Do midwives Need Sexology in Their Undergraduate Study Programme? Study Among Graduates of Midwifery Programme who Attended Sexology Course

The midwife is recognized worldwide as being the person who is alongside and supporting women giving birth. The midwife also has a key role in promoting health and well-being of childbearing women and their families before conception, antenataly and postnataly, includ‐ ing family planning [1]. The role expands to the field of family planning and promoting sexual health [2]. Since midwives work on the field of perinatal health, but also in the field of gynaecology and reproduction, they face different situations that are closely connected with sexuality.


Introduction
The midwife is recognized worldwide as being the person who is alongside and supporting women giving birth. The midwife also has a key role in promoting health and well-being of childbearing women and their families before conception, antenataly and postnataly, including family planning [1]. The role expands to the field of family planning and promoting sexual health [2]. Since midwives work on the field of perinatal health, but also in the field of gynaecology and reproduction, they face different situations that are closely connected with sexuality.
Despite the fact that our societies become much more open and relaxed regarding the sexual issues, there are still hindrances to discuss the issue freely with someone you are not familiar with [3,4]. So women do need trust in midwives, before they open to reveal the concerns, problems or hesitations on the topic. And midwives should be educated in how to manage delicate situations, concerning sexual problems. Definition of Midwives acknowledge midwives' role in managing sexuality [5] and International Confederation of Midwives request this competency to be met within the undergraduate education [6], but on the other side, midwifery textbooks are very parsimonious on this topic [1,7].
In order to equip the Slovenian midwifery students with knowledge and skills about managing sexuality issues, the subject Sexology in midwifery was introduced into the undergraduate midwifery programme in 2004. It ran continuously every year until today. This chapter presents the results of the evaluation of the subject, by the graduates of midwifery, who attended the course.

Background
The focus that this chapter deals with, lays in the cross-section of midwifery and sexuality, however these two components is hard to separate completely. The state of the motherhood is obviously bound up with definitions of sexuality. The interlinking with sexual identity, sexual activity and motherhood is very complex tangle to unpick [8]. Midwifery is closely connected with sexuality of a couple; the birth is the take of the period that started with the sexual act. As sexual intercourse is not just the physical act, also pregnancy, birth and processes after the birth cannot be considered only bodily -they are multidimensional in its nature, affecting emotions, social and spiritual aspects of individual. These effects are not limited only to woman, but affect the family as a whole.
The intercourse, pregnancy, childbirth, breastfeeding and establishment of new relationships after the birth are very intimate milestones of the family life. As Price [9] acknowledges: "The physical changes of woman are linked also to her views of her sexual self". Her changing physical shape reveals that she is recognized by others as a sexual being [10].This process affects all aspects of her life.
The midwife that actively enters in the life of the couple/family during these periods must be therefore consciously aware of the emotional value of these periods for the clients. Already in 1975 World Health Organization acknowledged [11]: "Opportunities for the provision of sex information and counselling are particularly likely to arise in services for maternal and child health, family planning, mental health, community health, abortion and sterilization, and sexually transmitted diseases".

Midwifery
There are many subthemes of midwifery that are closely connected to the management of issues of sexuality, however because of the above reasons, the author exposed the most evident connections, such as empathy or emotional work, communication skills and ethics.

Empathy and emotional work
Empathy is essential for the effective provision of midwifery care [12]. However, in case of dealing with sexuality issues, is even more crucial. It helps midwife not to invade in womens' intimacy. In relating empathy to the therapeutic relationship of a midwife, it is seen to require midwife to be intuitive, with the woman then being able to show the depth of her understanding of another person [13].
It was Hochschild who was the first person exposing the importance of emotions in work, however, his work was largely focused on commercial organizations. Emotional work in midwifery is of great importance, however largely unrecognized. Midwives need to work in a sensitive way in order that woman's feelings are acknowledged and responded to. To do this effectively, midwives also need to be aware of their own feelings, as their unrevealed inside conflicts can affect communication and relationship with women [14].
Students learn the emotional work during the study. The senior staff at the clinical placements are usually the role models for them and the perception changes over the educational process [15]. When dealing with problems in sexual area, it is of crucial meaning that midwives learn how to communicate and manage the feelings.
On the surface it could be presumed that midwifery is "on the happy side" of healthcare, and that only positive emotions will usually be felt [14]. But it is not always so. Midwives work also with clients that experience undesired pregnancy, live in an abusive relationship, have problems with conception, decide to end pregnancy etc. In these cases midwives need to support women even with greater emotional awareness.
The word partnership is often used to describe woman-midwife relationship. Some authors even go further and name it "professional friendship" [16]. Relationship between woman and a midwife can vary in its intensity, trust, openness and level of intimacy. This often depends on the level of reciprocity [17] and is closely connected with the way of communicating with each other.

