Online continuing education for midwives in China: current trends, barriers, and future directions

Abstract

Aim

This study investigated the state of online continuing education for midwives in China via a web-based questionnaire, identified current trends, explored potential barriers, predicted future research directions, and provided insights into improving the effectiveness and quality.

Background

The COVID-19 pandemic necessitated the shift from in-person to long-distance online education, significantly modifying continuing education for midwives. Online continuing education is crucial in improving midwifery skills and has been widely adopted in China.

Design

A cross-sectional design was used.

Methods

This study used a cross-sectional design with convenience sampling. Data were collected from midwives working in Level I to Level III hospitals across 31 provinces of mainland China through an online questionnaire platform called WenjuanXing from October 2021 to April 2022.

Results

A total of 12,122 midwives participated, of which 10,102 (83.34%) had previously attended online courses, primarily using DingTalk (52.79%), Tencent Meeting (48.75%), and WeChat (44.4%) for online learning. More than half of the participants had experienced blended learning (59.74%) rather than only online learning (31.54%). Most participants (10,541, 84.38%) had limited knowledge of online continuing education. Flexible scheduling (94.76%) was the top reason for participation, whereas clinical work pressure (85.9%) was the main barrier. 10,315 (85.09%) participants preferred more interactive online learning methods. Ordered logistic regression analysis revealed that geographic location, demographic factors, employment characteristics, and hospital attributes significantly influenced healthcare professionals' willingness to use online resources. Midwives in Central regions, unmarried, elderly, highly educated, non-formally employed, working in obstetrics wards, and lower-tier hospitals showed a higher inclination for online continuing education.

Conclusion

With rapid technological advancements, online continuing education offers a valuable way for clinical midwives to obtain up-to-date information and knowledge. However, it remains in the early stages and requires further development.

Background

Continuing education became available in China in the 1980s following a government policy and economic reform change. It is primarily used to train specialist technicians. The importance of continuing education is increasing as China undergoes development and modernization [1].

Over the past two decades, because the number of direct-entry midwifery programs has been limited in China, most midwives have graduated from secondary and diploma nursing programs. These programs provide little training in midwifery and as little as three months of clinical training in labor and birth [2]. Therefore, continuing education is essential to the development of the midwifery profession.

The International Confederation of Midwives (ICM) described a lifelong learning approach in its position statement: Basic and Ongoing Education for Midwives [3]. The ICM states that midwifery competence can be achieved through multiple formal educational pathways based on the ICM Global Standards for Midwifery Education [4], that all midwifery educators should be competent in theory and practice, and that learning is an ongoing process to ensure continuous professional development. The ICM further stressed that each midwife's ethical duty is to always remain safe and current in practice [5]. Therefore, continuing education should be compulsory for all practicing midwives.

As a result of the global outbreak of the COVID-19 pandemic, countries worldwide have carried out various restrictive measures to protect against the spread of COVID-19, which has affected millions of people worldwide in business, social life, education, the economy, tourism, and health care [6].

Although continuing in-person education was the most frequent and preferred format before and during the COVID-19 pandemic, midwives had to pivot from in-person continuing education to online courses.

In addition, online education plays a critical role in midwives'continuing education, particularly in addressing challenges related to accessibility and flexibility. For midwives in remote or underserved areas, online platforms provide a vital avenue to access high-quality training that may otherwise be unavailable due to geographic or resource limitations. For example, midwives in rural regions of China can participate in specialized courses offered by leading institutions without traveling, ensuring they stay updated with the latest practices and guidelines. Furthermore, the flexible scheduling of online education accommodates the demanding clinical responsibilities of midwives, allowing them to balance work and professional development. This is especially beneficial for those working irregular shifts or in high-pressure environments, as they can engage in learning at their own pace and convenience. By overcoming barriers of distance and time, online education empowers midwives to enhance their skills and knowledge, ultimately improving maternal and neonatal care outcomes.

