In this report describing the transition of the undergraduate teaching programme in obstetrics and gynaecology from the traditional hospital based interpersonal teaching methodology to a blended learning programme partly delivered online, we found high levels of satisfaction among the students and a strong interest in postgraduate specialisation. Reassuringly, there were no examination failures and no student undertaking the module was diagnosed with COVID-19.
The use of a blended learning programme (BLP), which combines face-to-face learning and e-learning has expanded rapidly, including prior to the COVID-19 pandemic and is commonly used in medical education for both undergraduate and postgraduate training.  Results from a meta-analysis found that blended learning appears to be more effective than or at least as effective as non-blended instruction for knowledge acquisition in health professions education.  Previous studies have examined the effectiveness of introducing blended learning for particular aspects of undergraduate and postgraduate obstetrics and gynaecology training demonstrating a positive effect [5–9], however there are no studies to our knowledge describing the transition of a full undergraduate module in obstetrics and gynaecology to a BLP.
There are a number of strengths of a blended learning programme. The increased learner and teacher flexibility is advantageous. To demonstrate the impact of this in our own programme; prior the pandemic, teaching faculty based at multiple hospitals delivered didactic synchronous lectures and students at other hospitals joined collectively through a videoconferencing system. There were approximately 15-18 hours of these per week. If a student missed the lecture, there was no way to review it. Whereas asynchronous online lectures allow students to review content in their own time and their own pace. Equally, for teaching faculty, many of whom have busy clinical roles, providing asynchronous lectures online means that they can use their limited time to facilitate interactive small group tutorials and they have greater flexibility within the schedule as they need to accommodate fewer students at a single hospital site.
The social cognitive and social constructive theory emphasise the importance of social interaction for stimulating effective learning. There is greater opportunity in a BLP for student-teacher interaction as students can come to class with background knowledge, leaving more time for problem based learning and for the implementation of a flipped classroom approach.  For the majority of our tutorial sessions, students were aware of what topics were going to be covered, and were advised at the beginning of the module that asynchronous lectures on tutorial topics should be reviewed prior to class time however we did not measure student engagement with this. There are concerns that by implementing a flipped classroom approach students will not complete the online material.[12, 13] Studies suggest that the effectiveness of a BLP depends on the learner characteristics and their ability to self-regulate their own learning. [14, 15] Implementing a flipped classroom or problem based learning approach also means teaching staff have to make adaptations to their teaching with their roles changing from giving information to facilitating and enabling students.  Teaching faculty involved in our BLP commented on increased interaction during class, getting to know the students better and increased enjoyment, however further research is needed to evaluate teacher satisfaction with the BLP.
Challenges and disadvantages also exist, some of which are temporary and many can be resolved with adequate resourcing. There is an increase in workload initially, associated with the transition phase, in order to develop and organise asynchronous online learning materials. There is also a greater technology hardware and skills requirement for staff and students requiring financial resourcing and training. Interestingly, our findings suggest that improved technological hardware seemed to improve student experience of joining tutorials virtually. The addition a webcam for Group 3 and 4, allowing students to see the classroom and teacher, appeared to result in fewer students feeling like they were missing out and may have improved the audio experience. (Table 5) Although the addition of the webcam was the only identifiable difference between the initial and final groups, it is possible that greater teacher comfort with the technology and new format could have improved student experience. Students require a suitable location to complete online learning. This was perhaps exacerbated by the closure of university study facilities and public libraries during the pandemic.
Online learners with a greater sense of community feel less isolated and have greater levels of satisfaction with their academic programmes.  Therefore it is important that opportunities for interaction are available for students undertaking asynchronous online learning. During our programme, students joined tutorials in hospital virtually, providing opportunity for interaction with teachers and students. This daily interaction with tutors and other students may have fostered a sense of belonging and connectedness.
Finally, clinical experience can be unpredictable and learning is often opportunistic. There is a risk that by students spending fewer days on the clinical site, they may not get the experiences that they require during the module. Therefore, it is our opinion that a BLP for clinical modules requires flexibility to increase specific clinical assignments if required.
Interestingly, 68.7% of students ‘agreed’ or ‘strongly agreed’ that they would like a blended learning programme in other modules. The implementation of a flipped classroom approach for gynaecology oncology topics within an obstetrics and gynaecology programme has been discussed. Student satisfaction with the approach was very high and students advocated for this method to be expanded to other parts of their curriculum.  The high level of interest in Obstetrics and Gynaecology as a future career amongst our students was particularly interesting and whether the high levels of satisfaction with the BLP could have contributed to this is a potential area for further study.