Sexology
Sexology defined by Oxford dictionary [24], is "the study of human sexual life or relationships". On the Kinsey Institute website [25] sexology is defined in much more detail: "Sexology is the systematic study of human sexuality. It encompasses all aspects of sexuality, including attempting to characterise 'normal sexuality' and its variants, including paraphilias. Modern sexology is a multidisciplinary field which uses the techniques of fields including biology, medicine, psychology, statistics, epidemiology, pedagogics, sociology, anthropology, and sometimes criminology to bear on its subject. It studies human sexual development and the development of sexual relationships as well as the mechanics of sexual intercourse and sexual malfunction. It also documents the sexuality of special groups, such as handicapped, children, and elderly, and studies sexual pathologies such as sex addiction and child sexual abuse. Sexology is considered descriptive, not prescriptive: it attempts to document reality, not to prescribe what behaviour is suitable, ethical, or moral. Sexology has often been the subject of controversy between supporters of sexology, those who believe that sexology pries into matters held sacrosanct, and those who philosophically object to its claims of objectivity and empiricism".
The concept of sexology as a science in Europe was first proposed in 1907 by the Berlin dermatologist Iwan Bloch. His ideas were quickly embraced by interested colleagues in the same city, especially Magnus Hirschfeld, who in 1908 edited the Journal of Sexology, in 1913 co-founded the Medical Society for Sexology and Eugenics, in 1919 the Institute for Sexology in Berlin and organized the first international conference on sexology in 1921 in Berlin. Both Bloch and Hirschfeld believed that the traditional medical approach to sexual questions was too narrow and had to be broadened. Only a combination of methods taken from the natural and social sciences could do justice to the complex bio-psycho-social phenomenon of human sexual behavior [26]. The very important document that set the scene of sexology in the area of health was WHO document introduced in 1975 [11].

Sexual health and midwifery
It took several ages until the claim that all health professionals should have some basic scientific knowledge about human sex behaviour. It derived from the document on definition and promotion of sexual health by the World Health Organization [11]. That is to say, physicians and psychotherapists, nurses, hospital administrators, marriage and family counsellors, family planning officials, community health workers and even epidemiologists should receive at least some sexological training. But this enterprise is still marginalized in universities [26]. There is also an obvious shortage of interested teachers who can devote the necessary time to acquiring sufficient knowledge and skill in dealing with human sexuality to organize and lead educational programmes in this area [11].
Sexuality is essential to health and contributes to quality of life, personal development and well-being. Positive sexual experiences promote health when they generate a feeling of security [27]. Nursing and midwifery council [2] sees the role of the midwife in individual counselling, solving the sexual problems like advising women regarding the contraception (also appropriate for woman that breastfeeds), dealing with loss of libido (for example in the postpartum), giving advice regarding sexuality during pregnancy, solving the problems with discomfort of the perineum after the birth or even dyspareunia, dealing with problems of changed body image during pregnancy etc. One aspect of the midwifery care can be also advising about natural methods of family planning [28].
When women attend health-care services, there are opportunities to create a dialogue aimed at promoting their sexual health [29]. But often health professionals believe that they have insufficient education, feel poorly prepared and therefore they do not discuss sexual issues with their patients [30]. However women expect them to -in a study by Wendt et al. [31], a majority of young women approved of being asked about sexuality by midwife or clinician, because they trusted them [21]. Sexology training programs, whether academic or professional, must therefore be included in the basic study of health professionals, to improve attitudes as well as to impart knowledge [26].
Despite very clear role of the midwife in dealing with sexual issues, midwifery textbooks usually present only certain aspects of sexuality, such as contraception or intimacy during pregnancy and childbirth [28,32]. The question is, where midwifery students learn the skills and approaches to address the issue of sexual health. Health-profession students commonly state that conversation about sexuality with patients makes them uncomfortable [33]. The author identified that this field of midwifery is largely neglected, however very important for women, therefore she decided to include the subject of Sexology into the undergraduate study programme of midwifery.

