gms | German Medical Science

One of the factors that can impact the health development of children is family psychosocial stress [13][48]. Some of the documented consequences of this stress include significant behavioural problems [13][48], delayed cognitive development and reduced affect regulation among children [48]. Some authors claim there is a correlation between increased vulnerability to physical and mental illness in adulthood and psychological stress in childhood [6].

According to a representative study of psychosocial stress among parents, around 13 percent of families with newborns are highly stressed thus emphasising the need for early prevention. A family is defined as highly stressed if at least four of the following characteristics apply: single parent, unplanned pregnancy, childhood dysregulation, high parental stress levels, parental impulsiveness, parental exposure to relationship violence, frequent conflict between spouses or partners, high risk of anxiety disorder or depression, negative childhood experiences of parents, welfare benefit recipients and maternal age under 21 years at the birth of the child [7].

Since 2012, as part of the German Federal Initiative for Early Prevention (Bundesinitiative Netzwerke Frühe Hilfen und Familienhebammen ([17] Section 3 Para. 4) [45], support has been provided for the development and expansion of specific services with the aim of improving children’s development opportunities within the family environment [25]. Cooperation between health care and child and youth welfare professionals is emphasised as key to the fulfilment of this objective [27].

The notion of family midwives as partners in early pre-vention is explicitly enshrined in the German child abuse prevention law (Gesetz zur Kooperation und Information im Kinderschutz ([17] Section 3 Para. 4). Family midwives are certified midwives with an additional qualification. They provide physical and psychosocial support and advice to families in greater need of support during pre-gnancy and the first 12 months of the baby’s life [14]. Family midwives are appointed and remunerated by the public health service, child and youth welfare services, independent welfare organisations or foundations and associations [14][23]. There are several studies substantiating the finding that interprofessional cooperation is a key feature of the work of family midwives [2][14][16][22] ([33] p.11). To some extent, debates about needs-oriented care for highly stressed families are conducted in the context of a shortage of family midwives in Germany [26][27].

In addition to family midwives, freelance midwives are also urged to cooperate with the early prevention networks as “relevant actors from the health care system” ([45] Art. 2 Para. 3). All women are entitled to midwife care as a standard health care benefit ([39] Section 134a) during pregnancy, birth, and in the postpartum and breastfeeding period. Midwife care also targets pregnant women and mothers with particularly high levels of social or medical stress [14][23]. Freelance midwives are not as involved in the early prevention networks as family midwives [19]. The development and expansion of early prevention networks in Germany has been accompanied by calls for cooperation between freelance midwives and the actors in this field. This has raised fundamental questions about the interprofessional cooperation of midwives.

An integrative review revealed very few studies focusing exclusively on interprofessional cooperation from the perspective of the midwife. In the majority of studies on this subject, the midwife’s perspective is subsumed under a cross-disciplinary view [35].

Midwives in Sweden, Australia and Germany see cooperation with the health and social care professions as advantageous in the context of caring for women and families in greater need of support [3][4][29][30]. This cooperation helps midwives make contact with women and families that are usually difficult to access, which, in turn, facilitates the development of a relationship with these families [29]. Midwives also state that they benefit from attending interprofessional meetings where the problems arising from specific cases [30] and the psychosocial needs of families are discussed [36]. By attending interdisciplinary case conferences, midwives acquire competences that enable them to better assess families facing problems [3]. Midwives and child and family health professionals in Sweden and Australia are of the opinion that effective networking at the transition between antenatal care, postpartum care and child health care also benefits the parents. In both countries, care for women and their babies during pregnancy, birth and the postpartum period is provided by midwives [4][15]. Moreover, there is established health care covering the period from birth to early childhood provided by child and family health nurses in Australia and child health care nurses in Sweden [4][15]. The successful cooperation between the two groups of professions means parents feelings of confusion and being“lost in the chain of care" [4] can be avoided. Effective professional relations between the various relevant actors help develop positive relationships with the families and ensure that contact is maintained with them in the longer term [31]. According to a German study, developing patient relations also results in confidence building being ascribed constitutive significance [8]. The study emphasises the autonomy of the patients who have to actively place their trust in the professional caring for them. This trust should not be considered an unquestioned personal resource [8].

