Keywords

1 Midwives’ Role Concerning Sexuality and Sexual Well-Being

Midwives are acknowledged, all over the world, as having an important role in sexual counselling and sexual health issues. The International Confederation of Midwives (ICM) and the World Health Organization (WHO) recognise that counselling and education on sexuality and reproductive health are among the tasks of midwives [1, 2]. Since the first State of the World’s Midwifery report in 2011, evidence indicates that midwives are essential care providers at multiple health system levels. In addition to maternity care, they provide a wide range of clinical interventions and contribute to broader health goals, such as addressing sexual and reproductive rights, promoting self-care interventions and empowering women and adolescent girls [3].

They contribute to SDG 3 (Sustainable Development Goals), including universal access to sexual and reproductive health services, family planning, information, education, and the integration of reproductive health, and SDG 5 aims, to achieve gender equality and empowerment of women and girls. Various sources indicate that sexual education by midwives during pregnancy and postpartum can improve the couple’s sexual well-being. An essential element of this midwife’s vital role in sexual health is the skill to adequately initiate the conversation on sexuality and intimacy based on the necessary knowledge about sexual health and well-being. However, the sad reality is that, within midwifery teaching and practice, this only happens in a small part of the more affluent countries.

While sexual counselling requires a positive and respectful approach to sexuality and sexual relationships [4], personal or societal attitudes towards sexuality may affect the implementation of sexual counselling services [5]. In some countries, sex educationFootnote 1 is integrated into schools, universities, and media. In other countries, it is far less available or non-existent, or its content is unsatisfactory [6]. When sex education is taboo in a community, the implementation of sexual counselling in health care will be hampered [5]. In addition, the cultural and gender reference points of the maternity care professional may influence the approach towards the couple in counselling [4]. A recent study in Sweden found that midwives’ insecurity regarding sexuality was even more remarkable in patients who deviated from the heterosexual norm or had a different cultural background [7]. These insights present significant challenges for midwifery education worldwide.

The ICM Essential Competencies for Midwifery Practice outlines the minimum knowledge, skills, and professional behaviours required by a newly graduated midwife when entering midwifery practice [8]. Regarding sexuality and sexual well-being, the knowledge and skills include anatomy and physiology related to reproduction and sexual development, guidance about sexual and reproductive health, and information about safe sex. Newly graduated midwives are expected to be competent to assess sexual and reproductive health needs comprehensively [8]. Given the extent to which the ICM gives attention to sexuality-related competencies for midwives and the virtual absence of sexuality subjects in many midwifery schools’ curricula, one can wonder if midwifery schools today are fully aware of the ICM’s stance on sexual health and well-being.

A UK study indicated that midwifery students lacked knowledge or had difficulty translating theoretical knowledge into practical clinical situations regarding postpartum contraception and sexual health advice [9]. A Bulgarian study on teaching midwifery students in contraceptive counselling revealed that interactive work methods and cooperation with a regional family planning centre were critical for skills acquisition in this area [10].

A Turkish study on midwifery students’ attitudes towards sexual counselling indicated that their attitude on sexuality was positive, but they were not always comfortable providing counselling, especially to particular groups of women [5]. Another Turkish study showed that midwifery students’ attitudes towards sexuality, contraceptive methods, and abortion were strongly influenced by social-value judgements. Many students believed that a girl should be a virgin when marrying, that abortion was morally wrong, and that only married couples should receive information on contraceptive methods [11].

In a UK study, final-year midwifery students reported a lack of confidence in their knowledge regarding contraception and sexual health, despite considering this part of their professional role. They stated that more practice-based educational methods would increase their confidence [12].

It seems clear that midwifery education must integrate knowledge, skills, and attitude-building regarding sexuality and sexual health into their teaching curriculum. This chapter aims to help midwifery schools ensure that their student midwives enter the workplace with the necessary knowledge and skills, combined with the right attitude, concerning sexuality and sexual health. Then they can proactively integrate these essential topics into the care they provide in the context of pregnancy, postpartum, and young parenthood.

