortality rates, since 1996, Indonesia has
approved a large number of midwifery education providers. The
aim of educating midwives to be the primary maternity and
neonatal health providers, particularly in the villages, has led to a
proliferation of midwifery schools. Since 2000, midwifery’s
advanced diploma for midwifery lecturers opened. Since 2005,
the regulation was changed to stipulate that midwifery lecturers
must hold a master’s degree following the opening of a master of
midwifery programme in some universities. Some of the require-
ments to be met in order to be able to apply for a master
programme are teaching experience and holding an advanced
diploma or bachelor’s degree. At present, Indonesia offers a
diploma, advanced diploma, bachelor’s degree and a master’s
degree in midwifery.
The number of midwives had risen to over 135,000 in 2012, and
68.6% of maternity services at childbirth were provided by
midwives in 2018 [2,13]. Despite the Indonesian Government
licensing around 856 private and public institutions offering
midwifery programmes, the performance of the newly graduated
midwives and the quality of midwifery education in Indonesia has
been questioned [12,14,15], given that Indonesia’s maternal
mortality rates were three times higher than MDGs target in
2015 [8].
The Indonesian Ministry of Research, Technology, and Higher
Education and Ministry of Health licence midwifery programmes,
and are tasked with ensuring that midwifery students acquire
appropriate midwifery knowledge and skills, and also, that they
are provided with qualified midwifery lecturers and clinical
mentors. For example, the curriculum structure of the diploma
of midwifery programme has a balance of 60% clinical practice and
40% theory, which follow the International Confederation of
88
Women and Birth 35 (2022) 87–95
Midwives (ICM) education standards [16]. Midwifery students in
the diploma of midwifery programme attend for six semesters, and
there is a specific period for clinical placements during this time.
Midwifery students are placed in clinical placements where they
are allocated to a clinical setting, such as a hospital, maternity
clinic, public health centre, private midwifery practice or rural area
to achieve a specific number of clinical competencies. Once
midwifery students have completed all examinations and require-
ments during their three-year midwifery programme, they need to
sit a national competency test set by the Indonesia Ministry of
Research, Technology, and Higher Education. However, since 2015,
the national competency test for the diploma of midwifery
graduates has had fluctuating pass rates [17]. The pass rates have
called into question the quality of midwifery programmes.
Thus, to understand the current challenges of midwifery
education, a study was conducted to identify the barriers and
enablers to strengthening midwifery education in Indonesia.
However, this paper focuses on reporting midwifery clinical
experience as one theme emerging from the larger study.
2. Participants and methods
2.1. Research design
A qualitative descriptive approach was used to collect and
interpret data from in-depth interviews with Indonesian newly
graduated midwives, midwifery students, midwives, midwifery
lecturers, and obstetricians who are involved in midwifery
education. Qualitative description provided the researchers with
a way to obtain a better understanding of the nature of what may
strengthen midwifery education in Indonesia [18–20]. Midwifery
education research in Indonesia is limited. There are many studies
which have highlighted the maternal and neonatal mortality
problems, but no research about how midwifery education can be
strengthened. The qualitative descriptive methodology was used
to understand the experiences of participants involved in
midwifery education in Indonesia. This is in line with Sandelow-
ski’s suggestion that qualitative descriptive provides an accurate
summary of phenomena when there is limited information on a
topic [19,20].
2.2. Setting
This study was conducted in 12 midwifery schools (private and
public institutions) in eight cities (Jakarta, Bandung, Purwokerto,
Yogyakarta, Surabaya, Malang, Mojokerto, and Padang) which were
situated in six provinces out of 34 provinces in total across the
country (West Sumatera, Jakarta Special Capital Region, West Java,
Central Java, Special Region of Yogyakarta, and East Java). This study
also included the central board of the Midwifery Association in
Indonesia. Java and Sumatera were selected as the study locations
because they were areas with high maternal and neonatal mortality
rates. A broad range of educational institutions running midwifery
schools were covered, including universities, institutes of health
science, polytechnics of health science and academies under the
Ministry of Research, Technology and Higher Education and the
Ministry of Health. Private organisations, such as Muhammadiyah
societies, and a range of academic qualifications (diploma, advanced
diploma, bachelor’s, and master’s of midwifery programmes). The
number of midwifery students or graduates from these 12 midwifery
schools was approximately 600 per year.
2.3. Participants and recruitment
A combination of purposeful and snowball sampling was used
to recruits participants from different backgrounds [19,21], and to
Q.E.S. Adnani et al.
gain a broad range of perspectives from the participants’
experience. Purposeful sampling is used to obtain cases deemed
information-rich for the study [21]. For inclusion criteria, clinical
midwives had to be licensed registered midwives and had to have
at least five years of experience guiding midwifery students or
newly graduated midwives. Similarly, midwifery lecturers and
obstetricians had to have at least five years of experience guiding
and teaching midwifery students. Midwifery students had to be
aged 18 years or over, and enrolled in their final year of studies.