During the COVID-19 pandemic, online course platforms and applications, including massive open online courses(MOOCs), Rain Classroom, WeChat, MOOCs, QQ, Tencent Meeting, and DingTalk, were further developed and implemented in distance teaching in China. Although these applications provide valuable outlets for continuing education, there are no uniform standards for online tools. Nevertheless, these platforms share common advantages in that they are designed to be accessed through computers or smartphones. Therefore, midwives can learn more conveniently, without time or space limitations. However, no relevant study has explored midwives'attitudes toward, and perceptions of, online education. Our study aimed to investigate the present situation of online continuing education for midwives working in hospitals in China to provide information for future research.

Methods

This nationwide cross-sectional study surveyed midwives from Level I to Level III hospitals across 31 provinces of mainland China using a web-based questionnaire. The questionnaire was developed regarding existing questionnaires and research literature to ensure it was grounded in established methodologies. Additionally, the content of the questionnaire was reviewed and tested by a panel of experts and professionals in the relevant field. Their feedback was incorporated to ensure that the questions were clear, relevant, and of sufficiently high quality to obtain the necessary information to answer the research questions. It aimed to gather in-depth insights into their online learning experiences, including barriers, motivations, preferences, and attitudes toward online continuing education. Multivariate ordinal logistic regression analysis was used to analyze the factors affecting willingness to use online midwifery education resources.

Participants

The inclusion criteria were midwives currently working in Level I to Level III hospitals in 31 provinces in mainland China. The top level of the hospital is Level III in China.

Variables

Participants'demographic data were collected, including age, working location, hospital type, number of years worked, and highest level of education. The web-based questionnaire included (1) the current situation of online continuing education(including Access to Online Education, Engagement with Online Resources, Quality and Sufficiency of Resources and Attitudes Toward Online Education), (2) the benefits of and barriers to online education from participants'perspectives, and (3) the requirements of online continuing education.

Data analysis

Descriptive analyses and multivariate ordinal logistic regression were conducted on the dataset obtained from the web-based questionnaire, using SPSS Statistics 20.0 for Windows (IBM Corp.) for the computational procedures.

Results

By April 2022, 12,122 midwives working in clinics were included in this study. Figure 1 shows a heatmap of the proportion of midwives taking web-based questionnaire in the 31 Chinese provinces.

Fig. 1

Heatmap of the proportion of midwives taking web-based questionnaire in different Chinese provincial administrations

Participant demographics

Among the 12,122 participants in this study, 12,109(99.89%) were female. 9,043 (74.6%) were between 16 and 40 years old, and 9,132 (about 75.3%) held bachelor's degrees. Regarding work experience, 5,971 (77.10%) had been employed in hospitals for over five years. Additionally, 9,186 (75.78%) worked in China's highest-level hospitals. The results are illustrated in Table 1.

Table 1 Participant demographics

Current status of online continuing education in China

Online training courses have widespread support in hospitals, with over 80% of the participants reporting availability. Significant engagement was noted, with 83.34% (10,102 out of 12,122 participants) who had attended online courses. A notable preference for blended learning was expressed by 59.74%, compared to 31.54% who favored purely online formats. However, there appeared to be a knowledge gap, with 55.4% (6,715 participants) needing a greater understanding of online continuing education.

Despite recognizing the indispensability of online education by over 60% of respondents, actual usage could have been more varied, with only one-third engaging occasionally. Most strongly preferred live-streaming (78.76%) over prerecorded courses (58.49%). Platforms such as DingTalk (52.79%), Tencent Meeting(48.75%), and WeChat (44.4%) were popular choices for facilitating learning.

While more than half (51.03%) found the volume of online resources adequate, there is a consensus on the need for quality improvement, underscoring a critical area for development in online continuing education which is shown in Table 2.

