gms | German Medical Science

The specialist literature presents a plethora of arguments demonstrating the need for a change in the structure of training in the healthcare professions, implicitly also in midwifery. Higher education in this sphere is also a frequent topic of discussion. In his study, Kälble emphasizes that the healthcare professions are in a constant state of flux. The increasing quality demands on individuals in terms of fulfilling their professional duties and the need for evidence-based practice make high-quality, competency-based training a prerequisite in this field. In this context, reference is frequently made to the notions of higher education, skills development, and professionalization ([8] p. 15 ff).

In 2010, the German government adopted what was referred to as the “model clause” (Modellklausel) in the law on midwifery (Hebammengesetz), the objective of which was to further develop the midwifery profession. As a result of this clause, in accordance with para. 6 (3) of the law on midwifery, each German federal state could deviate from this provision and offer midwifery training at an institute of higher education [2]. Since the clause was adopted, it has been implemented through several model study programs which are being simultaneously evaluated.

Based on the findings of the evaluations of these model study programs, in 2016, the lower house of German parliament (Bundestag) reached the conclusion that midwifery training should be conducted exclusively in the form of an academic bachelor program and this transition should be completed by 2020. The aim of the change is to align professional qualifications across Europe and thus to ensure the recognition of the German midwifery qualification in other European countries [5]. By adopting this legislative change, the German parliament is complying with the demands of the German Association of Midwives (Deutscher Hebammenverband), which has been calling for midwifery training to take place exclusively at the higher education level since the 1990s [5]. The German Council of Science and Humanities (deutsche Wissenschaftsrat), an advisory body to the German government, also supports the move to train midwives through a higher education study program with the objective of introducing a bachelor of sciences in midwifery as the qualification required to enable students to practice as midwives [13]. Internationally, the step of providing midwifery training at higher education level was taken considerably earlier than in Germany ([9] p. 31). It is not possible to identify uniform approaches to implementation, however, due to the specific historical circumstances in the different countries ([9] p. 28). In Austria, for example, it takes six semesters to complete a bachelor degree, whereas in the Netherlands, eight semesters are required to obtain the same qualification [1].

However, there are presently only a very small number of university graduates already practicing midwifery and the specific legal and political foundations required to implement midwifery training at higher education level are not yet in place. Consequently, to date, there are very few research studies and reports based on actual experience examining the specific demand for a degree in midwifery as well as the potential areas of practice, and, derived from this, the relevant competency targets for such a course of study.

As part of a study conducted within the framework of the Future Education in Midwifery (FEM) research project, funded by the German Federal Ministry of Education and Research (BMBF), expert interviews were carried out with the objective of contributing to the debate on the benefits of an academic study program for midwifery and of acting as a basis for competency profiles. The aim is to develop a cooperative degree in applied midwifery sciences combining on-the-job training and academic studies at Baden-Wuerttemberg Cooperative State University (Duale Hochschule Baden-Württemberg, DHBW) in Stuttgart.

As a frame of reference for establishing competency targets, this study uses the competency profile for midwives developed by the educational advisory council of the German Association of Midwives. As well as the actual competencies required to practice midwifery, this profile also comprises the corresponding performance criteria to indicate the level of competency achievement [3]. The profile is expanded to include the CanMEDS model [6] from which we can derive seven roles that draw on specific areas of competency relevant to the midwifery profession: Collaborator, Leader, Scholar, Communicator, Medical Expert, Professional, and Health Advocate.

The findings and demands of the experts interviewed were taken into account when developing the module handbook for the collaborative program of study in applied midwifery sciences at the DHBW.

To analyze the need for and requirements of academically trained midwives from different practice perspectives, our research sought to address the following questions: “What is the demand for and requirements of academically trained midwives?”, “What are the benefits of higher education for midwives?”, “What competencies should be covered by a degree in midwifery sciences?”.

To fulfil its main purpose, the present study uses an exploratory, findings-oriented research design. To capture as many facets of this new research field as possible, a qualitative analytical approach was selected ([7] p. 69). The qualitative interview format with open-ended questions was chosen to allow respondents to speak candidly and to ensure that the study remained open to unanticipated information ([10] p. 320). The interviews were based on a guideline to help steer the discussion and increase the comparability of the data captured ([11] p. 36).

As part of the FEM project, expert interviews were held with various practitioners, scientists, academics, trainers, and educators during the period between November 2015 and January 2016. The respondents were specifically selected based on their expert knowledge. Our objective here was to cover all professional categories in the field of midwifery to achieve the broadest range of responses. These included: midwifery trainers, students of midwifery, a head midwife, a practice manager, three individuals from related healthcare professions (pediatrics, gynecology), freelance midwives, professors and/or tutors from other universities, and academics. The aim of selecting this range of respondents was to ensure that we captured the existing heterogeneity of views and attitudes of all individuals potentially interested in a course of study in midwifery.