Interprofessional working relationships are the key to the success of innovations at the transition of care from maternity to child and family health services [29]. With a view to acquiring a more in-depth understanding of Australian midwives’ working relationships, respondents were presented with a list of professions and asked to select those with whom they cooperate most frequently. This revealed that midwives tend to foster cooperation particularly with related health care professions. The esta-blishment of working relations with the other actors is often very time consuming and maintaining those relationships frequently proves to be rather difficult [31]. The Australian study also shows that midwives and other professions attach more importance to the relationship dimension in terms of intensity of cooperation than to organisational factors [31]. This finding was corroborated by a Norwegian cross-sectional study of 1,418 employees from the health and social care system who attached less importance to management structures and formal factors than to interprofessional relationships [5].

A relationship based on respect and trust was seen as crucial for successful interprofessional cooperation [5][37]. In answer to the question as to the most im-portant factors for the achievement of effective cooperation, midwives, doctors, child protection workers and public health nurses in Norway rated trust and respect highest followed by collaborative competences [5].

As part of the planned integration of midwives in early prevention networks in Germany, they are urged to cooperate with the various health and social care professions. In this context, it would be of particular interest to gain an insight into the perspective of freelance midwives on cooperation with the actors in this field.

This article presents the partial results of a study which aims to acquire empirically based insights into interprofessional cooperation between freelance midwives and actors in early prevention networks. The study focuses on the midwife’s perspective.

The key research question that the excerpt of the study presented in this article seeks to address is:

What, in their own opinion, are the key concepts that shape the behaviour of freelance midwives in the context of interprofessional cooperation and early prevention?

To address the research question, a qualitative design was selected. This was a well-suited approach to enable us to gain an insight into facets of midwives’ daily work on which there has been very little research to date. Qualitative research methods aim to describe the “actions and interactions of the subjects” ([9] p.27) in their day-to-day lives. Qualitative research helps us to understand and explain the data ([44] p.5). The objective of this approach is to give us a more detailed insight into social realities and reveal processes, interpretive frames and structural features ([10] p.14). The target group for the study comprised freelance midwives providing at least one of the following services on the basis of the agreement on the provision of midwifery care (Vertrag über die Versorgung mit Hebammenhilfe ([39] Section 134a): midwifery services during pregnancy, childbirth and/or the postnatal or breastfeeding period. The amount of freelance work carried out by the midwife should fulfil a minimum requirement of at least ten hours per week to ensure a reasonable minimum level of experience.

In order to capture contrasts at the regional level, study participants were recruited from across Germany. The fact that the primary author herself is a practicing midwife and a member of the German Association of Midwives (Deutscher Hebammenverband e.V.) provided excellent access to the midwifery profession. Local mailing lists were used and the project was publicised at the Association’s meetings and conferences where attendees were urged to participate. Access to the field was also gained through the support of gatekeepers as well as a call for participation in the study which appeared in German midwifery journals.

Data collection was based on 27 script-based problem-centred interviews [46] which were digitally voice recorded and then transcribed. The script comprised several dif-ferent thematic blocks covering interdisciplinary cooperation between freelance midwives and the health and social care professionals or respondents’ understanding of early prevention, for instance. In order to ensure openness in the interview, the script questions were adjusted according to the course of the conversation and interviewees were allowed to decide which specific themes were most relevant ([46] p.57).

A typical characteristic of the problem-centred interview is that it ties in with the inherent theoretical and scientific knowledge of the researcher ([20] p.333). This means the interviewer has a better understanding of the statements made during the interview and can pose problem-centred follow-up questions [47]. The openness and theory-oriented data collection process subsequently enables a suitably thorough evaluation of the data ([46] p.53). Against this backdrop, the problem-centred interview is considered to be more suited to our purpose than other interview forms.

