gms | German Medical Science

In 2011, in order to scientifically underpin midwifery practice, the [German] Health Research Council recommended that the research focus be further extended to explore midwifery care of women and babies during pregnancy, labour, and the postnatal period [9]. Though not the only option, healthcare research is suitable for this purpose. It covers four areas: Input (requirements, uptake), Throughput (models and processes), Output (services provided), and Outcome (health, quality of life) ([15] p. 4).

To support development, evaluation, and implementation of evidence-based care provision and in cooperation with the German Society of Midwifery Science (Deutsche Gesellschaft für Hebammenwissenschaft e.V.; DGHWi) and other players, Cochrane Germany developed a research methodology guideline in order to first establish the healthcare problems which are relevant to care [23]. It is hoped that ‘research waste’ (i.e. useless research) can thus be avoided [11], and instead healthcare problems, interventions, and outcomes of primary interest to the target groups examined.

Chalmers and Glasziou [4] and Chalmers et al. [3] stip-ulate that – in addition to healthcare providers, who suggest or make decisions in the line of care – service ‘users’ be involved in determining research priorities [21]. The targeted application of research resources supports the client’s right to self-determination (autonomy) regarding their care ([25] p. 15-8) and the ethical consideration of cost-benefit.

For the purposes of focus and content-driven healthcare research it would be helpful if midwifery researchers were able to follow a national research agenda. A systematic review¹ (see Figure 1 [Fig. 1]) found that midwifery research agendas have already been created in Ireland [2], the United Kingdom [5][19], Australia [7][17], Africa (Kenya, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe) [12] and on an international level [20]. Most studies on agenda setting [1] used the Delphi Method [2][7][12][19], but also a single survey [17][20] and a discussion group [5] were applied. Four studies interviewed midwives [7][12][17][20], one included midwives and trainee/ student midwives [19], and only two studies interviewed mothers, either additionally [2] or exclusively [5].

A glance at the primary literature provides an impression of the diversity of concrete research questions and aspects. The wide-ranging results of the studies are briefly outlined below and divided into four research topics. Midwives suggested the following relevant research topics for Midwifery care: antenatal care [7][12][19], birth preparation [19][20], care in labour [2][7][17][19], quality assurance (including emergency and transfer management) [12][19], postpartum care [7][17][19], the evidence base and relevance of research for practice [2][12][20]. Of particular interest hereby were the support of physiological processes [20], woman-centred care and communication [2][17], documentation [12], psychosocial factors [17] and specific target groups [12][17][20]. For the research topic Models of care, midwives were interested in systems of care [2][19] and the shortage of midwives [12]; and on the subject of The midwifery profession, the role of the midwife [19], professional aspects [2][7][17] and practice management [19] were of interest. Life-long learning was highlighted as a research topic in Education [2][12].

Regarding Midwifery care, the mothers (users/user representatives) interviewed considered antenatal care [5], care during labour (latency, induction, and caesarean section) [2][5], and postpartum care (in particular child nutrition) [2][5] important future research topics. Further, woman-centredness [2], continuous care [5], participatory decision-making [5] and evidence-based risk assessment [5] were regarded as relevant aspects for research. The research areas Models of care [5], The midwifery profession [2][5] and (Ongoing) Education [2] were not addressed in detail.

In contrast to the four research topics outlined above, Renfrew et al.’s Framework for quality maternal and newborn care [18], which was developed on the basis of reviews and claims international validity, describes 5 components of healthcare provision by midwives: practice categories (such as information, advice, health promotion), organisation of care, values, philosophy, and care providers (e.g. skills and interprofessional cooperation).

An assessment of the topics across the spectrum of midwifery care which women and midwives consider of priority for healthcare research has not yet been undertaken in Germany. This gap has been filled by the study presented here and entitled Preferences and deficits in midwifery care in Germany from the perspective of users and midwives: a qualitative exploratory study, financed in 2015-16 by the German Research Foundation (Deutsche Forschungsgemeinschaft; DFG). The study was broken down into four goals: 1. To identify women’s wishes and needs, 2. To identify the midwives’ perspective regarding determining women’s wishes during care, 3. To combine the perspectives of both groups, and 4. To develop “hot topics” for research into healthcare provision by midwives from the data collected. The research question for the fourth goal, presented in this article, was: what priority topics of research into their healthcare can be identified from the subjective perspectives of women and midwives?

