Keywords

1 Introduction

In many countries, midwives are considered the professionals who guide uncomplicated pregnancy, childbirth, and the postpartum period. Their independence varies widely around the world. In some countries, midwives manage the first stage of labour and later hand the woman over to the obstetrician. In other countries, midwives supervise the entire process autonomously unless pregnancy or labour complications require an obstetrician referral.

In both cases, midwifery services may be extended to various areas, such as prenatal care, childbirth classes, and family planning. Often this is done without consideration of sexuality and intimacy. That could be called sexuality-insensitive care. This book aims to change that and ensure that midwives and other health care professionals (HCPs) begin to adequately incorporate the topic of intimacy and sexuality into their care. Attention to sexuality and intimacy should be integral to midwifery practice and competencies.

This final chapter of the book takes midwifery to the next level. In the broadest sense, sexuality-positive midwifery creates space for expanding the domains of women’s health, with the inclusion of sexual and reproductive health. Sweden is an excellent example of such progressive, sexuality-positive midwifery. While this may sound like midwifery fiction to some parts of the world, this chapter will elaborate on this advanced level and outline visions for the future of midwifery.

2 Developing into the Next Level of Sexuality-Positive Midwifery Care

Sometimes, growth and development just happen, and sometimes they are deliberately planned. We are providing examples of possible developments from several perspectives.

2.1 The ‘Unmet Needs Perspective’

In daily work, the sexuality-positive midwife may become aware of gaps in care. One example is midwife Elena, who saw many young women struggle with unplanned pregnancies. At the local community centre, with the help of local authorities, she set up a weekly contraception and sex education consultation.

Awareness of “unmet needs” can also come from research. That happened, for example, in the midwifery school, where not only pregnant women and women who had recently given birth but also midwifery teachers answered a questionnaire on how to deal with sexuality and intimacy. While most pregnant women said they desperately needed such information, almost none of the teachers talked about this topic to their students or pregnant women. These results shocked the school management and prompted them to add a sexologist to the teaching team and gradually integrate the subject into the curriculum.

2.2 The ‘Career Perspective’

Midwives who want to expand and develop their competencies in women’s health have many essential fields to work within. An example is midwife Mirjam, who, at age 53, changed career, got additional training and continued as a sexuality counsellor with competencies in advising about contraception.

2.3 The ‘Specialisation Perspective’

Whereas some professionals are pleased with the common daily midwifery challenges, others gradually realise to feel very at home in one of the subareas of the profession, in which they like to invest and develop extra expertise. Such specialisation can be very efficient in group practices with many midwives.

In an extensive urban practice with 17 midwives, Ursula was requested to take care of the antenatal classes. She developed a session for couples entirely devoted to sexuality and intimacy. That session became very well appreciated.

This example calls for a point of attention. When one midwife of a group practice specialises in sexuality, the others are not absolved from the obligation to address sexuality with their own clients.

2.4 The ‘Curiosity Perspective’

“How about this?” is the fundamental question behind science and the motivation to challenge the usual structures and routines. Janet became interested in sexology when she found that her role as a midwife inspired great confidence in women. With more expertise in sexology, she could also help and support women who had different problems and questions related to sexuality and relationships. Janet’s curiosity led to a training in sexology, and she now works for one day a week as a clinical sexologist.

2.5 The ‘Who Else? Perspective’

When something needs to be done, we usually know which professional should be asked, depending on factors such as skills and knowledge. When it is a task involving people, attitude, confidence, and familiarity with the target population are critical [1]. Midwives seem well equipped for many sexual and reproductive health tasks. They have the essential skills needed for these tasks and work in the right context [2]. The frequent and close contact between the midwife and the woman at a vulnerable stage of life fosters the necessary trust in the midwifery profession, which is essential for promoting healthy sexuality among the women they encounter, fundamental for facilitating healthy sexuality in the long-term [1].

The question “Who else?” may depend on whether other professionals are available. For example, in most affluent countries, there are 20–40 physicians per 10,000 population, while in some low-income countries, there is not even 1 physician per 10,000 population. In these countries, midwives perform tasks that are not fulfilled by other HCPs. In some places in sub-Saharan Africa, midwives with 3 years of additional training in surgery perform caesarean sections to reduce maternal mortality [3].