Socio-demographic data about the participants is col-lected using a short questionnaire. Initial ideas regarding the interpretation of this data are noted in a postscript.

Midwives were selected based on the principle of theo-retical sampling ([11] p.61-91)([43] p.148-52) with the objective of determining different facets of the issue being analysed ([44] p.22). Theoretical sampling means that, throughout the entire period covered by the study, a parallel process of data collection and analysis is con-ducted and, at the same time, decisions are made as to who should be included in the research next ([12] p.151). Consequently, when it became apparent at the end of the first phase of the analysis that only a small number of midwives were active in local networks, researchers then specifically looked for freelance midwives who were involved in early prevention projects in their federal states or who had additional competences in the field of early prevention. To provide a contrast, interviews were con-ducted with midwives with many years of experience as well as with those just starting out in the profession. The rationale for this was that the analysis suggested a correlation between professional experience and the form of cooperation. Once “theoretical saturation” ([11] p.76-7) had been reached, i.e. no new information was obtained that contributed to the development of additional characteristics of the categories, the sampling process was concluded.

Data evaluation was conducted using qualitative text analysis in line with Kuckartz’ ([18] p.100) approach which is heavily based on hermeneutics ([18] p.17-8). This emphasises the interpretative form of contents analysis according to which text analysis is a “process of human understanding and interpretation” ([18] p.27). The method of analysis selected appears especially suited to this study because it enables us to integrate pre-exis-ting knowledge and, at the same time, incorporate analy-tical perspectives into the process.

Case summaries and memos were created for all interviews ([18] p.57-62). This enabled us to develop an overall understanding of each interview text based on the research questions ([18] p.58). The case summaries constituted the basis for formulating the key themes which, in turn generated the provisional primary catego-ries. Additional primary categories were developed based on the script. The process of creating the categories was both inductive and deductive ([18] p.62). During the initial phase, a wide range of interpretations emerged in the form of memos, which during the later stages of the analysis became more detailed. This proved to be an important step in the process of category development. In an initial coding process, all existing material was coded based on the primary categories. In a second step, subcategories were created based on the material assigned to the relevant primary category.

The research followed Steinke’s quality criteria ([41] p.323-31). Interpretations of the data produced by research groups comprising experts from the fields of nursing and midwifery sciences at Osnabrueck University of Applied Sciences and deliberations on the creation of the categories with the co-author were a key component of the research process and ensured intersubjective transparency. Empirical anchoring is secured through quotes which relate the categories back to the statements made by respondents.

Ethical clearance for the research was received in March 2014 at Witten/Herdecke University. Participants signed a statement of informed consent.

The midwives questioned (n=27) had an average age of 41.4 years and average professional experience of 16.6 years. The interviews were conducted in urban and rural regions in 13 federal states across Germany. The duration of the data collection phase was June 2014 to February 2016. Data analysis was conducted in parallel and was continued after data collection had been completed. The majority of midwives interviewed were exclusively free-lance (70 percent, n=19), whereas 30 percent (n=8) combined their freelance work with a hospital position. Postnatal care was the most frequently provided service and, in fact, was carried out by all respondents. This was followed by antenatal care. A total of 45 percent (n=12) of the midwives questioned performed obstetric duties though the majority of these (26 percent, n=7) assisted with births in the context of a salaried hospital position.

The study explores the freelance midwife’s view of their cooperation with actors from the field of early prevention. The establishment of trust between midwives and their clients was identified as a key factor in freelance midwives’ involvement in early prevention. This is reflected on two levels: in the working relationship between the midwives and their clients and in midwives’ cooperation with child and youth welfare professionals.