Newly graduated midwives had to have graduated within the last
year.
Once the approval letter from each midwifery school was
granted, poster advertisements and an email were distributed
amongst midwifery schools and midwifery associations. The
participants contacted the first author through email, text and
phone communication. Before collecting data, verbal and written
informed consent was obtained from participants who met the
inclusion criteria.
No midwifery students participants were under the first
author’s tutelage or dependent on the first author’s decision
making. The first author reassured the midwifery students that
their studies would not be impacted by participating in the
research project and would not affect their final programme
progress. Participants were also assured that no identifiable
information would be published. Conflicts of interest were not
expected to arise because there is currently no social, professional,
and financial relationship between the first author and the
participants.
Participants were predominantly female (86.5%) and the rest
were male (13.5%); the characteristics of the 37 participants can be
found in Table 1. The midwifery lecturers, midwives, and
obstetricians were currently working in midwifery schools and
had between 6 and 40 years experience in midwifery schools and
midwifery services in Indonesia. The newly graduated midwives
were educated through a variety of midwifery programmes:
Bachelor of Midwifery, Advanced Diploma of Midwifery, Diploma
of Midwifery and Master of Midwifery programmes. Each
participant chose or was given a pseudonym to maintain
confidentiality in the presentation of participant information.
2.4. Data collection
The development of the interview questions was informed by
evaluations of midwifery education in low-and middle-income
countries [22]. The first author conducted a pilot interview process
in Bahasa Indonesia, with two Indonesian midwifery lecturers, two
midwifery students and two newly graduated midwives who did
not participate in this study. The process evaluated the interview
questions and how they worked to address the research question.
Academic scholars reviewed the final questions (see an appendix).
Data were collected through individual, face-to-face semi-struc-
tured interviews between August 2016 and January 2017. Inter-
views were undertaken by the first author (QESA), an Indonesian
midwife and midwifery lecturer, and native Bahasa Indonesia
Table 1
Characteristics of participants.
Participants Gender Total
Female Male
Newly graduated midwives 9 9
Midwifery students 9 9
Midwives 6 6
Midwifery lecturers 7 7
Obstetricians 1 5 6 detailed exposition of a research process. An audit trail and
Total participants 37
89
Women and Birth 35 (2022) 87–95
speaker who has experience in research projects in the Indonesian
context. The interviews were held in a private room at the work
place of the participants. Participants could withdraw their
participation in this research within the data collection period.
None of the participants withdrew. Braun and Clarke suggested
that a considerable sample size would provide in-depth data which
is appropriate to the qualitative descriptive methodology [23]. In
this study, after interviewing 37 participants, data saturation had
been achieved, and further interviews did not generate new
information. The average length of time for all of the interviews
was around 40 90 min. All interviews were audio-recorded. Data,
field notes, transcripts, translation files relating to the research
were kept confidential and stored and password protected on the
first author’s computer. Throughout the data collection, the first
author was mindful of her position as a reseacher in her home
country and regularly discussed the work with co-authors in New
Zealand, to reflect upon the process of data collection and the
project as a whole.
2.5. Ethical considerations
Approval to conduct the study was provided by the Auckland
University of Technology Ethics Committee, New Zealand, on 19
July 2016 (Ref 16/259) and the Health Research Ethics Committee
Padjadajaran University, Indonesia on 7 October 2016 (No 953/
UN6.C1.3.2/KEPK/PN/2016). Approval letters were received from
each of the research settings.
2.6. Data analysis and interpretation
The first author transcribed the audiotapes for each interview
verbatim and translated them to English. The translation process
enabled non-Bahasa Indonesia speaking co-authors to contribute
to the trustworthiness of this study. The analysis was conducted
primarily by the first author and ongoing discussions were held
with co-authors during data analysis; as the transcripts had been
translated, the co-authors could engage with raw interview data.
Consistent with the qualitative analysis approach outlined by
Braun and Clarke, this study employed six-stages of thematic
analysis [24]. Initially, rereading and reviewing a transcript and a
translation file for each participant was conducted as the starting
point for involvement with the data. Next, each transcript was
analysed individually – read line by line then highlighted and
annotated on the right side of the transcript file to identity the
patterns, repetitions, differences and similarities. The third stage
was a technique to format sub-themes into themes. After the first-
stage coding was applied, second-stage coding continued to
identify possible themes and sub-themes. The fourth stage was the
thematic map approach which involved categorising sub-themes
and themes. As part of the ongoing analysis, discussions and
reflections were conducted to refine each theme. Finally, the
identified themes and sub-themes were agreed and finalised by all
authors.