Consider the management of sexual disorders and dysfunction. In countries where few health professionals have knowledge of sexology or sexual medicine, midwives could fill this gap. Currently, only physicians and psychologists can specialise in sexual medicine. We believe that sexology organisations should recognise that midwives are capable of addressing sexuality. They should either open their courses to midwives or offer courses specific to the midwifery profession. That seems like a win-win situation benefitting clients, midwifery, and sexology.

Women’s health can be improved by enhancing the role of midwives [4] and building their basic competencies to include communication about sexuality and sexual health [2]. However, even if women feel comfortable talking to a midwife about sexuality, most women do not start this conversation without being asked or prompted. If a midwife does not proactively approach the topic, women do not get answers to their questions and problems.

Some women feel that sexuality-related questions from health professionals are too personal [1]. While this is not just a matter of trust, a trusting environment increases women’s chances of talking about sexuality and intimacy [5]. Creating such opportunities can be critical for many women.

Countries and cultures differ in how they talk about and deal with sexuality. However, although taboos vary, most aspects of love, sexuality, intimacy, hormones, conception, and orgasm are the same worldwide. Some midwives have already taken important steps to incorporate sexuality and intimacy into their daily work. This has happened in Sweden, for example. It could become a model for midwifery profession worldwide.

3 The Swedish Experience

Sweden is one of the most affluent countries globally and scores the highest on the European Gender Equality index. Already in 1886, Swedish midwives established the Swedish Association of Midwives. In Sweden, the midwife starts with a bachelor in nursing, followed by 2 years of midwifery. Many continue their education, and 2.5% reach the PhD level, which is one of the indicators of the profession’s high professionalism [5].

Swedish midwives work independently and autonomously in basic midwifery care. In addition, they prescribe contraceptives, insert intrauterine devices and implants, and perform medical abortions. They provide over 80% of Sweden’s sexual and reproductive healthcare [6].

Below we display, in adapted order, the Swedish list of competencies, specifically mentioned under the umbrella of sexual health [7]. This Swedish list is an addition to the core competencies that the International Confederation of Midwives (ICM) prescribes for midwifery.

The Midwife Has the Competence to:

  • perform a gynaecological examination and identify abnormalities,

  • inform and give advice on gynaecological conditions and diseases,

  • provide care for gynaecological illness and disease.

  • provide care in the event of a miscarriage,

  • inform about menopause and connected hormonal changes and sexual health,

  • inform about treatment for infertility,

  • inform and give advice on contraceptive methods and contraceptives,

  • inform about sterilisation,

  • prescribe contraceptives to healthy women for birth control purposes,

  • apply intrauterine and intradermal contraceptives,

  • inform about abortion methods,

  • provide care in the event of induced abortion,

  • identify and provide care in the event of abortion complications,

  • perform sampling and counselling regarding sexually transmitted infections (STIs),

  • inform about treatment, infection-tracing and laws, and prescribe drugs and treat certain conditions/diagnoses [7].

It is not just the list of competencies that makes the Swedish model an example of quality midwifery care. Also, this model’s perception of women’s sexual and reproductive rights, their attitude towards clients and their tendency to practice woman-centred midwifery care are important. We realise that various competencies from this list may seem unachievable for many midwives. Neither all midwives are identical nor their cultures. However, one will not advance to a higher level without striving for better.

In the following subchapters, we will elaborate on sexuality education and then on various midwifery skills.

4 Sexuality-Positive Midwifery and Sexuality Education

Sexual and reproductive health is essential for people’s and society’s quality of life. Numerous women die every day because they lack access to various elements of reproductive health care: proper sexuality information, reliable contraception, safe abortion, and adequate maternity care. But also because they lack the power to change their life situation. In many cultures, women lack the right and freedom to decide on their sexuality and cannot choose if and with whom they want to have sex and have children. Among the serious consequences of this lack of rights and power are poverty and poor physical health of women and children.