With regard to establishing a relationship of trust between freelance midwives and the clients they care for, respond-ents emphasised the importance of the trust women put in them. In the experience of some midwives, their professional status automatically means people have confidence in them. They often benefit from “a fundamental level of natural trust”:

In the opinion of the midwife quoted here, she does not need to do an awful lot to establish trust with the women she cares for. She benefits from a fundamental level of trust, apparently anchored in tradition, that is associated with the midwifery profession. Another midwife describes the situation in similar terms stating that women autom-atically trust her which, compared to other professions, she finds “actually slightly undeserved”. However, not all interviewees have had the same experience. Sometimes the trust between a woman and her midwife still has to grow over the course of the care situation. One freelance midwife emphasises just how long it can sometimes take to establish trust:

This respondent demonstrates that it is sometimes hard work gaining women’s trust. Although the building of the relationship is a time-consuming process, she sees this as part of her professional responsibilities. Confidence building is thus seen as the basis of the working relationship between the midwife and the woman in her care.

If midwives are subjectively critical of their client’s family situation, they sometimes abandon their conventional care principles and limit the focus of their work to maintaining trust with their client. In situations like this, trust becomes a key element in the formation of professional relationships with the objective of ensuring that access to these women is not lost.

The midwife draws on her client’s resources and puts access to her client above her professional expectations of a good mother-child relationship. “To have a good re-lationship of trust” has become a targeted approach for this midwife in order to “prevent the worst from hap-pening”. This possibly means she is pushing herself to the limits of her abilities.

However, for midwives, the loss of women’s trust has also become a subject of discussion. This aspect comes to the fore at the interface with early prevention such as when a family midwife is brought on board or in the context of cooperation with child and youth welfare services.

Freelance midwives consider the continuation of an established relationship of trust with a client to be important when they hand over care to a family midwife.

In the experience of this midwife, joint home visits with an freelance midwife and a family midwife can prevent the client from losing trust in the midwife. Another midwife describes her concerns regarding the transition of care to a family midwife as a “relationship of trust reaching a tipping point”. The strategy she uses to address the sit-uation is similar: she would like to see freelance midwives and family midwives “working together as a team”. By this she means that she would continue her work as an freelance midwife while the family midwife visits the client “in addition” to her.

For an freelance midwife supporting her clients during the antenatal period, childbirth and during the postnatal and breastfeeding period, handing over to a family midwife is something rather inconceivable. Her strategy to ensure she does not lose the trust of her client is:

Through this midwife’s contact with her client, a trusting relationship has evolved. Against this backdrop, handing a client over to a family midwife represents a loss for the midwife. Although she is aware of the services offered by family midwives, she would not necessarily always refer her client to one. The relationship of trust is apparently functional for the midwife, the woman’s needs may be subordinate to this. The same midwife states that she has, so far, had barely any experience of a situation like this which she attributes to the fact that her clients are usually “educated or contemplative” and that she tends not to look after those families “in greater need of support”.

In the interviews, respondents raise concerns that they will lose women’s trust due to their cooperation with the Youth Welfare Office. For example, one midwife describes how a mother ceases contact with her because she assumes that the midwife is collaborating with the Youth Welfare Office.

This midwife experiences a woman withdrawing trust in her as a result of her assumed cooperation with the Youth Welfare Office. Although, according to the midwife, there never was any contact with the Youth Welfare Office, we are surprised by the extreme sensitivity of the client here whose relationship with the Youth Welfare Office is clearly marked by fear. The client’s relationship with the midwife comes to an abrupt end. According to the midwife, this is manifested by the client, with whom she had initially had a trusting cooperative relationship, suddenly “flicking the switch”.

The fear that cooperating with child and youth welfare services could result in a loss of parents’ trust is expressed by a young midwife who, parallel to providing family support through the Youth Welfare Office, also provides postnatal care to a client. In her experience, a simple conversation between individuals from these two professions on the doorstep of a client’s house can have major consequences.