The complete study examined preferences and deficits in health care from the perspective of women and midwives. Gadamer’s [8] hermeneutic method was applied in an exploratory and cyclically interpretative approach. The central principles – openness, research as com-munication (dialogue with the subject/text), process character and reflection (iterative analytical process from the individual statements to overarching contexts and back), clarification (presentation of the method) and flexibility [8][10] – permitted exploration of the subjective perspectives, attitudes and experiences of the participants with regard to their content, context and meaning [16].

To this end, focus group conversations (FGC) were carried out in a number of German federal states. 50 women participated in 10 FGC, and 20 midwives in four FGC, all of which were digitally recorded and transcribed. The researchers approached potential participants via midwives, hospitals, social networks and relevant associations. Before invitation to a focus group (FG), those interested in participating completed a brief questionnaire (comprising of a few sociodemographic questions, satisfaction with midwifery care [women] / professional experience and services offered [midwives]). This information was to enable the creation of FG which were as heterogenous as possible. The groups were small (4-6 people) and homogeneous in terms of educational status to aid the flow of conversation as much as possible. The use of FGs to answer this research question is appropriate as par-ticipants express their own point of view in conversation, stimulating thoughts and memories of others, reflect, take a stand on, and sharpen their own point of view in the course of the discussion. The researchers who moderated each of the two-hour FGs opened the discussion with open questions on women’s experiences of healthcare provision by midwives. In the FGs with midwives, the questions were also about women’s needs and wishes and about existing deficits. If necessary in the course of the discussion, the researchers asked open-ended questions and steered the conversation back to the research question [16]. Further information regarding participant selection and study conduct is available in the journal BMC Pregnancy & Childbirth [13].

The two samples comprised of 50 women and 20 midwives from 5 (resp. 4) federal states. Of these, 15 women were pregnant (6 primiparas, 8 multiparas, 1 not specified), and 35 were mothers with babies (22 primips, 13 multips), of whom 9 had had 10 or less years of schooling (see Table 1 [Tab. 1]). Of the 15 women who had had a miscarriage or lost their child at a later date, 6 were members of a support group (“Empty Cradle”) at the time. A separate FG was created for these women and another for the 5 participants who were living in a mother-child home. On average, participants gave the midwifery care they experienced a grade of 2 [B], although some assigned a 4 [D] or 5 [E] (note: 1 [A] being the highest grade, and 5 [E] being the lowest; see Table 2 [Tab. 2]).

The midwives presented a broad spectrum of qualifications, years of experience and fields of practice/expertise. The majority offered services listed in the Contract of Provision of Midwifery Care according to the relevant Social Security Statute Book (Vertrag über die Versorgung mit Hebammenhilfe nach §134a SGB V [6] (see Table 3 [Tab. 3]).

The FGs of women and midwives for the first and second goals of the study were analysed separately. In the third stage (or goal) the ‘sense units’ of the previous stages were collated by means of interpretation and condensing within a larger context (see http://www.medizin.uni-halle.de/Hebammenversorgung for the results). An intermediate level of abstraction was the goal in order to retain the richness of participant’s statements and extrapolated themes as far as possible. The analysis performed to achieve the fourth goal is presented here.

As in the previous stages of analysis, the researchers used the MAXQDA [22] software. Applying it to the texts resulting from stage three, which essentially presented the needs, wishes and experiences of women regarding midwifery care, they sought to discover the research topics most important to women. The texts were coded and progressively developed into a code tree with codings of research topics and relevant aspects in an open and axial process [16] by one researcher (GA). The other researcher (EM) evaluated the content validity and categorisation of the 369 codings. Content-related aspects and large topic areas were differentiated into diverse aspects over several cycles of synthesis and differentiation. Lastly, the researchers discussed content-relevant characterisation and appropriate terms until reaching consensus, which resulted in a code tree of eight potential research areas, each with 4-12 aspects (see Figure 2 [Fig. 2]).

The Ethics Commission of the medical faculty of the Martin-Luther-Universität Halle-Wittenberg in Halle/Saale approved the complete study. Data and personally identifiable characteristics were pseudonymised and filed in a password-protected system.

With the aims of staying as true to participants’ viewpoints as possible (validity² [8]), transparency and reproducibility of the stages of interpretation, in addition to precise documentation of the process and the decisions made (reliability² [8]), the methodological quality of the complete study was supported by [24]: heterogeneity of the research team in terms of qualifications and previous experience; the articulation of and reflection on own assumptions [8]; an open approach to the parallel processes of data collection and analysis; reflective, iterative interpretation of data – initially independently and then as a team until consensus was reached; evaluation of each stage by an uninvolved team member and lastly careful documentation.

The following results were arrived at by means of condensing and merging the essential contents (see Methods) of all focus groups. Quotes have not been included to validate interpretation, as FG content typically consists of long passages in a fragmentary conversational style.