The age range of the respondents was 21 to 70, though age-specific differences in attitude were taken into account. Just as with age, the range of interviewees’ professional experience also varied (from 0 to 40 years). Interviews lasted from 12 to 42 minutes. All respondents were initially contacted directly, either via email or telephone. A total of 15 interviews were conducted, all of which were tape recorded. Prior to the interview, participants were asked to sign a data protection declaration and a form consenting to the electronic recording of their interview.

Both the expert insight and the sociological basis of Meuser and Nagel’s methodology for the implementation and evaluation of expert interviews provided a useful starting point for this study. By using open-ended interview questions and a set of guidelines we were able to access complex spheres of knowledge, which were then processed using a systematic analysis procedure. This procedure is divided into six steps: transcription, paraphrasing, coding, thematic comparison, sociological conceptualization, and theoretical generalization [12].

First the recordings were transcribed without the use of a time-consuming notation system. In a second step, the text was sequenced by thematic unit using paraphrasing in such a way that, as far as possible, the structure of the interview remained intact. In a third step, these sequences were organized by theme and given headings and/or codes. The objective was to identify interview passages on the same theme, which, at the same time, enabled us to determine differences and contradictions. In the sociological conceptualization step, statements were generalized and interpreted. The theoretical generalization step was not conducted. This is permissible because the aim of the study is to acquire contextual knowledge, i.e., the focus is on gaining an insight into the general situation and not on verifying theoretical assertions ([12] p. 466 ff).

From the research questions outlined above, we can derive the following three categories: requirements, benefits, and competencies. Our research and development related questions were examined within the framework of these three parent categories.

Respondents were asked which areas should be covered or addressed in more depth by an academic degree in midwifery – on the assumption that these areas had not been accorded sufficient importance in midwifery training to date. The following areas were referred to: practical activities in general and scientific techniques such as independent and evidence-based working, issues around freelancing/self-employment, interdisciplinary expertise, and the possibility of acquiring international experience. Interviewees also stated that the fields of physiology and psychology should be covered in more detail, as should prenatal care, the role of the health advocate, teacher training, the promotion of involvement in political issues pertinent to midwifery, and homeopathy (see Figure 1 [Fig. 1]).

The aforementioned evidence-based way of working was most frequently referred to in the expert interviews. According to respondents, there is a fundamental need for research and more studies on current research topics should be conducted. These act as a catalyst for animated debate between midwives on certain practices and can be used as a scientific basis for methods and their implementation.

In response to the question as to which areas of practice should be covered in more detail by midwifery training, almost all respondents referred, first and foremost, to the postpartum period as well as how to conduct Leopold’s Maneuvers. The subject of women’s health was also peripherally broached.

Another important point referred to by several respondents relates to the freelance/self-employed status of midwives in Germany. It was noted that this point was barely touched on during midwifery training even though many graduates envisaged becoming freelancers. There is a need to cover the legal and economic issues pertinent to self-employment and freelancing.

In terms of the academic degree, working independently was mentioned and, in this context, particularly how to search for suitable literature.

In the experts’ responses, the notion of “health advocate” pertains to the management and care of mothers-to-be and their expectations of midwives. This point is discussed in more detail in the section on “competency profiles.”

On the subject of the interdisciplinary areas that should also be covered by a degree in midwifery, the following aspects were mentioned: first, a better knowledge of chemistry is required to give future midwives an idea as to the exact effects certain medication can have on the women who take it. Here, teaching should be specific to midwifery. Respondents viewed networking with other disciplines and professions as equally important, e.g., psychology, physiotherapy, and health and pediatric care. Here, professional exchange is called for, not necessarily a separate course subject.

Some respondents believed that students should obtain qualifications as mentors or practice managers already as part of their academic degree so that university graduates can automatically transfer their experience to successive students.

The aforementioned aspect of involvement in political issues pertinent to the profession was also mentioned in the interviews as this has not been taught in midwifery training to date. Here, it would be important to help foster the autonomy of the midwifery profession.

Overall, the benefits of an academic degree in midwifery are covered by the following points: more recognition for the profession, acquiring an insight into scientific/evidence-based working, general skills development in the profession, a wider range of options for future professional life, broader networking, improved supply of new talent, increased and more comprehensive training, and improved supervision by skilled teaching staff (see Figure 2 [Fig. 2]).