2.7. Trustworthiness
Throughout the study, trustworthiness was maintained by
using the framework of Lincoln and Guba, the criteria being
credibility, dependability, confirmability, and transferability [25].
In order to ensure credibility, this study applied the major
strategies suggested by Lincoln and Guba, including member-
checking, peer-debriefing, prolonged engagement, and persistent
observation. Strategies to demonstrate dependability include the
reflexivity were maintained and explained to demonstrate
confirmability. The provision of thick description and maximum
Q.E.S. Adnani et al.
Table 2
Trustworthiness.
Trustworthiness Meaning Techniques
Credibility The processes to maintain the accuracy of Member-
the data checking
Peer-
debriefing
Prolonged
engagement
Persistent
observation
Reflexivity
Dependability Ensure the data were analysed according to Audit trail
the accepted standards
Confirmability The findings of a study represent the Audit trail
participants’ responses and the Reflexivity
contexts of the research rather than the
researcher’s viewpoints
Transferability Identifies how a study’s findings could be Thick
transmitted to other settings descriptions
Maximum
variation
variation was carried out to attain transferability. A summary of
trustworthiness in this study, shown in Table 2.
3. Findings
“Midwifery clinical experience” was one theme identified in a
broader study [26]. This paper presents the findings which
revealed the importance of clinical experience for strengthening
midwifery education. Four sub-themes emerged under theme of
“midwifery clinical experience”, namely: “effective hand-on
clinical experience”, “theory-practice gap”, “role of the mentor
in practice”, and “the system in the clinical environment”.
3.1. Effective hands-on clinical experience
For the participants in the study, having effective hands-on
practice was an important part of strengthening midwifery
educaiton. Effective hands-on practice was not just about clinical
skills, and a number of participants talked at length about woman-
centred care and attributes such as empathy.
Dyah, a midwifery student explained:
I really helped a mother, she felt pain. I gave her pain relief, caring
until the end. Until she got angry with me, “Yes you don’t feel how
painful it is, you haven’t got married, miss? You haven’t.” Oh, yes
she is right. But I can still learn to be professional if I haven’t had a
baby yet. I still have to be empathic, placing myself as if I am the
labouring woman and understanding that the pain is extraordi-
nary. So I release my own ego and I think about what the mothers
are feeling. So I have more empathy for women. (Dyah)
Dyah explained that the quality of the relationship and being
empathic, supportive, providing counselling and education is all an
essential part of becoming a midwife.
Widya, a midwife, also discussed the importance of woman-
centred care.
Yes, students need to learn about ethics, and also woman-centred
care. They (students) should see the woman and the family. The
students focus on filling in the written form. Sometimes they are so
busy with their phone. (Widya)
Widya talked about students focusing on the woman in a
holistic way, seeing her and her family, her culture and her
community. She was committed to teaching this to students and at
times became frustrated as the students’ focus was elsewhere. For
midwives like Widya, teaching through their interactions and
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Women and Birth 35 (2022) 87–95
connection with the woman is an important part of what student
midwives need to learn. Widya and other participants expressed
frustration about how to get students to understand how
important this was for effective hands-on learning.
Moreover, Rully shared how a focus on targets and numbers
leads at times to inappropriate hands-on practice:
So how do I become a competent midwife if I don’t have relevant
clinical experience? I feel I don’t have that much practice. One
patient was shared with other students in practice. I was rarely
allowed to do all the care by myself. One woman who delivers a
baby is divided into several students, so every student has an
opportunity to handle the women. One student did the first stage,
another student did the second stage and another student did
placenta delivery, so on. Every student writes up the midwifery
report as one patient and one woman can have about 10 students
and the midwife signs the midwifery report because she feels sorry
for us and knows we have to get our numbers. (Rully)
The pressure to reach targets means that the midwives in
clinical feel they have to divide the women into several student
groups so each student gets to engage in practice. Yuni, a
midwifery student, spoke about’ observations counting as births
and numbers of students doing different stages of the birth counting as
a birth’. Another midwifery student claimed that ‘The target is not
achievable but the clinical instructor feels pity for us because of the
target and they sign the report even though you only touch the head or
the placenta’. For midwives and midwifery students, the sheer
number of students alongside the targets means not only is there
not effective hands-on learning but it is also at odds with the
woman-centred care the participants experessed as being at the
heart of midwifery practice. This is captured so well by student
midwife Al Syifa who said ‘pursuing the target number of skills. If
students think that they must achieve this, the soul of becoming
midwife is lost’.