The WHO describes sexual health as ‘a state of physical, emotional, mental and social well-being in relation to sexuality’, which not only means the absence of illness and harm. It requires a positive and respectable attitude towards sexuality and sexual relationships and the ability to have pleasurable and safe sexual experiences free from coercion, discrimination, and violence.

The WHO describes reproductive health as ‘the possibility of a satisfactory and safe sex life without worries about illness, ability to reproduce and freedom to plan your childbearing’. Women deserve access to effective and acceptable family planning and good healthcare to undergo pregnancy and childbirth safely and be guaranteed the best opportunities to raise healthy children.

Reproductive rights include, among other things, women’s right to decide on the number of children and the space between pregnancies. These rights also include access to contraception, education, and sexuality education.

That brings us to the role of the midwife. Midwifery is eminently the profession with several responsibilities in this area.

  1. (a)

    The midwife should maximally integrate these rights into daily care and practice.

  2. (b)

    The midwife should integrate this information into all educational activities.

  3. (c)

    The midwifery profession should proactively promote and practice these rights in society.

To reach these goals, developing skills in counselling and teaching about sexuality and sexual and reproductive health and rights has to be part of the midwifery curriculum; in a basic undergraduate and advanced level. Each of those areas should be integrated into the education of midwives, with a substantial amount of attention directed to sexual pleasure and the wide variety of the normal range of sexual behaviour and a smaller amount focused on sexual problems.

4.1 Maximally Integrate Sexual and Reproductive Health and Rights in the Daily Midwifery Care and Practice

Midwives should be competent to support women under their care when they need help or want to talk about sexual pleasure, sexual insecurities, sexual function and dysfunction, orgasm, dyspareunia, sexual desire, and desire differences with their partner. Sexual health also deals with self-respect, with the notion of being mentally, physically, and sexually worthwhile, but also with insecurities nourished by peers, social media and society. Self-respect includes the crucial area of being able to say both ‘yes’ and ‘no’ to sex. The midwife can be the ideal person for the woman who wants to talk about intimate relationships and family life in positive aspects but also about negative experiences like various forms of intimate partner violence.

We believe that midwifery should develop adequate interventions to sustain women’s health within the woman’s reproductive life and empower women for choices tailored to their dreams.

Midwives could also consider couple’s groups for sexual and relationship education, just as in prenatal education.

Even if women can feel comfortable having a dialogue with midwives regarding sexuality, many do not raise such questions without being prompted [1]. This means that women experience hindrances in getting answers to their sexual questions and problems. Some women might feel that sexuality-related questions from health professionals are too personal [1]. These women may become comfortable enough to approach the subject in a trusting environment [5]. Creating such opportunities may be crucial for women.

4.2 Integrating Sexual and Reproductive Health and Rights Information in All Educational Activities

One may wonder who could be the expert in educating in sexuality. Who gives young people the right and appropriate information at the right moment? In the ideal situation, young people might get information from their parents. However, in many countries, this doesn’t happen enough or not at all. The explanation for that is, on the one hand, a combination of religious and cultural taboos and, on the other hand, because many mothers and fathers have never learned such educational skills from their own parents.

The professional knowledge and skills combined with a sexuality-positive approach make the midwife the right professional to educate about sexuality. The midwife’s role can be crucial to youngsters who have most of their sexual lives ahead and can benefit from the empowerment created by proper sexuality education and sexual health promotion. When such education (for teenagers of both sexes) includes body integrity, dealing with consent, and saying ‘Yes’ and ‘No’ to sexuality, it can prevent many future problems. A small addition to that package can be the integration of ‘pelvic floor education’ for girls and young women provided by the midwife who has gained such expertise.

Understanding the changes in sexuality over the stages of the woman’s life, midwives seem the suitable professionals to educate young girls, and in some situations also their mothers, about physical development, personal hygiene, addressing budding sexuality, sexual pleasure, facts about clitoris, menstruation, tampons etc.

Midwives could be the sexuality educators in the upper years of primary school and in secondary school. Youngsters must navigate cultural messages that, at the same time, idealise and demonise sexual functioning [8]. On the one hand, it is relevant to prevent the apparent risks of sexual behaviour, such as unwanted pregnancy, STIs, and the damage of sexting.Footnote 1 However, to develop a healthy sexual future, the benefits of sexual pleasure and sexual behaviour as a basic form of human health and happiness need maybe even more attention. The sexuality-positive midwife pre-eminently appears to be fit for such education.