Midwifery study programme and sexology
In 2004 midwifery education in Slovenia faced great changes. With Slovenia entering EU, changes of curriculum had to be made to address all midwives' competencies, according to the European directives [34]. Within the implementation of the undergraduate study programme that is delivered at the Faculty of Health sciences in Ljubljana (the only midwifery programme in Slovenia), also new subject was added to the curriculum, called Sexology in midwifery. It was composed of 20 hours of lectures and was allocated in the last (third year) of the midwifery study. It was a compulsory subject [35].
With the changes of the programme in 2007, due to the Bologna reform, subject Sexology in midwifery expanded to 15 hours of lectures and 30 hours of seminars. It was still allocated in the last (third) year of the programme, however it was not mandatory anymore [36].
The content and the aim of the subject stayed the same; however the expansion enabled to discuss the themes more in depth and the use of different forms of study provided the possibility to use other teaching methods, not just lecturing.
The contents of the study are: • views on sexuality throughout the history; • views on sexuality in different cultures and effect of the religion on the perception of culturally acceptable sexual behaviours; • perceptions of sexuality in postmodern society; • individual aspects and prejudices regarding sexual issues; • sexuality in art; • midwives role, approach and communication regarding sexual issues; • interconnections among love, sexuality, partnership, parenthood; • sexuality in different periods of woman's life; • sexuality during pregnancy, birth and puerperium; • women's sexual problems and midwifery care [36].
The goal of the subject is that students get an insight into own standpoints and attitudes regarding certain sexual issues and through the discussion identify own barriers, prejudices and hindrances for open communication about this matter with women.
At first the only method used was lecture, but later it become evident that students appreciate also debate, projects and benefit from role playing. At first the subject had an exam at the end of the course. But since the main aim of the subject was never testing theoretical knowledge of the students, the subject is now assessed on the basis of students' work within the project/ seminar and involvement in the discussion.
Since undergraduate study programme of midwifery is going to be implemented again in 2015, there was a need to evaluate the subject in order to decide, whether to still include it into the future 4-year curriculum.

Methodology and research design
With the aim of evaluating the form, content, methods and employability of knowledge and skills gained through the realization of the subject Sexology in Midwifery, which is included in the undergraduate midwifery study programme, the quantitative research method was used. For the administration of the questionnaire, author used web survey, using EnKlikAnketa [37], the tool that provides the option of transmission of the data into the SPSS programme.

Research tool
The research tool was questionnaire, developed especially for the study that evaluated all aspects of the curriculum. Questionnaire was not pilot tested, however it was discussed over with methodologist and was given to two academic colleagues to fulfil and define vague questions.
Questionnaire was composed of 16 questions: 11 closed questions, 3 semi-closed questions (with the possibility "other") and 2 open ended questions. The first two questions ("Did you study midwifery" and "Did you attend subject Sexology in midwifery") were selective -if participants answered them no, they were not able to answer all the other questions. In questions regarding the general satisfaction with the subject, satisfaction with contents and teaching methods, author used Likert scale. Participants had to answer all the questions, otherwise they were not allowed to move to the next question in the survey.

Participants, sampling
The approach was total population sampling [38] -the sample included all generations of graduates of midwifery study programme, from the year, when Sexology was introduced in the study programme, till June 2014. It consisted of 174 participants. 3 mails returned with the notification that e-mail address is not active anymore, so final number of participants included in the study was 171.

Data collection, ethical considerations and analysis
Participants were approached through the alumni club list; the request with the link to the web survey was sent to them via e-mail address. The web survey was available online from 19 th of June, till 20 th of July 2014.
When graduates were approached, they were ensured confidentiality. It was stressed for several times (in the mail and in the introduction letter of the survey) that their cooperation is voluntary. In order to ensure participants confidentiality, we did not ask about the gender (since only few graduates in midwifery are males and would feel exposed) and the year of attendance in the subject, so it is impossible to track participants from their answers.
Data from the survey were analysed with SPSS (version 20) programme. Basic descriptive statistic measures were calculated for this paper, to get the general insight into the participants' views on the subject. Some of the results of the study are presented below.

