Introduction
Midwifery education equips student midwives with the skills required to provide competent maternal and neonatal care. This will ensure that student midwives are competent and confident at the point of registration with the regulatory body as midwives. Symphysis-fundal height (SFH) measurement is a key antenatal competency used to monitor foetal growth (Department of Health 2017). Despite being a routine procedure required at each antenatal visit in South Africa, incomplete or inconsistent SFH recordings have been observed in maternity case records (Dlamini 2023). This gap highlighted the need to investigate the factors influencing student midwives’ competence and confidence in SFH measurement, plotting and interpretation. Consistent and accurate measurement of SFH at every antenatal visit results in early identification of risks such as intrauterine growth restriction (IUGR). If the students understand the significance of mastering SFH measurement skill, the gap identified will be bridged so that in future all SFH graphs in the maternity case records are plotted, interpreted and plan of management recorded and implemented. This will contribute to positive maternal and neonatal health outcomes. Strengthening the clinical learning environment is essential to complement existing teaching strategies and ensure consistent, high-quality preparation of midwives.
Clinical learning is a cornerstone of midwifery education, integrating theoretical knowledge with practical experience to develop professional competence. A supportive clinical environment fosters students’ confidence and skill development, preparing them for safe and accountable practice (Immonen et al. 2019). Confidence is essential in midwifery, where practitioners must make autonomous, evidence-based decisions during the antepartum, intrapartum and postpartum periods.
Studies have shown that students’ confidence and competence are influenced by effective supervision, mentoring and constructive feedback (Bäck & Karlström 2020; Sharma et al. 2018). A lack of confidence may also be associated with reduced skill performance (Bäck & Karlström 2020). Sharma et al. (2018) identified several factors influencing confidence, including student–teacher relationships, positive feedback, mentoring and student support. Their findings further indicated that most midwifery competencies and components of midwifery practice are regarded as essential. The International Confederation of Midwives (ICM 2021), in collaboration with the World Health Organization (WHO 2018), outlines four main domains of midwifery practice: antepartum, intrapartum, postpartum and newborn care. In this study, the researcher focuses specifically on the antepartum domain.
It has also been found that inconsistent support, resource constraints and negative staff attitudes can hinder clinical learning (Gemuhay et al. 2019; Mbakaya et al. 2020). Although several studies have examined students’ clinical competence, few have focused on specific technical skills, such as measuring SFH (Lawes & Jones 2020). Symphysis-fundal height measurement refers to the distance (in centimetres) between the top of the pubic bone (symphysis pubis) and the top of the uterus (fundus). It is measured using a non-elastic measuring tape placed along the pregnant woman’s abdomen. From about 20 weeks to 36 weeks of gestation, the SFH (in cm) roughly corresponds to the number of weeks of pregnancy (Papa 2022). The SFH measurement is important because it provides a simple, effective and non-invasive way to monitor the health and development of both the mother and the foetus during pregnancy. A smaller-than-expected measurement may suggest IUGR, while a larger measurement may indicate macrosomia (a large baby) or excess amniotic fluid. Helping detect abnormalities early, SFH measurement supports safe pregnancy monitoring and contributes to reducing maternal and neonatal morbidity and mortality (Pay et al. 2015). In low- and middle-income countries, SFH is often the primary or only available tool to estimate gestational age, making proficiency in this skill particularly critical (Mbakaya et al. 2020). In South Africa, government guidelines require SFH measurements at every antenatal visit to ensure proper foetal monitoring (Dlamini 2023).
Clinical competence and confidence are critical components of midwifery education, as they determine a student midwife’s ability to provide safe and effective maternal and neonatal care. Clinical learning, which combines theoretical knowledge with practical experience, plays a central role in developing essential professional skills (Immonen et al. 2019). A supportive clinical environment, along with mentoring and supervision, significantly enhances students’ confidence and competence (Immonen et al. 2019). Conversely, factors such as lack of support, poor supervision and negative attitudes from clinical staff may adversely affect skill acquisition and performance (Bäck & Karlström 2020; Sharma et al. 2018).