2 Implications for Midwifery Education

As described above, international professional organisations have strong arguments to equip students with the knowledge and skills to address sexuality, though not all educational institutions follow the recommendations. Midwifery curricula must implement sexuality and sexual well-being-related aspects defined by the ICM and the EU Directive and emphasise the topic. One could state that ‘making midwives experts in sexual or reproductive health issues’ is essential to achieving midwifery’s full scope and potential.

The midwifery curriculum requires a model in which theoretical knowledge is reinforced practically, with practice-based scenarios and with the tutor as a role model [12]. As the role of mentors appears to be very important in helping students gain confidence in sexual counselling and sexual health, we will start by elaborating on their function and profile within the scope of this chapter.

3 Integrating Sexuality and Sexual Health into your curriculum

To educate midwives with adequate skills and knowledge regarding sexuality and sexual well-being, a midwifery school must tackle two significant tasks. The first task is content related: scanning the existing curriculum for courses that already touch upon sexuality (for a concrete scanning tool, see Table 27.1 Midwifery & Sexuality Curriculum Scanning Tool, based on the chapters of this book). It’s seldom the case that midwifery schools have to start from scratch. Carefully scanning the existing curriculum and thus identifying the work already done can make implementing knowledge and skills on sexuality and sexual well-being less daunting. Once the school has identified its current state of affairs, it can fill in the theoretical and practical gaps, making room for those courses needed to make its student midwives experts in sexual health and sexual counselling. The framework and content of this book might serve as a guide through this process of curriculum optimisation.

Table 27.1 Midwifery & Sexuality curriculum scanning tool
Full size table

During this exercise, the midwifery school should remember the general rule put forward by the 2021 ICM Standard for Midwifery Education that a good ‘midwifery curriculum includes both theory and practice elements in clinical settings’ [13]. This rule also applies to midwifery knowledge and skills in the area of sexuality and sexual well-being.

4 Matching the Tutor to the Courses

Once the curriculum has been adapted to include the needed themes, a second task is identifying tutors. On the one hand, they should have the skills and knowledge needed to educate about sexuality in a way that applies to midwifery and, on the other hand, possess the individual traits for successfully educating about that area.

It’s a given that the experienced midwifery tutors who integrate sexuality in their own work are the best to teach these subjects. Furthermore, more so than for the other course material in midwifery, we believe that how the tutor covers the topic of sexuality will inevitably serve as a role model for dealing with sexuality. A key component of effective learning and effective practice regarding sexuality is a relaxed but still professional attitude about all matters concerning sex. Only the midwifery tutor who can address a couple’s sexual habits equally comfortable as addressing a woman’s eating pattern will be able to teach students the communication skills needed to start a conversation about sex. Such a ‘teaching by example’ attitude can instil in the future midwife the belief that sex is a normal aspect of the human condition, equally important as other basic functions such as nutrition and rest. Still, even for the midwifery tutor, ‘practice creates perfection’. One does not yet have to be 100% comfortable to start teaching about sex, given that one recognises one’s current level of expertise and is not afraid to communicate it to colleagues and students alike.

Regarding teaching sexuality, the midwifery tutor is never just educating on knowledge or skills but also on how to position oneself towards sexuality as an everyday part of life. Secondly, the tutor best suited to teach midwifery students about sexuality does not necessarily have to be a midwife. Where the first choice should be a midwife with additional training and experience regarding sexuality, such midwives might not always be at hand. Just as midwives in practice provide the best care when working multi- or even transdisciplinary, one can argue that the best midwifery teaching comes from multi- or transdisciplinaryFootnote 2 working midwifery faculties. In the words of the ICM: “Individuals from other disciplines who teach in the midwifery programme are qualified to teach in that area” [13].

Transdisciplinary midwifery teaching can be ideal for training sexuality-sensitive and competent midwives. That means that the midwifery faculty can, for instance, choose to take on board a non-midwife clinical sexologist experienced in working with women and couples in the various stages of reproduction, to teach on these specific topics. In this way, the school moves towards multidisciplinary midwifery teaching. Such a sexologist-midwifery tutor can influence the standard midwifery courses to include attention to sexuality and sexual well-being and the midwife-midwifery tutors can foster greater knowledge and understanding of midwifery in their non-midwife colleagues.