Results
112 graduates participated in the survey, 26 of them did not finish the whole questionnaire, however their answers were used, where given. That gave the survey the response rate of 65%.
The majority of the participants were satisfied with the subject, as shown in Table 1. Author asked students whether they think subject is comprehensive enough. One third of students thought it is not correctly emphasized, however the proportions of those who thought that it is too extensive and those who thought it is undervalued were evenly distributed (Table 3).

Do you think subject is correctly evaluated (3 ECTS = 90 hours of student's work)? (N=101)
N %

Yes 72 71%
No, I would wish more hours 17 17% No, I would wish less hours 11 11% I do not know 1 1% Table 3. Participants' estimation of the appropriateness of students' workload to the subject Participants were also asked whether they think the subject should be mandatory for the midwifery students. The opinions of the participants were almost equally distributed as shown in Table 4.

Yes 59 58%
No 42 42% Table 4. Participants' view about the mandatorily attendance of the subject When discussing the size of the group, appropriate for the realization of the subject, half of the participants thought that the group of 30-35 students is too large. None of them thought it is too small, as shown in Table 5.
The group is very coherent, since all participants are midwifery students of the same generation and they know each other very well; they are relaxed in the company of one another and do not feel restrain to express own thoughts. If conversation turns to intimate questions it is very important that participants feel reassured that nothing will be revealed outside the group.
What do you think about the size of the group (30-35 students)? (N=101) N %

Too large 50 50%
Too small 0 0% Just right 51 50% Since there is an interest for the subject also from other health professions (such as nursing students, occupational therapists etc.), author asked students whether they would agree for other students to join the class. More than half of the participants disagreed (Table 6). From the open ended comments, two major themes for disagreement emerged -one revealed participants' opinion that dealing with sexual issues is not relevant for other health professionals so much as for midwives; the other important issue expressed was that other (unknown) students would affect the openness and relaxedness of discussion within the group. Since there is also a tendency to open the subject for incoming students from other countries that come to the faculty via international exchange, the participants were also asked whether they would attend the subject if run in English language. 62% of students would join the subject even if lectured in foreign language.
Should other students join the subject? (N=97) N %

Yes 46 47%
No 51 53% Table 6. Participant's opinion about the appropriateness of multi-disciplinarity of the subject The question that seemed even more important than general satisfaction with the subject was whether the gained knowledge seemed useful to participants for their clinical work. Only 11% of participants did not perceive information helpful, as seen in Table 7. In the open-ended section, the most often exposed general comment of these participants was that they already knew things that were discussed/lectured about and therefore they did not see the benefits.

Do you think knowledge gained was useful for midwifery practice? (N=94) N %
Gained information were helpful for my midwifery work 63 67% Gained information were not helpful for midwifery work 10 11% Otherwise: 21 22% Table 7. Participants' opinion regarding the usefulness oft he gained knowledge for their clinical work When asking participants regarding the satisfaction with the specific content of the subject, it was obvious that majority of the participants were satisfied with all included contents; the satisfaction ranged from 69% to 89%, depending on the theme. Students evaluated as best the lecture about "sexuality through history", while the content "sexuality in art" was least appreciated. More details on the evaluation of the content of the subject can be seen from the Table 8. Only few participants gave concrete answers on the open comment, where they were asked what else they think should be added as a content in the subject. Some of them proposed themes such as: sexuality of disabled people, more about the relaxed conversation with couples regarding the sexual issues. Some did not see the relevance of lectures like "sexuality through history" or "sexuality in art"; this didn't seem relevant to them for their professional work. On the other side, some of the participants would like the listed themes to be debated in much more details.
Author asked participants also how they liked different approaches to teaching that were used. The evaluation of the study methods by participants is presented in Table 9. The most negative response was to seminar work and they liked debates the most. The majority (90%) were satisfied with lectures. It might be concluded from the results that they prefer conventional teaching methods.  Table 9. Participants' satisfaction with teaching methods of the subject Next question asked participants, which method do they think would be the most appropriate to teach and learn about sexuality. Their responses are presented in Table 10 -again it was confirmed that they would like more debates and guided conversations on the topics. In the category other, they exposed also field work. Again it is very clear that they do not estimate seminar work as useful in gaining knowledge on the topic. Since the aim of the subject is that participant gets the insight into their own attitudes and believes and that they relax in conversation about the delicate theme such as sexuality, the author questioned whether the exam is needed at the end of the subject. However, as presented in Table 11, only 12% of participants thought the subject should not be marked. The majority thought that the most appropriate would be to mark the exercises and home works they were assigned to.
Which type of the evaluation do you think is appropriate for this subject? (N=89) N %