Several studies have examined midwifery students’ confidence across the four core domains of practice: antepartum, intrapartum, postpartum and newborn care. Research indicates that diploma students often report higher confidence levels compared to bachelor’s students, despite both groups having limited clinical exposure (Sharma et al. 2018). Key factors influencing confidence include supervision quality, relationships with midwives, positive feedback, mentoring and supportive student–teacher interactions (Almarwani & Alzahrani 2023; Bäck & Karlström 2020; Sharma et al. 2018). These findings highlight the importance of clinical support and structured learning experiences in developing self-confidence and professional competence.
Teaching methods also influence students’ confidence in performing clinical skills. Studies have shown that classroom teaching, laboratory demonstrations, supervised clinical practice and innovative approaches such as video podcasts can enhance skill acquisition and self-confidence (Sharma et al. 2018; Stone, Cooke & Mitchell 2020). Students reported high confidence in laboratory-based skills and supervised clinical placements, and preferred combining face-to-face teaching with other instructional methods to deepen understanding.
Although previous research has explored general clinical competence and confidence, few studies have focused on specific antenatal skills such as the SFH measurement. Competence in SFH measurement is essential for monitoring foetal growth, estimating gestational age and detecting potential complications during pregnancy (Department of Health 2017; Mongelli 2018; Whelan et al. 2022).
Competence in clinical practice is influenced by multiple factors, including effective supervision, structured orientation, access to resources, professional support and prior experience (Gemuhay et al. 2019; Hailu et al. 2021). Studies in Ethiopia and Tanzania have shown that students who receive orientation, staff encouragement and preceptor support demonstrate higher clinical competence and confidence, whereas those experiencing poor supervision, limited resources or absenteeism show lower performance (Gemuhay et al. 2019; Hailu et al. 2021). These findings underscore the importance of both environmental and instructional factors in shaping students’ ability to perform essential midwifery skills such as SFH measurement.
According to the South African Nursing Act No. 33 of 2005, a midwife must meet prescribed educational requirements, maintain competence and be registered to practice professionally. Midwives are expected to take full responsibility for maternal and neonatal health, providing care during antepartum, intrapartum periods and postpartum periods while practising ethically and within legal parameters as guided by the scope of practice, Regulation 2127 (Nursing Act 2005). The ICM similarly emphasises that midwives must acquire knowledge, skills and professional behaviours during training, including competencies in antenatal assessment, foetal monitoring and maternal care (ICM 2018).
Research aim
To investigate factors influencing student midwives’ competence and confidence in the measurement, plotting and interpretation of SFH in KwaZulu-Natal of Nursing and selected public hospitals in KwaZulu-Natal.
This research forms part of a larger mixed-methods study aimed at developing guidelines for SFH measurement for student midwives. A scoping review of the literature was conducted to map the evidence on methods used in Africa for estimating gestational age during pregnancy.
Research methods and design
Research paradigm and design
This study was guided by pragmatism. Pragmatism is defined by Creswell and Creswell (2018) and Terre Blanche et al. (2018) as a worldview encompassing a set of philosophical assumptions that inform and guide one’s approach to inquiry. This study adopted a mixed methods design to gain an in-depth understanding of student midwives’ competence and confidence in measuring, plotting and interpreting SFH. Pragmatism allows the study to commence with a quantitative phase to generalise findings, followed by a qualitative phase to explore deeper insights (Creswell & Creswell 2018).
Study design
The study adopted a quantitative approach, employing a descriptive cross-sectional design to investigate the factors influencing student midwives’ competence and confidence in SFH measurement, plotting and interpretation. Data were collected using Online Appendix 1 comprising closed-ended questions. Some items were adapted from previously developed instruments, including the National Competence Questionnaire (National League for Nurses 2006) and the study by Foolchand and Maritz (2020).