Potential developments in sexuality education for the midwife of the future:

  • Combine sexuality education for mothers and daughters with the potential benefit of enhancing mother-daughter communication.

  • After leaving secondary school, youngsters tend to be lost. However, reaching women in this phase for advice concerning contraception, dating, and STIs could have extensive preventive advantages. Midwives could deliver sex education in the workplace or in a community centre. In this phase, preconception health counselling should be an essential element.

  • (Group) sexuality enhancement education for divorced/separated women. For re-empowering, re-finding self-respect and re-developing sexuality.

  • (Group) sexuality enhancement education for aged/widowed women. For re-developing sexual self-respect and re-balancing sexuality.

4.3 Proactively Participating in Advocacy and Promoting Sexual and Reproductive Health and Rights in Society

Midwives should be more involved in the political debate on women’s (sexual) health and rights.

The midwifery profession regularly has to go up to the barricades. To prevent their work from drowning in medicalisation and to remain valued as autonomous professionals. In some countries, the midwives have to fight for respect and to be able to gradually develop their field in the direction of the above-mentioned Swedish model. Let us call this aspect a struggle of empowering midwifery. In addition, midwives should fight for the empowerment of women and girls. Via private advocacy and through their midwifery associations, midwives should have an influence in creating laws that enable women to practice informed decisions regarding their reproduction, such as freely choosing the place of birth and not being prevented when deciding on safe pregnancy termination.

Few professions can better explain the consequences of insufficient sexual and reproductive laws and the consequences of a society that is unfriendly or unsupportive to women.

5 Midwifery and Specialised ‘Sexuality-Related Skills’

Here we will elaborate on midwifery possibilities that are both sexuality-positive and progressing. In that imagination, we have used various ‘sections’.

5.1 The Gynaecology Section

Having extensive knowledge of reproductive hormones, anatomy, and the female mind, the midwife could greatly help in caring for minor gynaecological problems and performing PAP smears. With great skills for education during history-taking and examination, especially at the first vaginal examination, they can have a significant impact on future woman’s attitudes towards gynaecological examinations [9, 10].

The vaginal gynaecological or pelvic examination can be a real challenge for girls and women. That procedure is still routinely done in some countries with the introduction of oral contraceptives. One of the drawbacks of that routine is delayed visits for contraception and thereby increased number of undesired pregnancies, especially in women with experiences of intimate partner violence [11]. In many countries, that routine is dropped, focusing on good history-taking and blood pressure checks [12].

When the vaginal examination is needed and performed, the first one can significantly impact the young woman, making her feel safe regarding her body and functions. The examination, and everything surrounding it, needs an intimate atmosphere to feel safe, and the woman needs to feel seen and heard [10]. With models of the vagina, uterus, and clitoris, the girl or the woman can better understand those parts of her body that she cannot see herself. HCPs should not underestimate the importance of the woman’s participation in the examination itself. Encouraging her to follow the examination through a mirror while the midwife narrates what they see and explain the anatomy and physiology is a way for women to get in touch with what is imperceptible to them about their genitals. Although not every woman will feel comfortable being examined, or even less via a mirror, the midwife has to consider the individuality of every client. However, encouragement to participate will make most women do so, and in this process of observation and explanation, appreciation can follow with respect and awe for the beauty of her body and its functioning.

5.2 Preconception Section

We separate this relatively new area of reproductive healthcare into two parts. On the one hand, preconception deals with the various risk factors that impair future fertility (for instance, smoking, obesity, alcohol, and especially age as a very relevant factor in the affluent Western World) [13, 14]. The midwife can guide fertility awareness and educate or counsel on retaining reproductive abilities when postponing parenthood. Here the importance of communication skills will be obvious.

The other part of preconception deals with the couple that intends to conceive- family planning period. Then the focus is not on fertility but on a smooth process through conception, pregnancy, childbirth, postpartum and healthy parenthood. The sexual aspects of that approach are addressed in Chap. 5. The real challenge here is to reach and ‘catch’ the couple already half a year before deciding on a pregnancy.