A lack of hands-on clinical experience and a focus on targets
rather than quality found in this study were a significant barrier in
developing midwifery knowledge and skills. The quality of clinical
experience is critical and is a core element for the better
preparedness of midwifery students to competently fulfil their
role as midwives.
Continuity of care was also identified playing an important role
in effective hands on learning.
Fardina discussed the positive experience of continuity of care:
I am doing continuity of care too. I have to follow the women from
antenatal care, delivery process, postpartum until she goes back at
home. I felt delighted for this experience and it helped my learning,
making a partnership with the woman and her family. I know the
reality of being a midwife with one-to-one midwifery care.
(Fardina)
Continuity of care experience provides the opportunity to work
with women across the scope of midwifery practice. Fardina
believed this experience developed her competence and increased
her awareness of a midwives role.
Al Syifa, a midwifery student, also valued the relationship with
the women and the family during continuity of care experiences:
The process of birth is not just about listening and watching it. It is
now not about the numbers. With COC (continuity of care) from the
start of pregnancy until after the birth is more memorable as a
lesson, knowledge and experience. The learning from 1 to 2 COC
feels more in- depth than 50 childbirths, especially if the student
didn’t understand but just wrote the report even though she only
watches or listens to the birth. (Al Syifa)
The learning with continuity of care provided invaluable
experience for Al Syifa and was by far her most effective hands
on learning.
Q.E.S. Adnani et al. Women and Birth 35 (2022) 87–95

Juju, a midwifery lecturer, also recognised the value of She stated that practice in the real setting in the clinical sites was
continuity of care for midwifery students to gain knowledge and not always consistent with the lessons taught at school.
skill:
Students need to do three continuity of care. This experience is 3.3. Role of the mentor in practice
essential to provide the good way for students to learn all the scope
of practice of the midwife (Juju) For example, in the diploma programme, the curriculum
structure in practice is 60%, so total hours in laboratories and
It was also recognised by midwifery lecturers such as Juju that
clinical placements are 2560 contact hours. Generally, clinical
continuity of care in Indonesia was ‘a lot to organise because we
placement organised by midwifery schools and midwifery student
need to arrange for the method, schedule, fee, and the field so the
is part of the midwifery unit roster. Thus, memoranda of
students and all parties care comfortable’. At this stage, to make
understanding with terms and conditions applied and clinical
continuity of care the norm for students would involve significant
mapping practice between midwifery schools and clinical settings
changes to the clinical culture, systems and organisation of clinical
were required. Different kinds of clinical settings, therefore, have
placements.
their administrative requirements before clinical placement. Some
However, continuity of care was seen by both students and
midwifery student cohorts and owners of midwifery schools
midwifery lecturers alike as providing the most effective hands-on
(private or public) were strongly influencing the midwifery schools
learning along with educating students about the midwifery scope
to pay for clinical practice. Generally, each midwifery school
of practice and enabling relationships to be formed, connections to
identifies the enrolment fee, the tuition fee, and the building
be made with women, and woman-centred care to be provided. A
services fee. However, further investigation is needed regarding
lack of continuity of care, alongside financial problems and
the cost of midwifery education as none of the midwifery schools
management challenges in implementing continuity of care was
transparently or briefly explained how the midwifery schools pay
a barrier to strengthening midwifery education.
for clinical placements.
When students are in clinical placements, they are assigned a
3.2. Theory-practice gap
mentor midwife who supervises their practice. Participants spoke
of how important their mentor was in facilitating effective learning
Participants highlighted the gap between what is taught in the
in clinical. The midwife mentor has responsibility for providing
midwifery school and what is practised at clinical sites. Often the
midwifery care for women and their families as well as guiding the
theory is taught independently of clinical practice, with a
midwifery students’ clinical experience. The midwife mentor was
significant amount of time passing between the theoretical
appointed by the head of the maternity room to guide midwifery
learning and clinical practice. Lisa, a midwifery student, for
students. Midwife mentors are commonly senior and more
example, said:
experienced midwives.