Written exam 11 12%
Oral exam 12 13% Mark of the exercise (seminar, project etc.) 33 37% Collaboration in the debate 12 13% Subject should not be marked 11 12% Other 10 11% Table 11. Participant s' opinions about the most appropriate examination at the end of the subject In the category other, where students had an opportunity to explain their selection, the majority of propositions contained the idea of combining the above mentioned methods of evaluation. The most common combination was the mark of the assignments and the consideration of student involvement in the debates.

Discussion and conclusions
Midwifery is, as shown in the literature, closely connected to sexuality. Midwives should be those in the relationship that give woman permission and stimulation to raise also questions regarding the topic. In order to promote women's sexual health, there is a need for improved dialogue between patients and health professionals; midwives and clinicians have the main responsibility to initiate this dialogue. Communication between patients and professionals is an important part of health care [21]. Women, however, seldom raise questions regarding sexual problems [39]. And as seen from the literature, midwives and clinicians might fail to raise questions due to a series of obstacles [20].
Wendt et al. [21]. claim that one of the problems can be also that only a minority of clinicians, midwives and nurses have vocational training in sexology, and suggest that increased knowledge, support and opportunities for reflection concerning dialogue regarding sexual issues might evoke the interest and intent of health professionals to approach these issues. Authors [40], albeit considering other aspects of midwifery care connected with sexuality, suggest that critical thinking around the cultural and moral dimensions of sexuality should be emphasised in undergraduate training and continuing education, to help nurse-midwives and other health practitioners to deal more empathetically with the sexual matters.
The described subject "Sexology in midwifery" that was included in the undergraduate study programme of midwifery, aimed that midwifery graduates would understand the connection between sexuality and midwifery. However, the goal was not only to raise the awareness, but also to reflect upon students' individual perceptions and attitudes. When woman experiences problems in sexuality it is of great importance that midwife is capable to act as an emphatic professional. And there is a close relationship between attitude and behaviour [41]. Therefore it is important that student midwives are aware of their own beliefs and how these attitudes affect their professional acting and judgement.
WHO [11] identified three necessary stages in educating health professionals regarding the sexuality: • in order to develop a better understanding of problems of human sexuality, it is necessary for health workers to develop healthy attitudes to sexuality, marriage, and contraception. An understanding by the worker of his/her own sexuality and a rational approach to his/her own sexual problems will help him/her to be better able to deal with the problems of others; • in order to approach the topic with confidence, the health workers must themselves have accurate scientific knowledge regarding the facts of human reproduction and human sexuality; they must know what are the common sexual problems and how to deal with them; • to enhance his or her ability to help those people who ask for help in the solving the problems related to sexuality, it is essential for the health worker to develop the necessary skills in the art of communication and good listening.
The contents of the teaching about the sexuality can be extracted from the above WHO's suggestion. WHO [11] document also warns that "where sexology is a part of the health study programme, emphasis is frequently on deviancy and pathology rather than on normal sexual development and behaviour". It can be claimed that normal sexuality is satisfactory covered in the midwifery curriculum. It is also obvious that the contents of the subject "Sexology in midwifery" are not prone to pathological sexual behaviour. The contents also do not deal only with the topics, relevant to manage sexual issues in perinatal period, but are more spread in order to give graduates the broader insight. Some of the participants did not see the relevance of certain contents, however attitudes and believes can be changed also with the subtle impressions that sometimes are not directly connected [42].
Already in the document of WHO was acknowledged that different methods in teaching about sexuality can be used to attain the best outcome: "in the more developed programmes there is a considerable amount of methodological experimentation and innovation; among the methods being tried are: panel discussions, male-female teaching teams, videotape case presentations, guest speakers from the community, and survey questionnaires for assessment of sexual attitudes and knowledge. A number of teaching methods have been selected because they oblige students to confront their own attitudes, values, and feelings regarding sexuality. Examples of these are the use of frank sexual films followed by small group discussions; interviews with homosexuals; role playing; and other methods requiring the active involvement of the learner" [11]. Especially meaningful are the methods, which enhance student's active involvement, like debates and role playing. That was identified as beneficial also from the opinions of participants in the study presented. However the debate must be grounded on the solid theoretical base that defines the theme. In order to achieve that, author often used combination of lectures and discussion.