Building on this vision, one can imagine that bringing such a lived and experienced form of multi- and interdisciplinarity to midwifery students’ practical courses by actively having midwifery students engage with gynaecology residents, sexology students and pelvic floor therapy students would further their formation as practice-experts in the field of sexual health and sex counselling [14, 15]. Finally, the midwifery tutor best suited to teach about sexuality should have experience in ‘teaching’ sexuality. Teaching sexuality has to go beyond just giving psychoeducation to midwifery clients. Here we refer to experience with actually teaching other professionals, not necessarily midwives, about sexuality and sexual well-being. Ideally, this teaching experience also entails teaching practical skills, e.g. talking about sexuality and also knowledge about sexuality and sexual well-being [13].

In summary, the ideal scenario for a midwifery school is to expand the midwifery faculty with one or more HCPs trained and experienced both as midwives and sexologists. Preferably this midwife-sexologist is already proficient in teaching sexuality to HCPs.

5 On the Practice of Teaching Student Midwives About Sexuality

Once a midwifery school has made room in its curriculum for sexual health and sexual well-being and has identified a suitable tutor to teach sex or attracted a new colleague with the needed skillset to do so, it just comes down to teaching student midwives about sex. What should go on in the classrooms and training rooms? What are the most effective educational ways to form midwives who are not only knowledgeable about sex but also proficient in talking about sex with clients and can actively integrate sexual health and well-being into their care?

Considering the most effective way to obtain learning goals, an important question is how to match the pedagogical method to the desired learning outcomes. The KASES model, developed by Sensoa, the Flemish Expertise Centre for Sexual Health and HIV, is designed to give a simple overview of matching desired outcomes to the most suited pedagogical methods [16].

KASES is an acronym for Knowledge, Attitudes, Skills, Emotions, and Support. Each learning outcome has its own methods best suited to work towards it.

  • Knowledge increase is best achieved through what one could call more traditional forms of education such as research work, academic reading, content exercises, and lectures.

  • Fostering attitude-change works better through group work, group discussions, writing, and presenting dissertations.

  • Skills are best acquired by combining modelling, role-play exercises, and authentic learning scenarios.

  • Emotional attunement and insight are best achieved through performing or watching interviews, testimonials and storytelling.

  • Every student, like every client, needs to feel supported for any positive change to occur. Support is best provided by positive feedback scenarios, group and one-to-one coaching, awareness about all possible support services, etc.

The midwifery tutor developing educational materials for midwifery students can then elaborate on which learning outcomes are connected to which part of the course. To achieve learning outcomes related to sexuality and sexual well-being, midwives need competencies with a mixture of knowledge-building, attitude formation, skill-building and emotional attunement. The emphasis is most heavily on knowledge and skills building for obvious reasons.

Globally, midwifery tutors know how to bring new information to students so that they understand it and can incorporate it into their midwifery knowledge. This chapter will not go into detail about how to compose and style lectures on sexuality and well-being. Still, midwifery tutors could do well to be aware that even when just lecturing on sexuality, they are in a perfect position to foster attitude building. One of the most important parts of attitude building regarding sexuality is the lived-through idea that sex is just another part of life, a basic need that obviously can have a major positive or negative impact on people’s general health and well-being. Such a sense of sex is central to our human condition. Approaching it as plain as sleep and nutrition is the needed basis for building skills to talk about sex with clients effectively. So even when giving a theoretical lecture on, e.g. sexually transmitted infections or sexual anatomy, one actively influences the students’ attitude towards sex. In a sense, the tutor is reshaping a professional way of talking about sexuality, which is the first step into acquiring skills.

Achieving skills requires a combination of modelling, role-play exercises and authentic learning scenarios. Modelling is not enough to foster the skills needed to talk with clients in a relaxed, neutral way about sex. When the tutor shows how to do a sexual anamnesis in front of a group of students, this can only ever be a first step towards the desired outcomes regarding skill-building. To learn how to talk about sex, one actually has to be in the position of the professional. Students need to go through the process of searching for the words to use that suit them, the right tone and posture to take on, etc., when talking about sex with their clients. One can only achieve that by personal exercise.