5.3 The Menopausal Section

Integral women’s health goes from birth to death. Menopause means, next to the start of a low-estrogen life and no more monthly cycles, the end of fertility. Midwives could support women also in this phase of life. Besides, more than the average health care professional, the midwife will understand the sexual implications of hormones, vaginal health, urinary incontinence, and dyspareunia. Some midwives will feel at home in this specific period of the woman’s life.

Beyond menopause, there is an era where for many societies, sexuality doesn’t seem to exist [15]. Focusing on the ageing women, midwives should draw attention to the fact that aged women are still sexual beings with sexual desire, dreams, questions, and disappointments. Few professional groups seem more appropriate for such care and advocacy than midwives.

5.4 The STI: Sexually Transmitted Infections Section

STIs will have a role in everyday practice and sexuality education for the average midwife. In the career of some of them, STI can get a more prominent place. The midwife appears to be an ideal HCP for prevention and education, diagnosis, treatment, and counselling. That will usually take place in the hospital or public health office setting. The more adventurous midwife can be an excellent HCP for education, care and counselling at music festivals, rave parties, and other major public events. The combination of many young people, alcohol, drugs, and exciting music creates situations that can result in STIs (and unplanned pregnancy).

STI care usually has a strong connection with the communities of female, male, and transsexual sex workers. Some midwives will feel at ease in the care for this group, providing contraceptive counselling, STI screening, and, where needed, psychosocial support.

5.5 The (in-)Fertility Section

Midwifery communication and skills are needed in subfertility and infertility management. Especially in women with vaginismus or sexual abuse experience, midwifery skills can be precious and welcome when vaginal procedures are required (see Chap. 11). The midwife in a fertility department might be the right person to counsel the patient, the couple, and the staff on fertility treatment’s emotional and sexual consequences. Being aware of those sexual implications, the midwife might also be the right professional to recommend considering starting with treatment of the sexual disturbance or the sexual trauma before entering the burdensome fertility trajectory.

5.6 The Contraception Section

Every midwife should be familiar with postpartum contraception and more-than-average family planning and child-spacing knowledge. In the Swedish model, the midwife is trained to deal with all phases of fertile life, knows about the sexual implications of various methods, prescribes oral contraceptives, and can also prescribe and insert IUDs or subcutaneous contraceptives.

Every midwife who participates in sexuality education in secondary school or community centres should (be allowed to and) provide emergency contraception and include aftercare and follow-up counselling.

Emergency contraception must be available around the clock (‘24/7’). In communities without other emergency health care facilities, the midwife’s office could or should offer that service.

Detailed information on emergency contraception is found in Chap. 20.

5.7 The Abortion Section

When contraception fails, abortion can be a necessary backup. Globally 30% of all pregnancies end in induced abortion, with >45% considered unsafe and an annual death rate of 26.000 women [16]. The ICM affirms that a woman who seeks or requires abortion-related services is entitled to be provided with such services by midwives [17].

Since oral treatment with ‘abortion pills’ has simplified the medical aspects, the midwife will, in many countries, be the ideal health care professional for such type of care.

In countries where abortion care is concentrated in specialised ‘abortion clinics’, the midwife could be an excellent staff member with expertise in history-taking, gynaecological and ultrasound examination, contraception counselling, psychosocial guidance, and aftercare.

Depending on the national jurisdiction, the midwife can even develop the skill to terminate pregnancies with manual or electric vacuum aspiration [18].

5.8 The Sexual Abuse and Rape Section

Every midwife should develop enough expertise to deal with pregnancy, childbirth, and breastfeeding, and with the aftermath of sexual abuse (see Chap. 24). With eventually additional expertise when expanding their field of work, some midwives will take that to a much higher level. Her bio-psycho-social skills make the female midwife a perfect partner in a rape crisis centre. She can combine emotional support with practical interventions such as physical examination, STI care, HIV post-exposure prophylaxis, and emergency contraception. The midwife’s female gender is especially relevant in direct post-abuse care, applying to 90–95% of situations where the perpetrator was male. In later treatment and trauma processing stages, a male therapist can have additional value for the abused woman to regain confidence in men.