Study setting
The study was conducted at five selected campuses of the KwaZulu-Natal College of Nursing (KZNCN) in KwaZulu-Natal province, South Africa. KwaZulu-Natal College of Nursing is a public nursing college accredited by the South African Nursing Council (SANC) and the Council on Higher Education (CHE), and it is registered with the South African Qualifications Authority (SAQA). The college has eleven campuses offering a range of nursing programmes. During the data collection period, the undergraduate programmes available included a four-year Diploma in Nursing (General, Psychiatric and Community) and Midwifery (SANC Regulation R425) and a three-year Diploma in Nursing (SANC Regulation R171). R171 does not include Midwifery. The five campuses that had midwifery students at the time of data collection were included in the study.
The study was also conducted in seven public hospitals across the five health districts in the province where the community service nurses included in the study were employed. Data were collected towards the end of the semester, from May 2023 to July 2023, after student midwives had completed all their theoretical modules and their comprehensive clinical examinations. At this point, the community service nurses were approximately six months post-completion. Although they are not student midwives anymore, they could provide data about their experience as student midwives. These hospitals were selected based on accessibility and cost-effectiveness. Some of the hospitals where community service nurses were allocated also served as the parent hospitals of the campuses that had students during the data collection period. A parent hospital is a hospital that provides a mandatory clinical training to affiliated nursing education institutions.
Population
The target population comprised all student midwives enrolled in the undergraduate R425 programme who had passed the comprehensive midwifery clinical examination. In addition, community service nurses allocated to the selected public health facilities were included. Community service nurses with less than six months of experience were eligible because their level of practice was comparable to that of student midwives who had recently passed the midwifery clinical examination.
Sample and sample size
An estimated 250 potential participants, comprising current student midwives and community service nurses, were eligible for inclusion in the study as they had already passed the clinical examination. A non-probability convenience sampling technique was employed, as participants were selected based on their availability and willingness to participate. In total, 184 participants (81 students and 103 community service nurses) provided informed consent to take part in the study.
Data collection
After obtaining ethical clearance and institutional approval, arrangements were made with campus principals and nursing service managers to schedule suitable data-collection dates. Data were collected between May 2023 and July 2023 using a self-administered questionnaire. Participants completed the questionnaire in a quiet environment during their free time, such as during tea and lunch breaks. An information sheet was provided to ensure participants understood the study’s purpose and procedures. Those who agreed to participate in the study signed informed consent forms before data collection.
The researcher personally distributed the questionnaires and remained available throughout the process to address any questions and ensure a high response rate. Confidentiality and anonymity were maintained at all times. Completed questionnaires were securely stored under lock and key to protect participants’ information.
Data analysis
The questionnaires were numbered and coded prior to data entry. Information was captured in an Excel spreadsheet and checked for accuracy before analysis. Demographic variables were verified, and missing data were identified and recorded. Data analysis was conducted using IBM SPSS Statistics (version 28) with assistance from a statistician. Simple descriptive univariate analysis was performed to analyse the data, and results were presented as frequencies and percentages for each variable. No statistical tests were performed because the aim was not to determine the relationship between the variables.
Rigour
To assess the questionnaire’s reliability, Cronbach’s alpha was used to evaluate its internal consistency. The Cronbach’s alpha coefficient for the total scale was 0.94, indicating excellent reliability. Values range from zero to one, with higher values (generally above 0.7) considered acceptable (Creswell & Creswell 2018).
To establish validity of the questionnaire, the researcher sought the opinions of educational experts, the research supervisor and a statistician. In addition, an extensive review of the literature on competence and self-confidence in midwifery skills was undertaken to ensure that the instrument adequately measured the intended constructs.