Table 2 Current situation of online continuing education

Benefits of and hindrances to online education from the participants' perspective

Participants highlighted several specific benefits of online continuing education, such as the flexibility to learn at their own pace (94.76%), increased opportunities for communication with peers and instructors (79.52%), and the ability to rewatch content to reinforce learning(79.5%). These advantages make online education particularly appealing for midwives with demanding schedules. However, they also identified significant dilemmas, including the pressure from clinical duties (85.9%), which often limits their ability to engage in training, a lack of motivation(63.29%) due to the impersonal nature of online learning, and the overwhelming selection of platforms (49.69%), which can lead to confusion and decision fatigue. These findings underscore the need to address these barriers to maximize the effectiveness of online continuing education for midwives. The results are illustrated in Table 3.

Table 3 Benefits of and hindrances to online education from the participants' perspective

Factors influencing midwives'willingness to use an online educational resource

The multivariate ordinal logistic regression analysis identified several key factors significantly influencing healthcare professionals'willingness to utilize an online midwifery educational resource platform. Geographic location plays a role, with midwives in Central regions showing a higher likelihood of using the platform than those in the East. Marital status also has an impact, as unmarried midwives demonstrated a greater inclination to use the platform than their married counterparts.

The study revealed that age and education level are essential determinants, with older midwives possessing higher educational qualifications exhibiting a stronger eagerness to engage with online resources. Employment formality and job title were also influential factors, as midwives in non-formal positions and those with lower job titles expressed a greater interest in utilizing the platform.

The analysis further indicates that the working department is a significant consideration, with midwives in obstetrics wards displaying a higher enthusiasm for the platform than those in other departments. Hospital type and ranking also emerged as critical factors, with midwives in general hospitals showing a greater interest in using the platform than those in specialized hospitals. Moreover, there is a more robust demand for the platform among midwives working in second-level and lower-tier hospitals than those working in top-tier institutions. The results are illustrated in Table 4.

Table 4 Results of the ordered logistic regression analysis

Discussion

This study provides a comprehensive overview of the current status of continuing online education for midwives in China and identifies the factors affecting their willingness to utilize online educational resources. The findings highlight the extensive availability of and support for online courses in hospitals, with a substantial proportion of midwives attending these courses. Nevertheless, the study also revealed a knowledge gap among midwives regarding online continuing education, emphasizing the need for further awareness and understanding of this learning modality.

The investigation showed a substantial degree of engagement in online training programs among midwives, with more than 80% indicating the presence of such courses in their healthcare facilities. This discovery is consistent with the increasing prevalence of online learning in healthcare education, a trend accelerated by the COVID-19 pandemic [7]. The widespread adoption of online education in Chinese hospitals demonstrates its potential to enhance the knowledge and skills of healthcare professionals. Although online courses have been widely used, the questionnaire revealed that many midwives need more expertise in online continuing education since more than half of the participants only had basic comprehension. This finding emphasizes the necessity for specific initiatives to increase awareness and enhance midwives'digital literacy [8]. Providing clear information about the benefits, formats, and platforms of online learning could help bridge this gap and encourage midwives to engage with digital learning resources.

Additionally, while most participants considered online resources adequate, the consensus on the necessity of quality improvement highlights a critical area for development in online continuing education. This finding is consistent with previous studies that emphasized the importance of quality assurance in online learning [9, 10]. The quality of online learning resources should be improved, and their relevance and efficacy in satisfying midwives'learning requirements should be guaranteed.

The study also revealed a strong preference for blended learning among midwives, with nearly 60% favoring a combination of online and conventional learning methods. This finding is consistent with previous research highlighting the effectiveness of blended learning in healthcare education [11]. Many authors have acknowledged the superiority of blended learning over traditional face-to-face courses [9]. Blended learning combines advantages such as flexibility and accessibility with the benefits of in-person engagement and practical skills training. The high demand for blended learning among midwives suggests that future educational initiatives should integrate online and offline components to optimize learning outcomes. In addition, Mitchell et al.'s study revealed that blended learning was perceived as more satisfying than only online learning [10]. More research is needed to compare the three different types of education and determine how to optimize blended learning through improved technological tools and pedagogies.