I was asked about the Leopold manoeuvre. I had forgotten about
Ani, a newly graduated midwife, spoke of having a positive
that. Even though it had already been explained, but that was in the
experience with her mentor in a midwifery degree programme
first semester. Then in the second semester we only imagined it and
after her diploma:
revised it. When the lecturers gave us materials we should directly
I have had clinical experience in some big hospitals, X,Y, Z hospitals
practice it and we should be given more time to practice. If we were
so at that time I felt thrilled. Even though the fees were expensive, I
only given the material, we tend to easily forget, it was better
got many cases also excellent guidance from the midwife so it was
learning when we practiced it. We were taught to memorise it, not
very balanced. Because the midwife mentor taught me many
to comprehend it. (Lisa)
things, I didn’t know. After handling many cases, I was feeling
Lisa spoke of receiving large blocks of theory at the beginning of guilty because I realised I had made mistakes in the past because of
the programme, yet only getting to practice at the end of her study. the limitation in my knowledge and skill. The midwife mentor was
Lisa said her education comprised of a lot of memorisation rather very facilitative, better than my previous study when I was
than comprehension of midwifery. Lisa found it hard and confusing studying the diploma of midwifery. I am very satisfied because I got
to remember the theory when it was separated from practice, and a lot, the knowledge, the skills, emergency cases. That experience
felt she was not learning midwifery. As a consequence, Lisa found was so different and make me feel good and right. (Ani)
that the way of learning impacted on her clinical experience and
Ani explained that when she had an effective mentor she had
subsequently, at clinical sites, she struggled to retain and apply the
more opportunities to learn in her clinical placement. Although,
knowledge learned in theory. She suggested that she should be
she had to pay an expensive fee (students in Indonesia have to pay
exposed in practice directly to that which is taught in theory,
for their clinical experience), it was worthwhile, because she had
otherwise a theory-practice gap may develop.
many cases and excellent guidance from a mentor in the field. She
Widya, a midwife, further discussed the theory-clinical gap as a
considered that the support from her mentor across the clinical
common issue at clinical sites.
sites that she attended positively impacted on her midwifery skills.
My role in clinical is to give guidance to students. When I met the
Negative behaviour of midwifery mentors towards students
teacher here, she talked about the theory, she explained this and
was identified as poor role modelling and a neglect of midwifery
that, the theory that she was teaching to her students. However,
students, and consequently it affected their learning process at the
now at the clinical sites, they (students) practiced with us. In
clinical sites.
practice it was sometimes different to the theory, and we teach
When I made a mistake, the midwife suddenly started screaming
that. (Widya)
and yelling in front of the woman and me. I felt uncomfortable
Widya said that her role at the clinical site is to guide midwifery because the woman did not trust me anymore. I had put medical
students. Regularly, midwifery lecturers supervise students in rubbish into a non-medical bin and in front of the woman and the
their clinical placements. She explained that midwifery lecturers family, the midwife was screaming, “where are your eyes, how
who worked with the students were often not experienced many eyes do you have? Look at the bins properly, take it” angrily. I
midwives but only knew the theory. Therefore, this could lead to understand that I made a mistake because I am so nervous at that
considerable confusion for the students between what Widya, as a time, but it was unpleasant. I feel I don’t want to come back to the
mentor, and the midwifery lecturer regard as appropriate practice. hospital and look at her face again. It was inappropriate and nasty.

91
Q.E.S. Adnani et al.
I still remember her face. Why can she not talk nicely and not
scream and be angry in front of the woman and family? Just talk to
me. (Cici)
The mentor’s aggressive behaviour had a significant influence
on the process of learning, and on developing confidence and
competency, as well as self-esteem. Cici, a newly graduated
midwife, was intimidated by her midwife mentor’s nasty words.
She felt less confident and could not manage the childbirth process
and the reaction of a midwife to her lack of midwifery skills.
Hapsari, a midwife, concurred on the significant position of the
mentor in the field of practice because of the task of guiding the
midwifery students in clinical settings.
I am happy guiding the students. So I have to become a role model
for them. It means that I have to have up-to-date information and
training, and do the skill correctly, because the students are more
with me, with us. Because if I am right as a mentor then I will
transfer the right things to students, won’t I? (Hapsari)
Hapsari acknowledged the attributes of mentors for midwifery
students were being a good role model and keeping up to date with
information and training. She was concerned that she wanted to
teach students the right things.
Participants recognised that optimising the clinical placement
of midwifery students was facilitated by a system that supported
an effective mentor. The mentor was deemed the primary person
to provide effective experience and develop midwifery skills. The
mentor could have either a positive or a negative impact on student
learning, so is crucial for effective learning.
3.4. The system in the clinical environment
Participants highlighted the clinical sites for the clinical
placements, and support for and guarantees of clinical placements
with maternity services are essential for appropriate clinical
experience. Fardina, a newly graduated midwife, spoke about the
conditions for the clinical placements for midwifery students:
I was just wondering why the clinical setting was not utilised by
the school. There was an excellent hospital that I attended but was
no longer used in the following semester. Now, I know it was not an
easy to process for clinical requirements and for clinical placements
until we looked outside the city. We have to advocate to the
midwifery association and to public health officials. Have to have
the memorandum of understanding, relationship, and connection,
otherwise there are less patients and too many students. Each
clinical setting has its own procedures for clinical placements, so
it’s like a vicious circle for us. (Fardina)
Fardina identified that there was not a simple process for
collaboration and building the relationship between a midwifery
school and clinical sites because many requirements had to be
addressed, such as advocating with the local midwifery association
and public health officials, and the availability of the memorandum
of understanding to ensure the preparation and facilitation of the
clinical sites for clinical placements. She also identified that
different clinical settings had various procedures conducted each
term to update the clinical sites. The process that had to be
followed before clinical placement was regarded as complicated to
manage.