Ethical considerations
Ethical clearance was granted by the University of KwaZulu-Natal (UKZN) Biomedical Research Ethics Committee (BREC/00004960/2022) and the Provincial Department of Health (DOH) Ethics Committee (KZ_202302_027). After obtaining the ethical clearance, gatekeeper permission was also obtained from KwaZulu-Natal College of Nursing (KZNCN) and the Director, Nursing Services. Information sheets were provided to participants to ensure they understood the research process and the research ethics principles. Participants provided written informed consent before completing the questionnaire. Confidentiality was maintained during data collection, analysis and reporting of the findings.
Discussion
Demographic data: Section A of the questionnaire
Demographic data were collected to determine the frequency distribution and percentages of the participants’ characteristics. The sample included a higher proportion of black participants compared to other racial groups, reflecting the racial distribution in the province of KwaZulu-Natal. The age of participants aligns with the South African Government bursary guidelines and learnership requirements. Females predominated in the sample, consistent with nursing being a female-dominated profession.
Summary of the findings: Section B of the questionnaire
Midwifery education involves comprehensive clinical training, which is essential for developing student midwives’ competence and confidence. This study aimed to investigate factors influencing student midwives’ competence and confidence in measuring SFH.
In this study (Phase 2, Stage 1 of the main study), Online Appendix 3 summarised the findings related to students’ learning experiences, exposure to SFH measurement and plotting, unit organisation, lecturers’ roles and confidence levels. The factors influencing competence and confidence are discussed in detail to address the research objectives. These findings will also inform the qualitative questions in Phase 2, Stage 2 of the main study.
Simulations were particularly valued by student midwives for reinforcing learning and providing practical experience. This aligns with Vermeulen et al., 2017, cited in Folkvord and Risa (2023), who reported that simulation training can increase students’ preparedness for clinical placements, reduce anxiety and promote self-efficacy.
Lecturers were able to align learning objectives with simulation content, consistent with South African Nursing Council (SANC) requirements. Midwifery students are required to complete stipulated clinical hours and achieve specific learning objectives during placements (Nursing Act 2005).
Participants generally felt that the orientation provided by the operational manager was good, although some expressed dissatisfaction with the clarity of clinical objectives. Responses were mixed regarding the presence of preceptors and the influence of standard operating procedures on learning. Most respondents indicated that clinical teaching and unit organisation were beneficial, with approximately 130 participants reporting that lecturers frequently accompanied students, as required by the SANC.
Student midwives reported positive perceptions of lecturers’ roles in setting expectations, aligning learning objectives and facilitating simulations. However, there was slightly lower satisfaction regarding the frequency of lecturers’ direct involvement in clinical work, suggesting room for improvement. This is consistent with Bäck and Karlström (2020), who emphasised that student supervision is crucial, noting that stress and disengagement from supervisors can decrease confidence. Similarly, Suliman et al. (2023) highlighted that a good supervisory relationship positively influences learning.
The findings also revealed that student midwives felt more confident in certain skills, such as plotting SFH, and less confident in others, such as interpreting SFH and making nursing diagnoses. This concurs with the study by Tallam, Kaura and Mash (2021), who found that midwives were less confident in certain antenatal skills.
Factors affecting student midwives’ competence in symphysis-fundal height measurement
To address the research objective of this study, the following factors were identified as influencing the competence of student midwives in clinical practice: communication, feedback, student-preceptor relationships, role modelling and the learning environment.
Regular communication
Ninety-three students agreed that clinical lecturers communicated regularly with them; however, 21 disagreed, and 47 were not sure. These findings suggest that communication was effective for most students but not consistent across all clinical facilities.
Good communication skills are essential for all healthcare workers. In nursing, communication underpins the nurse–patient relationship it can positively influence health outcome (Ottonello et al. 2023). Effective communication among team members can also affect interpersonal relationship (Norman 2024). This aligns with Afriyie (2020), who defined effective communication as mutual understanding between healthcare providers and patients, promoting satisfaction for both parties. In this study this refers to communication between the lecturers and students. Grant et al. (2024) further emphasised that effective communication supports high-quality physical and holistic care. Hence, effective communication could promote high quality midwifery care by the students. Nevertheless, communication can be hindered by various barriers within clinical settings.