Various online applications are currently being used as educational platforms. In our study, participants mainly used DingTalk (52.79%), Tencent Meeting (48.75%), and WeChat (44.4%) for online continuing education courses. These platforms facilitate remote work and online learning, enabling educational institutions to transition to in-person classes online during lockdowns and social distancing measures. For instance, video conferencing software such as DingTalk and Tencent Meeting have allowed Chinese universities to move traditional in-person courses online. In Western countries, Zoom and Microsoft Teams are the most commonly used video conferencing technologies (VCTs) [12]. Zoom has emerged as one of the most widely used video conferencing tools in online education after the COVID- 19 pandemic outbreak. Zoom is utilized for online learning by universities in developed countries, including the United Kingdom, the United States of America, and Australia [13]. Consequently, universities in various countries are inclined to implement VCTs that are already in use in their respective countries.

Currently, the most widely preferred types of online continuing education are live-streaming (78.76%) and prerecorded classes (58.49%). Perceptions of teaching and learning in synchronous and asynchronous online environments in the United States showed that they appreciated the flexibility and inclusivity of online synchronous engagement, which allows interactive discussions with diverse student populations [14]. Yao et al. [15] compared the impact of synchronous and asynchronous course models on student learning at a Chinese middle school and discovered that students performed better in synchronous lessons.

This study examined the perceptions of midwives working in hospitals regarding the advantages and challenges of online education. Our results suggest that most respondents (94.76%) identified schedule flexibility as the most significant advantage of online learning. A similar study from China found that this flexibility was also a primary motivator for clinical midwives engaging in online continuing education [16]. Additionally, 79.5% of the respondents noted improved peer communication and replay capabilities as secondary and tertiary benefits, respectively. Şenay Topuz's SWOT analysis corroborates this, citing replay functionality, enhanced efficiency, time savings, accessibility, comfort, and uninterrupted education as key factors contributing to their satisfaction with online learning. Among these, “replay functionality”, “increased efficiency”, and “time savings” were the most frequently highlighted [17]. Mpungose further identified the advantages of using VCTs for educational purposes, including spontaneous communication (via videos, animations, audio, and graphics), overcoming temporal, spatial, and financial constraints, accommodating diverse learning styles, providing authentic educational experiences, and immediate feedback opportunities [18].

Conversely, the primary barriers identified in this study included clinical work pressure (85.9%), low motivation (63.29%), and a lack of appropriate resources and online learning platforms (49.69%). Other researchers have revealed limitations associated with the utilization of VCTs in online education, such as digital fatigue, difficulties in maintaining teacher-student engagement, inadequate online teaching strategies leading to disorganization, problems with audio, video, and Internet connectivity, and the monotony of lengthy lectures and fixed camera perspectives [19, 20]. A recent review highlighted obstacles to the implementation of online learning, including insufficient preparation, inadequate resources, usability challenges, and limited teacher-student engagement [21]. Şenay Topuz's SWOT study also identified barriers specific to online education, including the unavailability of practical courses, technological deficiencies, inefficiencies, inadequate interaction, difficulties in course follow-up, environmental effects, and superficial lectures [17], differing from our findings. The differences in our findings may be attributed to disparities in participant demographics, as our study concentrated on midwives employed in hospital settings, whereas their study focused on midwifery students. A Turkish study also discovered significant challenges in online education during COVID-19, including a deficiency of technology resources (47%), Internet problems (46%), insufficient learning opportunities (36%), and inadequate resources for online education (20%) and interaction (16%) [22], which is consistent with the results of our study.