This midwife provides us with an insight into the family’s concern that she might be too close to the Youth Welfare Office. She witnesses just how closely the family observes her actions. This is illustrated by the parents explicitly raising the conversation she had had with the representative of the Youth Welfare Office on the doorstep of their house, insinuating that that there was some kind of dialogue that they were not happy about. What is also apparent is the midwife’s quandary as she is concerned that the trust in the relationship with the parents may have been undermined.

Confidence building between midwives and their clients is an important aspect, also with regards to relationships between professionals (in this case between freelance midwives and actors from child and youth services). Some midwives use women’s trust to set themselves apart from the Youth Welfare Office, others build on this trust to make the hand over easier.

For some midwives, in the context of cooperation with the Youth Welfare Office, gaining women’s trust becomes part of a strategy: they use this trust to distance themselves from child and youth welfare services.

This quote illustrates how the midwife uses stereotypes about her own profession as well as the Youth Welfare Office to draw a distinction between the two disciplines. The midwife generalises her position to emphasise her point. Her argument denies the Youth Welfare Office any type of relationship of trust with women. This might expose her lack of knowledge regarding the support services provided by the Youth Welfare Office. Another midwife sums up the situation along similar lines:

This respondent also uses stereotypes in her argument which can be summarised as follows: midwives enjoy a trusted status, the Youth Welfare Office, in contrast, does not. The argument reveals a perspective characterised by distance from the Youth Welfare Office.

At the same time, freelance midwives build on women’s trust in order to refer them to the services offered by the Youth Welfare Office, where necessary. In the experience of some midwives, the Youth Welfare Office is “associated with a great deal of fear” for some women and their services are thus rejected. The midwives interviewed saw this as an opportunity for them to inform their clients about the support options available and, if necessary, refer them to other types of help.

The midwife quoted above draws on the existing relationship of trust with her client in order to relativise prejudices and inform her about early prevention services.

Another midwife behaves similarly. She is aware that women might be afraid that their children could be taken away. She reassures her client, clarifies the situation and lastly, with her permission, puts her in touch with the Youth Welfare Office. Subsequently, her client receives support and relief from the Youth Welfare Office.

In summary, the relationship of trust with the client is a key concept shaping how midwives are involved in early prevention networks. Trust therefore assumes particular significance, also in terms of cooperation with social welfare professions.

The study’s starting point was to examine the interprofessional cooperation between freelance midwives and actors in early prevention networks. The focus of the analysis is the relationship of trust between the midwife and her client in this field. What was striking in the interviews was the heavy emphasis on building trust with clients which also appears to be a key concept in the context of cooperation with actors from early prevention networks. At the same time, this trust also shapes the structure of the relationship between midwives and professionals from child and youth welfare services.

The midwives interviewed construed trust as a key element of the working relationship. These findings correspond with statements in the specialist midwifery liter-ature: confidence building is described as “the basis of the relationship between a woman and her midwife” ([1] p.33), as “an essential aspect of relationship building” ([38] p.21) as well as the “heart of midwifery work” ([38] p.21). The inherently high level of trust that society automatically places in the midwifery profession has already been outlined in Lange and Liebald [22]. Rettig, Schröder and Zeller [33] also address the trust aspect of the relationship between family midwives and their clients and in this context identify trust as “something that requires constant effort by both the family midwife and the client” ([33] p.129). Ayerle also documents the fundamental importance of the relationship of trust between family midwives and women [2].

In view of the trust invested in midwives, their involvement in early prevention networks is emphasised. The result of this is that midwifery services are regularly used and therefore not seen as stigmatising [32]. Moreover, the relationship of trust is protected thanks to the midwife’s duty of confidentiality ([24] p.78)([42] Section 203).