An obstetrician also noted the complicated system regarding
the clinical sites:
We want the students to be skilled, but we have to compete to get
the hospital for the students because of the number of midwifery
schools. There are a lot of students and many complaints about the
low quality of education. It is difficult if we have to compete for the
hospital to ensure students gain practice experience. There is no
guarantee that if students get the place, that the student will be
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Women and Birth 35 (2022) 87–95
skilful. Midwifery school has no hospital or its own clinic for
practice. The fees are higher there too, of course. (Sony)
Sony felt unsupported by the system, especially the processes of
obtaining perceived appropriate clinical sites for the clinical
experience of midwifery students and newly graduated midwives.
It seemed that there was a significant hindrance to clinical
placements for the students. The unsupported system was not
congruent with the expectation of developing and building the
knowledge and skills of midwifery students. The financial cost was
captured by newly graduated midwife, Yuni, who said ‘I would have
to practice more and pay more for clinical placement’. Fees paid by
midwifery students for additional clinical experience reflect a
system that is not able to provide quality clinical experience.
Competition in the midwifery environment and the financial
cost incurred for additional clinical experience were significant
barriers to ensuring the quality of midwifery clinical experience. To
strengthen midwifery education, the participants recognised
appropriate clinical sites as an essential aspect of supporting the
quality of clinical experience. Nevertheless, the participants
recognised that arrangements for clinical placements could occur
at a number of sites.
4. Discussion
Despite the proliferation of midwifery schools in Indonesia,
questions have been asked about the quality of midwifery
education. This study aimed to explore the barriers and enablers
to strengthening midwifery education by drawing on the
experiences of Indonesian midwives, midwifery lecturers, obste-
tricians, newly graduated midwives, and midwifery students. In
this paper, the theme “midwifery clinical experience” is identified
as a critical element in strengthening midwifery education in
Indonesia.
This study has identified the value of ‘hands-on’ experience and
woman-centred care, which means there needs to be some
significant changes to clinical practice. One of the areas of
particular concern for participants was that students needed to
develop empathy with women. Midwives are expected to be
empathic, and this needs to translate through to working with
women. The only way this can be learned as Bradfield et al.
identified is through being ‘with women, by learning from women’
[27]. The ‘arts and skills’ of woman-centred care are at the heart of
midwifery practice and ‘being with women’ is about establishing a
connection [28]. The quality of this connection [28] is what
participants identified in this research as making hands-on clinical
experience effective learning. In the Indonesian context, midwives
are expected to provide the midwifery care of the woman across
the maternity continuum and facilitate essential primary health-
care services, including neonatal healthcare.
The understanding of an effective hands-on experience in this
study is, that one midwifery student would care for one woman
and give her all midwifey care. This effective hands-on experience
would ensure a student-centred learning environment, as well as
providing respectful midwifery care. The reality in practice that
students rarely got to do full practice but just ‘parts’ of the hands-
on experience, for example, touching the head of the baby,
perineum, and delivering the placenta, and this was seen as a
barrier to providing effective hands-on experience. This finding is
confirmed in other studies which found that midwifery students
should not be taught parts but instead must be confident with the
whole process of labour and birth [29–31]. The concern was that a
woman had too many midwifery students looking after her, which
was not a woman-centred but student-centred approach, and even
that could be debated, but it showed a lack of respect for the
woman. A woman should be looked after by one midwifery
Q.E.S. Adnani et al.
student, and midwifery students should not competing for clinical
experience. The impact of this fragmentation on a woman who has
several students providing aspects of care demonstrated mistreat-
ment of the woman. As long as midwifery students and newly
graduated midwives’ clinical experiences are limited in terms of
gaining hands-on experience and providing woman-centred care,
they are unlikely to be able to meet the standard expected of
competent and confident midwifery graduates.
An effective hands-on experience also means that clinical
experience must not be primarily focused on labour and birth but
must be across the scope of midwifery practice. For some time in
Indonesia there has been discussion about the reduction in
maternal and neonatal mortality that could be expected if
midwifery education prepared the workforce to work across the
full scope of practice [14]. The importance of hands-on experience
is also clear in international studies [32,33], which have shown
that hands-on practice enhances the quality of learning and so the
competency of midwifery graduates. This research highlights the
way in which the clinical environment influences the quality of
clinical experience. A system which allows midwifery students to
do parts of a woman’s care results in midwifery care that is not
appropriate or respectful. The current system often results in too
many students in placement at the one time and means they do not
get the opportunity to work across the scope of midwifery. This is
compounded by the fact that midwifery students are not
prioritised at clinical sites.