Some of the methods, suggested by WHO [11] are in details described by Haeberle [26]: "in the USA they provide special programme for health professionals to enlighten them with different sex behaviours and prepare them to work confident but still with sensitivity with different sort of patients". These approaches certainly provide experience that leave a strong impact on the students' minds; however some of the described methods would be impossible to use in Slovenia, due to different cultural context, and lack of options. Nevertheless, both references give very clear idea that the main goal of this education is not only to teach health practitioner the approaches to discuss sexual health with clients, but aim at affecting participants' believes and prejudices. Similar than in foreign studies [43], it was exposed also by Slovenian participants that they would want more practice-based educational methods. Foreign authors acknowledge that this is hard to provide, because of the ethical barriers [43] and therefore suggest a model, where theoretical knowledge is reinforced practically with practice based scenarios and mentor emulation as staging points, which help to develop confident practice. Other authors [44,45]. agree that problem-based scenarios can successfully replace lack of concrete situations and stimulate critical thinking.
The subject "Sexology in midwifery", taught in the undergraduate midwifery programme was overall good accepted by the students and almost all the graduates were satisfied with it. It seems that majority support the decision to put the subject in the last year of midwifery study; students are more mature, they already gain clinical experience and are well theoretically versed into the midwifery matters. Results confirmed the authors' anticipation that participants feel more relaxed in a homogenous group of midwifery students; many expressed restrains to be a part of the group of different unknown students.
Overall it seemed that subject covers the contents they expected (they did not give a lot of new suggestions to be included), however it could be improved via different and more various teaching methods. The very obvious message that derived from the results was the fact that participants would like more discussions. In parallel with this goes also their suggestion of dividing students into smaller groups. WHO [11] allows that human sexuality is taught as a required or an elective component of education. What is important is that the course organizers develop programmes that are appropriate, in both curriculum content and educational method, to sociocultural factors, the needs of students, and the health needs of the local population. It seems that the decision to alter the subject from mandatory to selective in 2007 was justified, since not all the participants are prepared to attend it and not all see the benefits of the contents for their clinical expertise, as proven from the participants' answers.
The dilemma regarding the evaluation in the subject still remains; author is aware that the theoretical exam undervalues the real aim of the subject, since the goal is to affect individual's thoughts. The final examination is however always a teacher's judgement of value [46]. Estimation of student's input in the case of revealing personal and intimate experiences, thoughts and perceptions can be also a matter of ethical question; the students might feel that a bad mark is a reflection of their unconventional opinions and expressed negative thoughts during the study. Therefore the authors' opinion is veering in the way of not marking the subject at all, however it seems that participants do not perceive that kind of hindrances as author.
The presented study has its limitations. For the in-depth information qualitative approach would be more appropriate, however for the first step of the study of evaluation of the subject, only a general overview was sought. The author is aware of the web-survey limitations [47,48], but this approach also has major advantages -it is more economical, time effective and since it is adjusted to the population that was researched (students frequently use technical equipment) can improve response rate [49]. The main limitation of the research tool was that participants had to answer all the questions otherwise they were not allowed to move to the next question, which resulted in the loss of participant when progressing through the questionnaire. Still the study provides useful information how to improve the subject and gives the author the confirmation that these topics are relevant to midwives and that the general form of the subject is solid and fair.