Where a practical course can start with a theoretical intro, possibly followed by an example by the tutor, classes on sexuality related skills need to move into self exercises quickly. Students must experience taking on this role and having the conversation themselves. Still, putting oneself in the position of the HCP talking about sex can feel somewhat unsafe for students because of the cultural load attached to the topic, possibly combined with the fact that their fellow students are watching them. Going back to the KASES model, the tutor needs to foster support. One way of doing this is by actively installing a positively focused feedback system before the start of role-playing. When the student talking in the role of the HCP can hear the tutor instruct the other students to only pay attention to what their colleague ‘does right’ during the exercise, this goes a long way to installing enough safety for students to try to talk about sex during role-playing actively. The tutor can instil an even greater feeling of support by declaring that the role-playing student can ask for a ‘time-out’ at any moment during the exercise to receive input and guidance from the group. At each time-out or at the end of the exercise, the tutor can start by first having the other students give all the positive feedback they’ve written down for their colleagues, before providing suggestions on how to do it even better. This way, students can feel empowered by one another through these sometimes challenging exercises instead of feeling judged on their performance. Such a combined focus on knowledge, attitude, skills, and support maximises the learning output.

Once the tutor has learned how to install enough safety for the students to try to talk sex during exercises actively, practicals are best organised within a learning curve, aiming for the most authentic learning possibilities in a classroom setting. One can first ask students to practice in small groups, just talking about sexuality-related topics in general. Then one can show examples of how HCPs talk about sexuality with their clients in various settings and conversations (e.g. anamnesis, psychoeducation, problem-solving, therapy). Examples can be pre-recorded and projected, or the tutor can give a live demonstration. At this point, tutors should realise that every student has to develop a personal style of engaging with clients. To prevent students from mimicking the example, providing demonstrations of different professionals/tutors talking with clients can be very helpful. The next step for the students is role-playing in small groups, alternatingly taking the HCP and client roles. Then practicals can move on to group exercises, with students taking the roles of the client and the HCP conducting a conversation for the entire group. If the tutor can install enough safety in the group to allow recording of the exercise, students can benefit greatly from the opportunity of watching themselves work at a later point and reflecting on how to improve their skills. The last step before practising these skills during internships is bringing in simulation clients, strangers to the students, to take on the role of the client during exercises in practicals. The tutor, at this stage, has to decide to work with simulation clients who either take on the client role, drawing on personal experiences as clients, or perform a role written for this exercise by the tutor. We suggest tutors select simulation patients who are sufficiently flexible and emotionally stable to allow them to draw on their own experiences of wanting to conceive, being pregnant, giving birth or caring for a newborn. When possible, it is a great advantage to have HCPs as simulation patients, for they are often familiar with these types of practicals and have experience in giving feedback to students. The ideal simulation patients for midwifery practicals on talking sex are midwives who are mothers (or fathers). Communicating with these ‘real women’ or ‘real couples’ pushes students to take their skills in talking about sex to the level required during internships.

6 Conclusion

Future midwives need to be aware of the diversities within human sexuality, understand the factors that influence views and norms about sexuality and gain insight into their own values and assumptions about sexuality [4]. Qualified midwives may need additional education and support from sexual and reproductive health services. Further education in sexology for midwives appears to significantly impact their skills and readiness to address sexual issues in their daily work. Stronger and interprofessional collaborations with clinical settings and government systems are required to solve the current challenges to midwifery [13]. We emphasise that multi- and transdisciplinary healthcare teams are the future models of health care, also concerning sexuality and sexual well-being. Therefore, it’s worth considering synchronising sexology and midwifery educational and practising teams providing appropriate maternity care for couples and so educate and maintain professional experts geared towards the sexual health and well-being of women and families worldwide.

The wise words of a midwife from the United Kingdom sum it up nicely: ‘I encourage midwives to speak to managers and primary care links to discuss the value of acknowledging families’ sexual and reproductive health needs within local maternity service provision — with a sense of optimism that in future, maternity service providers and midwives will make sexual health a public health priority’ [14].