Our findings show that, too often, the focus was on skill
numbers and midwifery targets instead of a focus on the quality of
clinical experience across the scope of practice. Midwifery
students in Indonesia have to do a minimum of 50 births prior
to finishing their midwifery programme. In this study, it was found
that a group of midwifery students can count the same birth if they
are all providing some midwifery care. However, this number is
high compared to the global standard (40 births) and other
countries such as Ethiopia (20 births), Pakistan (40 births), India
(30 births), and New Zealand (40 births) [7,32,34–36]. This study
calls for an evaluation of the midwifery target, particularly the
number of births that students must attend.
This research identifies that continuity of care experiences in
some midwifery schools offer positive experiences and very
effective learning. Kuliukas et al. identified the value of continuity
of care and how it enhances student learning particulary their
ability to work with and be with women [28]. Working in
continuity not only ensures effective hand-on practice but that
students understand the midwifery scope of practice and what it
means to connect with and develop relationships with women and
their families. This research is consistent with the study of
continuity of care experiences in Indonesia, which reveal that this
impacted positively on midwifery students [37]. The implementa-
tion of this finding will require changes to policy, guidelines, and
the organisation of the workplace. There will also need to be
collaboration on a number of levels along with a well-managed
change process.
Our findings show that the midwife mentors became role
models at the clinical sites developing the competency and
confidence of midwifery students. This finding identifying the
significance of midwife mentors as an essential element in
ensuring the quality of clinical practice echoes international
studies [22,32,38]. There was often a misconception between
midwifery lecturers and midwife mentors about clinical perfor-
mance and the appropriate evaluation of students in the clinical
sites. Midwife mentors and midwifery lecturers working side by
side at clinical sites would help midwifery students to retain
knowledge and midwifery skills. There were, however, concerns
raised in this research about negative relationships with mentors,
and the high workload of mentors due to there being too many
93
Women and Birth 35 (2022) 87–95
students in one room. The negative behaviour of some unsuppor-
tive mentors resulted in poor role modelling for midwifery
students and newly graduated midwives, and limited their
exposure to midwifery skills in clinical sites. Having a clearer
understanding of the mentor’s job description and an appropriate
ratio of mentors to students at clinical sites may help to ensure
adequate support for midwifery students’ learning objectives.
Moreover, the existence of a theory-practice gap, which was
portrayed in this research, highlights that midwifery theory should
not be separated from clinical practice. This finding was in line
with previous studies that have found a theory-practice gap to be a
significant barrier for midwifery students preventing from being
prepared for new midwives [39]. Tailored programmes and
adequate implementation to reduce this theory-practice gap need
to be a significant concern of midwifery lecturers, midwife
mentors, and midwifery programme leaders.
In the Indonesian context, institutional factors are constrained
by hierarchical and organisational systems which make the
process of gaining appropriate clinical sites for students’ clinical
placement challenging. This research highlighted that the many
layers of documents required, such as an memorandum of
understanding between schools and clinical sites, was unneces-
sarily time consuming. This finding was consistent with research
from Ethiopia which showed that a lack of coordination between
academic and clinical sites, including transport, inappropriate
clinical rotation, and overcrowding, to name some factors,
impacted significantly on the quality of clinical education [40].
The fees paid by midwifery students for additional clinical
experience also reflect a system that is not able to provide
adequate and quality clinical experience and meet targeted
requirements.
4.1. Strengths and limitations
This qualitative study highlighted the challenges currently
facing Indonesian midwifery education in preparing competent
and confident midwifery graduates in terms of midwifery clinical
experience. Based on our knowledge, this study is the first of its
kind to examine the experiences of Indonesian midwives (includes
with midwifery organisation), midwifery lecturers, obstetricians,
newly graduated midwives, and midwifery students about
midwifery education in Indonesia. However, there are some
limitations identified in this study. “Midwifery clinical experience”
was one theme identified in a broader study. One of the limitations
of this study is confined to the Indonesian context. This study was
conducted in 12 midwifery schools while there are 856 midwifery
schools across the country. Another limitation is that this study did
not include government officials’ views as decision-makers and did
not capture the stories from the women and families who received
midwifery care.
5. Conclusion and recommendations
Our study shows that intertwined complex factors, such as a
lack of hands-on clinical experience, a focus on targets rather than
quality, the lack of continuity of care experience, the lack of role of
a defined role for mentors, and competition in the midwifery
environment, were significant barriers to midwifery students
obtaining midwifery knowledge and skills. This study presents
some insights for midwifery programme leaders, healthcare
professionals, and decisionmakers concerning the systems of the
midwifery environment and the importance of addressing
midwifery students’ needs so that they obtain appropriate
midwifery knowledge and skills.