The majority of interviewees perceived the primary benefit of an academic study program in midwifery as being the (presumed) higher level of recognition of midwives by doctors, though many referred to the hope that it would also result in society holding the profession in higher esteem. Several respondents warned that, even once a degree in midwifery is introduced, the midwifery profession would remain a trade and that this must be taken into consideration. Interviewees thus called for a practice-oriented course of study.

Linked to this, one respondent anticipated that higher education could make the profession more attractive again. This is an important point since there is presently a shortage of midwives [4] and one of the objectives of a course of study in midwifery is to rectify this.

According to respondents, another benefit of an academic degree in midwifery would be the acquisition of the ability to work in a scientific or evidence-based manner. Interviewees anticipated that midwives who had completed their studies would be able to work in the research field and also that introducing a degree in midwifery would provide more in-depth knowledge about the role of the midwife and the profession would thus, backed up by research, receive more recognition. This point is also discussed in the section on the requirements of a degree.

It was also mentioned again that introducing a degree in midwifery is a judicious move if only to put the profession on level pegging with other EU countries. An academic study program would enable midwifery graduates in Germany to work in other countries too.

According to interviewees, another advantage of an academic program in this context would be the different perspectives provided by the reflective research carried out during a course which, in turn, would further develop the profession and drive change. As well as the advancement of the profession, the exchange between like-minded students would also contribute to the professional development of the individual.

The next point raised relates to the wider range of professional roles that would be open to midwifery degree graduates. An academic study program tends to offer better professional opportunities in different areas of work such as research.

Some respondents mentioned the creation of networks as another advantage of an academic degree. This refers, first, to networks with students from other universities and countries, which facilitate a transfer of knowledge (also between students of different nationalities) and, in turn, enable life-long learning. Communication between students should not only focus on the subject of midwifery, however. It should also promote professional, intercultural, and social exchange. Second, the creation of networks also improves cooperation across different disciplines.

Only one respondent saw an academic degree in midwifery as being of no benefit since they believed the profession was already respected enough and a study program would thus bring no additional advantage.

The German Association of Midwives’ competency profile [3] was used as a basis for the conception of the degree in applied midwifery, acting as a starting point for developing the course content and modules. This profile is expanded to include the CanMEDS model [6], from which we can derive seven roles that draw on specific areas of competency relevant to the midwifery profession: Health Advocate, Medical Expert, Collaborator, Scholar and Teacher, Leader, Professional, and Communicator. As well as professional competencies, personal competencies are also specified here.

In order to acquire more than just an overall impression of the range of the competencies mentioned (see Figure 3 [Fig. 3]) and instead to create a systematic order, we then assign the points mentioned to individual areas of competency.

In this area, respondents all agreed that the midwife should support the pregnant woman and her family as an experienced carer and point of contact from the beginning of pregnancy. In terms of advocating interests, aspects were mentioned such as protecting women’s interests against men, specifically when this involves women with different cultural backgrounds.

Regarding the aspect of health promotion in this area of competency, it was believed that midwives should provide more information on the birth process as well as take preventative measures. Another factor mentioned was involving the pregnant woman and her partner in the process and taking their individual needs into consideration. This is also about assuming responsibility for the child’s welfare. In this context, the experts interviewed also mentioned that midwives should be the point of contact for women and their families under difficult circumstances such as if the woman has a mental illness or the family is socially deprived, for example.

It was noted that midwives are required to have a broad range of knowledge. However, they must also specialize to a certain extent in order to be able to cope with complex situations. Cross-disciplinary knowledge was also seen as important, in other words, knowledge should be acquired in other fields such as the social sciences, psychology, physiology, pharmacology, and life sciences so as to be able to interpret processes and explain correlations. Particularly in emergency situations, cross-disciplinary knowledge can facilitate communication with doctors.

All respondents placed high value on the capacity of midwives to work in a team and cooperate across disciplines, both with other midwives and with experts from other professions such as those working in social institutions outside the hospital setting, for example. Respondents saw this as an important factor in maintaining a pleasant work environment and enabling midwives to provide mother and child with the best possible care.

The most frequently given response in this area of competency referred to a midwife’s recognition of his or her further training obligations. This is particularly important to ensure that practitioners working in the rapidly changing fields of medicine and midwifery are kept up-to-date. In the context of continuing training, reference was also made to the topic of reflection. According to respondents, midwives must be able to critically scrutinize their own work and, if appropriate, also take up training options in other related fields.