The eight potential research areas identified are presented below in the following four sections: in the sections (a), (b) and (c), the first of six themes represent components of healthcare provided by midwives. In contrast, the remaining themes in section (d) identify structural, or rather systemic potential or deficits. Although methodological aspects are sometimes referred to, they do not embody concrete research questions or suggest specific study designs. Many of the research topics identified are so complex that several methodological approaches (in some cases even combined) may be appropriate for one topic [23].

Both women and midwives feel that future research on The midwifery profession could examine both the self-image of the midwife and her professional roles and the personal and professional relationship between woman and midwife. Personalised advice, coaching and care are of primary importance for women in this regard. The challenges for midwives of this client-driven approach lie in the time-consuming nature of meeting such expectations and – in light of the shortage of midwives – the ability to find a colleague to substitute for them during leave periods.

Further challenges are dominant routine, the influence of technological advances on obstetric practice, caring for more than one woman at the same time, and hierarchy in the clinic. In view of the decreasing number of privately practising midwives, other potentially interesting topics are the unattractiveness of the midwifery profession and midwives’ self-image with regard to the role of expert, mentor, advocate, and primary carer.

Women feel that research on midwives’ scope of practice should focus on establishing individual care needs as well as on counselling, when women consult the midwife regarding foetal anomalies or sensitive subjects such as unplanned pregnancy, bonding problems, depressive tendencies. Pregnant women want evaluation of treatments for effective alleviation of their painful and (a-)typical pregnancy complaints. They also ask themselves what the deciding factors for experiencing a physiological birth are and what model of care by a hospital midwife might enable a woman to experience a self-determined birth. Further, based on women’s assumption that midwives know their own limitations and are able to enlist appropriate support in an emergency, examination of the signs and strategies conducive to this would be worth examining.

The research focus for postnatal care is on methods of effective transference of well-founded, detailed and up to date knowledge of everyday questions on infant nutrition (breastfeeding, weaning, formula and introduction of solids).

Women want the research topic Care needs to focus on practical and natural remedies for the alleviation of complaints in pregnancy and the postnatal period. A further topic worthy of examination is how midwives can recognise and address the individual needs of women: e.g. those of multiparas, single women, women with health problems, intellectual or learning disabilities, pregnant women suffering from fear of childbirth, mothers with bonding or relationship problems, women who have experienced a miscarriage or stillbirth/infant death. On the subject of promoting bonding of mother and baby, the questions which arose were: how best to support parents in building a relationship to their unborn child and to become more sensitive? How best to support bonding after a caesarean section? In addition, both midwives and women are interested in learning how to avoid (unnecessary) medical interventions.

The research topic Making (evidence-based) decisions encompasses factors and contexts which lead to limit-ation or denial of women’s decision-making ability, such as a high-risk diagnosis, lack of evidence or information about choices, anxiety- causing references to possible complications, women’s loyalty to anxious staff or circumstances outside their control. The question arises as to which interventions improve development of the decision-making process and midwives’ advisory abilities. Evidence-based written information could be produced on various topics (such as the woman’s handheld maternity card, the pelvic floor, neonatal regulatory disorders, prevention of Sudden Infant Death Syndrome – SIDS) could be evaluated in terms of didactic usage.

Further, whether the ability of academically qualified midwives to interpret research enables them to introduce evidence-based measures and communicate on an equal footing with members of the medical team could be examined.

Future research could focus on the type and scope of counselling and guidance provided by midwives; how midwives can be supported to meet the individual counselling needs of pregnant women and mothers (e.g. health promoting behaviour, pumping of breastmilk) proactively and appropriately in a motivational fashion. Improving counselling skills in special situations and related measures are important research topics for women with low levels of education or learning disabilities. The focus hereby should be on subjects which women find confusing or irritating, such as kangaroo care vs. safe sleeping (SIDS prophylaxis) or treatment of women who are ‘post-dates’. Further, ‘quality indicators’ could be developed for women to apply to information from books, the internet or apps.

Some examples of the numerous research topics to do with children’s health are: basic needs of babies and infants, care of the newborn in the first few days and as they develop, promotion of bonding and individual needs of the child, and the various courses on offer for mothers and babies. Regarding women’s health, subjects worthy of exploration, both in terms of content and didactically, are physical changes in pregnancy and birth, recommendations for diet and supplements, signs of postnatal depression, questions on sexuality and the pelvic floor, and differentiation between prevention, screening and prenatal diagnostics.

Women’s need for information about midwifery care is a research topic in its own right. The required scope of midwifery care and the various models available could be explored. Models of care could be examined with regard to client-orientation, dynamics of intimacy/distance in care, and activation of the social network.