In the 5–10% of cases where the perpetrator was female, it is paramount that a female HCP can be very frightening in immediate post-abuse care [19, 20].

5.9 The Midwife-Without-Borders Section

Midwifery is not a profession for the weak. But some jobs ask for midwives with above-average courage and stamina. During natural disasters, armed conflicts and war, midwives are needed to provide quality care to pregnant women. In wartime and among people on the run, girls and women are also at high risk of being raped. Under such conditions, there is emotional trauma and a more-than-average risk for physical trauma, STI and pregnancy. Midwives with several of the above-mentioned additional skills are dearly needed in the medical aid stations or refugee camps and behind the frontline.

5.10 The Sexology Section

Sexology can become the main street in a midwife’s career. To get there, one needs more-than-average awareness of the importance of sexuality. Given the midwife’s healthcare background, it will be logical to focus on those areas where the organic aspects of sexuality play a role. With the widening and professionalisation of sexology, subdisciplines are arising. One of them is ‘reproduction sexology’, the topic of this book, an area offering a career perspective, particularly suitable for the professional with midwifery insights and skills.

6 The Widening Field of Male Midwifery Future

We are aware that part of the midwife’s above-mentioned added value lies in her being female. That will create more trust and, in many women, a sense of ‘being understood’.

What if we change our perspective and look at the male midwife? A group that in some countries is forbidden by law or barely present. In the UK, they form <1% of the midwifery force, but in Spain and Chile 10%; in Ethiopia 33%; and in Burundi 50% [21]. Let us look at the added value of the male midwife, especially concerning sexuality-positive midwifery. We will give some examples that, in some places, will be a reality, but elsewhere still fiction.

  • The male midwife will much better understand the uncertainties of impending fatherhood.

  • During childbirth, the male midwife will better understand the male partner’s split between being concerned and the fear of showing it.

  • The male midwife can be the right person for sexuality and relationship education for boys in puberty and adolescence.

  • In case of physical or sexual abuse by men, the male midwife may be less suitable to guide the woman through pregnancy, childbirth, or fertility problems. However, being a male HCP will probably have added value to the 5–10% of women abused by females.

  • In STI and contraception, the male midwife might have more ‘convincing power’ when educating boys and men about contraception, especially condom use and vasectomy.

  • In sexuality education, prenatal courses will benefit from the participation of a male midwife in addressing the male partner role(s).

  • In educating boys and men on respecting the integrity of women, the male midwife can be very important.

  • Within the patriarchal structure of many societies, women (and men) attach more value to what men tell. As long as that is still the reality, it seems sensible to include the male midwife in women’s empowerment. His added value seems especially relevant when it comes to how the woman supposes men or her male partner to be and how she interacts with him.

7 General Recommendations for the Future

Although there are more ways to integrate the issues of sexuality and intimacy into midwifery practice and core competencies, this chapter used the ‘Swedish model’ as a starting point to elaborate on the future. We would like to believe that many professional midwifery environments have already deeply incorporated the theme into the standard midwifery management.

Midwifery and midwives can change the attitude toward how society looks at and treats women and girls and, in that way, achieve significant cultural changes in their societies.

We conclude with these recommendations for the future.

  • The midwife’s approach to sexuality should be woman-centred and holistic, focusing on physical and psychosocial aspects.

  • The approach should also be couple-centred for all women with a partner. Since intimacy is an integral part of partner sex, one cannot manage sexuality adequately without addressing and including intimacy.

  • Reproductive and sexual health care needs midwives who continue working in pregnancy and childbirth after gaining additional expertise and registration in sexology. That appears to be the ideal situation to become aware of the not-asked reproduction-related questions on sexuality and intimacy.

  • New knowledge on sexuality should be disseminated through journals focusing on midwives. For example - Sexual and Reproductive Healthcare is the official journal of the Swedish Association of Midwives, affiliated with other Scandinavian midwifery associations.

  • Midwives should be more involved in the political debate on women’s health and rights. Via private advocacy and through their midwifery associations, midwives should have an influence in creating laws that enable women to practice informed decisions regarding their reproduction.