The personal competencies listed by the respondents included a sense of duty and responsibility, the ability to act independently, assertiveness and attentiveness, the need for midwives to be psychologically robust and exhibit specific social competencies such as an understanding of human nature, sensitivity, and a certain degree of “motherliness.”

Here, respondents highlighted, first, a midwife’s ability to self manage. According to the experts interviewed, a midwife must be able to act independently (this point was also mentioned under “personal competencies”) and adapt to different situations and circumstances such as the hospital environment and shift work. Second, respondents pointed out that the subject of self-organization must also be factored into the study program concept with a view to further developing students’ competencies in this area.

Respondents also referred to error management as another important competency to be fostered. Future midwives must learn how to cope with errors and, where necessary, also be able to sensitively communicate difficult news.

Here, interviewees indicated the importance of legal knowledge, as well as the willingness to become involved in political activity promoting and advancing midwifery as an autonomous profession. Within this competency profile, there are also calls for binding ethical guidelines which currently only exist to a limited extent.

The next competency area referred to was communication skills. First and foremost, communication between the midwife and the pregnant woman was seen as important, especially in the difficult circumstances of a woman experiencing pregnancy complications. Second, cooperation between disciplines was also referred to in the context of effective communication facilitating collaboration with those from other professions, such as gynecologists or pediatricians.

Our findings highlight the demand for midwives with a university education from a practitioner’s stand point. There is strong support for an academic degree in midwifery because of the benefits to the profession. A particularly important aspect is recognition by the medical profession which is something that can be improved through an academic study program. Possessing the ability to work in a scientific and evidence-based manner is also seen a significant advantage. This is substantiated by our findings which show that there are definitely areas that are neglected in the current non-academic midwifery training program and that should be covered in more detail in a university degree course. This elucidates the university qualifications to be achieved and spheres of activity to be addressed. On this subject, the link between practice and theory was referred to as another major advantage of an academic degree. It is believed this link will enable midwives to justify their actions with more precision, underpinning them with theory. Moreover, this connection can facilitate an exchange among midwives and with experts from other disciplines.

The answer to our first research question is that there is a need for an academic degree in midwifery, not only from a theoretical but also from a practical perspective. Despite the significant support for this step, however, the fears and concerns regarding the introduction of such a qualification should not be ignored. The study program should always be implemented with professional practice in mind, preferably in open dialog with practitioners. In terms of our second research question, it is evident that there are many different benefits of an academic study program for midwives. Responses to the question were diverse. Interviewees not only referred to improvements within the profession but also benefits in terms of increasing the supply of new midwives, networking, future development of the profession, and many other areas.

The responses to the final research question, which focused on the competencies to be taught within the degree course, indicated that the professional competencies to be covered corresponded with both the DHV’s competency profile and the CanMED model. These can be expanded to include personal competencies and can be used as the basis for the development of degree course content and modules.

In terms of their validity and transferability, our findings are not representative. The range of experts selected for interview provided a broad spectrum of responses. In terms of content of the responses received, it was not always possible to clearly delineate between the three categories on which our research questions were based. Frequently, a single response contained a mixture of aspects which made assigning it to a relevant category more difficult.

The demand for academically trained midwives in Germany is undisputed, particularly in international comparison, though there are clear shortcomings and uncertainties in terms of the actual implementation of an academic program of study for midwifery and its consequences [13]. Worth mentioning here is the subjective and objective risk of overtheorizing the profession as well as its heterogenization through the different training options and the impact of this on the profession, all of which still need to be researched in more detail. When introducing an academic degree as the sole qualification for an occupation, it can be useful to have an insight into the situation in other countries that have already taken this step. The difficulties and problems faced in those countries during the process of transition can be analyzed to ensure that Germany avoids these same pitfalls when developing and implementing its own process. Insights and positive developments can also be compared and adopted.

Finally, it can be said that, despite the lack of study findings and the continued need for more research, the results of the current study certainly point toward a need for an academic study program in midwifery sciences. The findings and demands from the expert interviews were taken into account when developing the module handbook for the cooperative degree program (combining theory and practice) in applied midwifery sciences at the DHBW and they serve as a basis for further research.

The authors declare the presence of the following conflicts of interests: material conflicts: employment relationship at the Baden-Wuerttemberg Cooperative State University in Stuttgart. The project is funded by the German Federal Ministry of Education and Research (BMBF). Nonmaterial conflicts: Julia Butz, Kornelia Walper, and Sonja Wangler are all members of the German Association of Midwives (DHV) and the German Society of Midwifery Sciences (DGHWi e.V.).

The authors are grateful to Carla Welch, qualified translator, for assisting with the English translation of the manuscript.