Constructive feedback
Lecturers’ constructive feedback was perceived positively. Ninety students agreed, and 50 strongly agreed that they received constructive feedback. Feedback enabled students to identify areas for improvement and develop their skills. Folkvord and Risa (2023) highlighted that lecturers can support preceptors in providing effective feedback. Noble et al. (2020) noted that feedback is often given sporadically, which may affect students’ learning experiences. Constructive feedback also enhances self-esteem and confidence. Therefore, Folkvord and Risa (2023) recommended that preceptors utilise feedback skills consistently to maximise learning opportunities. In addition, constructive feedback promotes professional development and enhances quality patient care (Butler 2024)
Student–preceptor relationships
Nearly two-thirds of students perceived their relationship with preceptors as positive; however, 84 students felt less supported. A strong student–preceptor relationship fosters a sense of belonging within the clinical team (Folkvord & Risa 2023). Preceptors can encourage students while maintaining their supervisory role. Dewar et al. (2020) reported that successful preceptor–student relationships contribute to a productive learning environment. Neiterman et al. (2022) confirmed that positive student–preceptor relationship boosted students’ confidence in clinical learning.
However, in this study some students felt preceptor support was variable. This indicates that while preceptorship was strong in many cases, there were inconsistencies across different units.
Role modelling
Clinical midwives were generally perceived as good role models, with 97 students agreeing, and only 10.8% disagreeing. Effective role models should demonstrate competence in both cognitive and psychomotor skills. Mellish, Oosthuizen and Paton (2010) emphasised that clinical staff, unit managers and lecturers are expected to be good role models, foster team collaboration and demonstrate professionalism. This concurs with (Kurt, Turhal & Batmaz 2024) who reported that students took lecturers and clinical nurses as their role models.
Conflict among senior midwives was identified as a challenge affecting supervision (Folkvord & Risa 2023). Conversely, positive attitudes among midwives enhance student learning (Panda et al. 2021). Regular supervision by clinical instructors (clinical lecturers) supports positive learning experiences, although some students reported a lack of confidence among clinical instructors. Addressing these challenges could strengthen students’ confidence and ensure more equitable learning experiences across clinical settings.
Learning environment
Lecturers maintained a generally positive learning environment, with 141 students reporting that it was conducive to learning. Bäck and Karlström (2020) noted that a conducive environment is essential for learning, regardless of activity. Both human and material resources contributed to the positive learning environment, enabling students to acquire clinical competence through effective teaching and simulations. In addition, workplace environment and clinical training can affect clinical competence (Almarwani & Alzahrani 2023). However, barriers existed, such as unclear display of clinical objectives in units.
Suliman et al. (2023) found that undergraduate students achieved the highest competence in value-based nursing care, while competence in leadership, and organisation of nursing was lower. This aligns with the current study’s findings, suggesting that a conducive learning environment supports the development of competence in key midwifery skills, particularly SFH measurement which is an outcome-based nursing care. According to Zhu, Jiao and Chen (2025), the nursing students’ caring behaviours and psychological resilience are promoted by the positive clinical environmental factors. This necessitate the creation of a good clinical learning environment (Zhu et al. 2025). In support of Zhu et al. (2025), improved clinical learning experiences and effective role modelling may advance the students’ caring behaviours (Inocian et al. 2022)
Limitations
This study was conducted at the specific hospitals and specific nursing education institutions in one province; therefore, the results cannot be generalised to other provinces. A quantitative design was adopted, providing only subjective findings from participants. The study focused on factors affecting student midwives’ competence in SFH measurement, plotting and interpretation. Data were collected using questionnaires (subjective method), and no objective competence assessment was conducted due to the geographic location of the research sites and time constraints. Future research is recommended to adopt objective methods to assess competence in SFH measurement skill.