A quality midwifery clinical experience for midwifery students
is one of the critical elements in strengthening midwifery
Q.E.S. Adnani et al.
education in Indonesia. Continuity of care experiences should be
implemented and integrated into the midwifery curriculum. As
midwifery theory can not be separated from clinical practice,
midwife mentors and midwifery lecturers should work side by side
at clinical sites. The core competencies of mentors should be
defined and considered and professional development for the
mentors should be put in place to ensure they have the skills to
work with students. The core competencies for midwifery students
and newly graduated midwives should be strengthened for better
preparedness of midwifery students to competently fulfil their role
as midwives.
We also suggest that adequate procedures and administration
processes support midwifery students to undertake a clinical
placement, including a change in the policy of paying fees for
additional clinical experience. Effective communication between
the midwifery association, midwifery programmes, public health
officials, and the midwifery department in maternity services is
needed to provide a practical clinical site approach. Mapping the
distribution of midwifery students among maternity services
could reduce the overburden of midwifery students during clinical
placements. If midwifery education in Indonesia is strengthened
through students gaining quality midwifery clinical experience, in
line with the recommendations, it would directly impact new
midwives as the primary maternity caregivers in the community.
Conflict of interest
All authors declare that we have no conflict of interest.
Author contributions
This paper is part of a PhD of the first author and supervised by
the other authors. All authors planned this study. The first author
performed the data collection, data analysis and prepared the
original manuscript. All authors contributed to drafts and
approved of the final manuscript.
Ethical statement
The research was conducted as approved by Auckland
University of Technology Ethics Committee (AUTEC), Auckland,
New Zealand (Ref 16/259 on 19 July 2016) and the Health Research
Ethics Committee (HREC), Faculty of Medicine, Padjadajaran
University, Bandung, West Java, Indonesia (No 953/UN6.C1.3.2/
KEPK/PN/2016 on 7 October 2016). Also, the approval letters from
the research settings were granted.
Funding
QESA was supported by the Indonesian Ministry of Research,
Technology and Higher Education doctoral scholarship under
contract 178.21/E4.4/2014 and the Indonesian Ministry of Finance
Endowment Fund for Education dissertation scholarship under
contract PRJ-4592/LPDP.2/2016. The funder of the study had no
role in the study design, data collection, analysis process, and
writing the manuscript. The corresponding author had full access
to all the data and had final responsibility for the decision to
submit for publication.
Acknowledgements
The authors acknowledge all the participants who kindly
volunteered their time to be part of this study.
The authors are sincerely thankful to the Indonesian Ministry of
Research, Technology and Higher Education and the Indonesian
94
Women and Birth 35 (2022) 87–95
Ministry of Finance Endowment Fund for Education for funding
this study.
Appendix A. Example of prompt questions for in-depth
interviews
Newly graduated midwives
 Please tell me about your experience while you were studying in midwifery
school, as a new graduate midwife, after your graduation?
 What is your experience of being prepared to be a midwife and what do you
think could be improved to make the new graduates feel even better
prepared?
 What would you identify as being the most important thing that you have
experienced whilst studying midwifery?
 Tell me about a time you cared for a women (pregnant woman, birthing, etc)
while you were in midwifery school which prepared you for your current
position.
 What things can you identify to improve the midwifery programme to help
students become more confident?
Midwifery students
 What were the key subjects of the education programme that you participated
in? Were there any major changes in the program while you were a student?
 What is your experience of being prepared to be a midwife?
 What would you identify as being the most important learning that you have
received during your midwifery studies?
 What would you identify as being important things to improve midwifery
education?
 If you were advising midwifery schools and governing bodies, what issues
would you identify to help improve the midwifery school and curriculum?
Midwifery lecturers/Obstetricians who teach/work in midwifery school
 Please tell me about your experience as an educator. How do you organise and
manage a successful course of study?
 What changes have you made over the time that you have been lecturing as a
midwifery educator?
 What do you enjoy about teaching midwifery students?
 Please tell me about a time or times when you might have felt that it was “too
hard” and what sustained you and helped you keep teaching during that time
 If you were advising on midwifery education, what would you identify to offer
as advice to midwifery schools?
Midwives
 If you were advising a midwifery school, what advice would you give on how
to strengthen midwifery education?
 What do you think could be done better in relation to midwifery education?
 What would you identify as being the most important thing to strengthen
midwifery education now and how can it work?
 If you were advising on a new model of midwifery education, what advice
would you give to your institution/organisation and government?
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