Furthermore, multivariate ordinal logistic regression analysis revealed several key factors influencing midwives'willingness to use online resources in continuing education, including geographic location, marital status, age, education level, employment formality, position title, working department, hospital type, and ranking. Geographic location emerged as a significant factor, with midwives in Central China showing a greater propensity to use online platforms than those in East China. This discrepancy may result from the uneven distribution of educational resources across regions. Specifically, East China benefits from more developed infrastructure, greater access to traditional in-person training opportunities, and a higher concentration of training institutions, whereas Central China faces relative resource limitations. As a result, midwives in Central China may rely more on online education to compensate for fewer in-person training opportunities, while those in East China may have less incentive to engage with online platforms due to the availability of alternative resources. This regional disparity highlights the importance of considering geographic context when designing and implementing online continuing education programs for midwives in China [23]. Marital status also played a role, as single midwives showed greater willingness, possibly due to their more flexible schedules and fewer family responsibilities, allowing more time for professional development. Age and education level were similarly important; older midwives with higher educational qualifications expressed more interest in online education. This challenges the preconception that older professionals are less inclined toward continuing education, suggesting they may have a greater appreciation for professional development [24]. Employment formality and position title also influenced attitudes, with non-formal midwives and those in lower position titles showing greater interest in online continuing education, likely due to their limited access to traditional training, challenges in obtaining funding, and time off for professional development. The working department played a crucial role, particularly the midwives in obstetric wards, who showed higher enthusiasm. This might be attributed to the specialized character and rapid advancements in obstetric care, which require continuous knowledge and skill updates. Hospital type and ranking also affected attitudes towards online continuing education; midwives in general hospitals and lower-tier institutions showed greater interest in online education than those in specialized hospitals and top-tier institutions, likely due to limited resources and training opportunities in the former institutions. These findings indicate that online learning initiatives should be customized according to different midwives'specific needs and preferences. For example, providing additional support and resources to midwives in lower-tier hospitals and those with lower educational qualifications could help overcome the barriers they face in accessing and engaging in online education.

These findings are essential for developing and implementing online midwifery educational resources in China. The requirements that have been identified can provide valuable insights for developing specific strategies to encourage participation and optimal utilization of digital learning among various subgroups of healthcare professionals. Policymakers and healthcare institutions might provide additional support and incentives for married midwives, younger midwives, and those with lower educational qualifications while developing customized content and delivery methods for specific needs across regions, departments, and hospital settings. Further research should explore the barriers and facilitators of online learning adoption among healthcare professionals in China through qualitative studies involving in-depth interviews and focus group discussions. This study has the potential to provide valuable insights for designing online learning systems that prioritize the needs of midwives and are based on solid data, resulting in improved effectiveness and midwives' acceptance.

Limitations

Our study also has several limitations. Firstly, we used convenience sampling in our study which may still not fully represent the entire population, suggesting future research could benefit from more rigorous sampling methods, such as stratified sampling, to enhance representativeness. Secondly, data collection during the COVID-19 pandemic (October 2021 to April 2022) might reflect unique circumstances that may not be generalizable to normal periods. Thirdly, our reliance on self-reported data through web-based questionnaires may introduce response bias, as midwives with greater digital literacy might have been more likely to participate. Finally, regional disparities in internet access across China's diverse geographical areas may have affected participation rates, potentially underrepresenting midwives from remote or less technologically developed regions.

Conclusion

The COVID-19 pandemic has accelerated the adoption of online continuing education for midwives in China, with platforms like WeChat, Tencent Meeting, and DingTalk being widely used. However, many midwives lack sufficient knowledge of online education. While flexible scheduling is a key motivator, clinical work pressure remains a major barrier. Midwives prefer interactive learning experiences, and factors like geographic location, demographics, employment characteristics, and hospital attributes significantly influence their willingness to engage with online resources. To enhance the effectiveness of online education, it is essential to address barriers, incorporate interactivity, and tailor strategies to regional and institutional differences. Future research should focus on developing and evaluating interactive, region-specific online learning solutions.