The midwife’s ‘presence’, how s/he disseminates knowledge, provides practical guidance and emotional support are all important to women.

In this regard, a number of endpoints (such as feeling overwhelmed, alleviation of fears and concerns, body image, achieving goals), in addition to influential factors such as mothering, sufficient time and self-determination are relevant research topics. Strategies for the involvement of relatives in counselling and care could be evaluated in order to mobilise family resources and reduce maternal stress in everyday routine.

An important topic for women is intrapartum care. For this reason, the ways in which midwives (including hospital midwives) can proactively support women to overcome the pain of labour, avoid unnecessary interventions and have a vaginal birth should be explored. Effective interventions to uphold women’s wellbeing and privacy during birth must be developed and evaluated. Empirical studies should evaluate the experience of individual midwifery care (or lack thereof) in particular situations: caesarean section, vaginal operative interventions, after stillbirth/neonatal death, in addition to referral to more specialised support if necessary (e.g. dietitian, pastoral care, family midwives³). Whether reflecting on the birth with the midwife postpartum is an effective way to increase birth satisfaction and assist women to come to terms with their experience is another proposed question.

The research topic care deficits encompasses restricted or limited access to midwifery care, unavailability of midwifery services due to the shortage of midwives and divergent services offered, in addition to deficits in out-patient care and in the maternity department. Empirical exploration is needed regarding existing care deficits in latent/early labour, the implications and consequences for women, and the measures which could be implement-ed to ensure effective midwifery care in this transitional phase.

Further deficits occur in interprofessional cooperation and the interfaces of the healthcare system (such as support programmes for the early postpartum period, young mums etc.) On this topic, patterns of communication, practice ‘philosophy’ (values, goals) of the professions involved, indistinct boundaries between disciplines and potential loyalty conflicts of women could be examined. Implementation studies could be applied to explore interventions for effective interprofessional interface management, in particular for women with special requirements, such as those with complex problems in pregnancy, poor literacy, learning disabilities, mental health issues, and those in difficult social and financial situations.

In order to ensure comprehensive midwifery care availability for pregnant women and mothers, new models of care based on nationally representative data should be developed and evaluated.

New concepts for interprofessional education and shared care between midwives and doctors could be explored to ascertain whether they would enable evidence-based care in the hospital. New areas of practice and models of care, such as outpatient care of women in latency phase, midwife consults in maternal and child health/multidisciplinary centres (also by family midwives), postnatal or sibling courses, care in the late postpartum period, involvement of partners in care, and care of mothers with special requirements (e.g. mentally ill mothers) should be accompanied evaluatively, in economically underdeveloped areas among others.

For the development of new birth preparation class concepts, a minimum standard comprising both content and didactics should be defined and evaluated which encompasses information, practical exercises and reflection on self-determination. Structural factors such as flexible organisation and aspects such as practicability and partner involvement require consideration. The experience of, for example, midwife-facilitated peer groups and their effect on women’s autonomy could be empirically examined.

Essentially it is necessary to develop and evaluate extensive concepts and strategies to counteract women’s information deficits with regard to midwifery services and care models and support their right to freedom of choice. In this regard, it would be interesting to explore how digital media can be implemented effectively in care and how publicity about healthcare provision by midwives could reach women at the latest in early pregnancy.

A further potential research topic would be the assessment of various (midwifery) interventions and their intended and unintended impact. Such an evaluation could serve to improve the quality of care experienced by women, particularly combined with accepted quality indicators and standards and the creation of midwifery teams or interregional networks.

In order to manage interfaces within the healthcare system and across sectors (e.g. support programmes for the early postpartum period, and young mums among others), needs-oriented concepts need to be developed and evaluated. These should include effective dissemination of information (e.g. checklists, further entries into maternity card/booklet, handover protocols), and also measures to clarify the boundaries between the roles of midwives and doctors.

In future research assessing new models of care, women’s wishes for better access to their midwife, the facilitation of continuity of care, and the option of an out-of-hospital birth should be considered.

The interpretative-hermeneutic approach proved to be constructive. Both the heterogeneous composition of the FG in a number of federal states and the inclusion of women with lower levels of education and special social situations strengthen the validity of the results. The minimal level of abstraction ensures retention of relevant details of participants’ viewpoints. The fact that the fourth section/goal was the last step in a sequence of analytical steps makes sense methodologically, however readers must be referred to another publication for the results of sections/goals 1-3 [13], as only the methods and results of this goal are presented here. The ‘long road’ from raw data to results could be criticised for the reason that the number of analytical steps may have skewed the interpretation. However, the previous steps were unavoidable in order to extrapolate the needs and wishes of FG part-icipants in their respective contexts, and from these, the priority topics for research into healthcare provision by midwives.

The study’s time constraints posed a limitation in that more time for data analysis may have permitted a deeper degree of reflection. Furthermore, other researchers may have extrapolated different research topics or come to different conclusions from the results.

The results, i.e. the eight research topics extrapolated, provide a provisional framework which differs significantly from the theoretical Framework for quality maternal and newborn care proposed by Renfrew et al. [18]. Although the subject areas can be attributed to a) could be categorised under the framework level “Practice”, and those in b) under “Organisation of care”, the topics Care needs of women and Midwives’ scope of practice represent cross-sectional aspects implicit in several framework levels. Nevertheless, this international theoretical framework could be applied to the process of developing a research agenda in Germany in the future.

The results represent topics which the women and midwives interviewed in Germany consider to be of priority [3][4][11]. They correspond to some extent with topics identified in agenda setting processes [2][7][12][17][19][20], such as professional aspects (including education and further education), aspects of care (midwives’ scope of practice, midwifery care) and systemic challenges (deficits in care, models of care). Further research topics of great importance to both women in Germany and internationally are publicity to inform women of the spectrum of midwifery services, counselling and guidance by midwives, interventions to enable evidence-informed decisions and the involvement of relatives in care [18]. Although midwives know from experience that women are more likely to avail themselves of midwifery care from their second pregnancy onwards, until now it was not apparent that this might be due to women being poorly informed. The focus on decisions informed by evidence and family-oriented practice is not particularly widespread in midwifery care in Germany. The results of this research highlight its meaning for women as ‘users’ of care.

Deficits in care of women in latent stage of labour are described in international studies [2][5] which have not received enough attention in Germany either in practice or research. It is up to research to identify future models of care to solve the dilemma of the transfer of care of women from privately practising midwives without third-party obstetric insurance to hospital care.

The analysis also exposed the special needs of vulnerable women, such as single women, women with low educational status, those in difficult social circumstances and mothers mourning the loss of their child. It is urgent that future research focuses on the needs of such women. One possible line of study would be to examine the extent to which relatives or peers could be involved in care effectively. However, given the current shortage of midwives and the lack of differentiation of payment (set rate per home visit), the application could be problematic.

With regard to cooperation within healthcare and across relevant sectors, the topics research should be focusing on are interprofessional education/training, management of the interface and improving the quality of care via midwife networks. These aspects could be evaluated in new models of care such as family or interdisciplinary health care centres.

Further research topics relevant to German women are midwives’ counselling skills on sensitive subjects, care of women with painful complaints and infants with special needs. In addition to research into the effectiveness of measures of care and the implementation of evidence-based interventions, the usefulness of training content and didactic concepts for practice could be examined.

This research project determined research topics on the subject of healthcare by midwives from the subjective perspective of women and midwives in Germany. The results present an empirical basis for the development of a national research agenda which is aligned with women’s needs. In the future a process of consensus is necessary in which not only midwives but also ‘users’ participate. A research project fulfilling these criteria is currently in planning.

¹ A systematic search of the databases PubMed, CINAHL, PSYNDEX, Web of Science Core Collection und MIDIRS was performed on 10.03.2017 to gain an overview of the relevant literature. The search terms applied (title and abstract) were: “research OR Delphi study OR R&D” AND “agenda OR priority setting OR prioriti* OR schema OR program* OR criteria OR initiative OR national OR consensus” AND “midwi* OR maternity care”. The records retrieved which described creation of an agenda for midwifery research, be it cross-regional, national, or international were included. Letters, commentaries, reviews and study protocols or studies which were restricted to a single institution, and studies which did not focus solely on midwifery research or practice, were excluded (see Figure 1 [Fig. 1]).

² The quality criteria validity and reliability are not used here in the classical sense in the context of quantitative research, but as global constructs composed differently (in qualitative research) to those of quantitative research.

³ Family midwives provide specialised midwifery care for up to one year after birth to women in difficult circumstances.

The research was funded by the German Research Foundation (Deutsche Forschungsgemeinschaft; DFG).

The authors declare that the funding agency (DFG) didn't have any influence whatsoever on the study design, data collection and data analysis, drafting of the manuscript nor the decision to submit the manuscript for publication.

Moreover, the authors state that both of them are board members of the German Society of Midwifery Science (Deutsche Gesellschaft für Hebammenwissenschaft e.V.) and members of the German midwifery association (Deutscher Hebammenverband e.V.).