Confidence building between the midwife and her client has a variety of different facets. Several of the midwives questioned use the relationship of trust as a targeted approach when caring for women in difficult life situations in order to maintain access to those clients. What is striking here is that midwives primarily draw on the exist-ing resources of their client. A study on the work of family midwives ([33] p.122) shows that creating a professional relationship between family midwives and their clients can be aimed at maintaining their ability to act by praising and empowering those in their care. The authors of the study interpret this way of forming the relationship between the family midwife and her client as “the lowest common denominator” ([33] p.124). Since both midwives and family midwives use the relationship of trust strategi-cally this could be interpreted as part of midwives’ professional self-perception.

Other midwives build on women’s trust to enable them to refer their clients to the help provided by child and youth welfare services. Given that freelance midwives are under no obligation to cooperate [26], here, the high level of willingness of midwives to cooperate is evident. This is something that Ayerle, Mattern & Fleischer [3] have also described. Another study ascribes freelance midwives as well as the Youth Welfare Office and counselling centres an intermediary role placing women in contact with family midwives [2]. The legislature evidently also sees the importance of the role played by midwives in this field and in 2015, the Preventative Health Care Act (Präventionsgesetz [28]) came into force extending midwifery support during the postnatal period from eight to twelve weeks ([39] Section 24d).

Several of the midwives questioned found it difficult to refer women to early prevention services because they were worried about destroying the relationship of trust they had with their clients. Sayn-Wittgenstein, Lange and Knorz [34] also established that, in the event of clients requiring additional support, midwives very rarely referred those women to professionals from other fields. The reasons identified for this were midwives overestimating their own abilities as well as competitiveness. This study substantiates the authors’ assumption that, given the desire to protect personal interests, the needs of the user are not always given priority [34]. It becomes evident that, in the context of cooperation with child and youth welfare services, some midwives are more focused on distancing themselves than acting as intermediaries. They reveal a perspective that could limit the willingness to cooperate. The hesitant approach to cooperation with professionals from child and youth welfare services on the part of health care professionals is also described in the Interim Report of the National Centre for Early Prevention (Nationale Zentrum Frühe Hilfen [26]). This is explained by the lack of awareness on both sides of the system and rationale for action of the other which hampers cooperation and mutual understanding. It is observed that not all health care professionals are familiar with the support provided by child and youth welfare services [26]. It is possible that the tendency of some midwives in this study to want to distance themselves could be the result of a lack of knowledge about early prevention services as well as the working practices of those in other professions.

Some midwives stated that they rarely had clients in greater need of support. Further studies also evidenced that pregnant women with particularly high levels of social or psychological stress, single pregnant women and pregnant women with a migrant background are less likely to use antenatal care [34][40]. Freelance midwives’ care mandate does not exclude vulnerable women, however [14][23].

The study illustrated the significance of confidence building between midwives and their clients in the context of the cooperation of freelance midwives in early prevention networks. Further research on this topic is required. One area that would be interesting to explore is the user perspective on the cooperation of freelance midwives in the context of early prevention. The objective here would be to acquire an understanding of whether the women themselves see cooperation between different profes-sionals as being of benefit to their obstetric care.

This article provides us with an insight into the importance of the relationship of trust between midwives and their clients in the context of midwives’ cooperation in the field of early prevention.

With respect to data collection, there are limitations in terms of the generalisability of the findings as respondents were a specifically selected group of freelance midwives. The representation of the perspective of these freelance midwives is in line with the study’s main area of interest. The approach taken to data analysis enabled us to achieve a limited level of abstraction and the find-ings should thus be considered preliminary.

The significant focus on confidence building emphasises its fundamental importance for the involvement of free-lance midwives in early prevention. For freelance midwives, the challenge is to carve out their role as a cooper-ative partner in early prevention networks without undermining the trust women have in them. To ensure the successful fulfilment of the requirement, stipulated by law ([17] Section 3 Para. 2) for the involvement of free-lance midwives in early prevention networks, based on the study’s findings, the following conclusion should be drawn:

The early prevention networks should be structured in such a way that the concerns regarding the loss of women’s trust do not present an obstacle to midwives’ cooperation in early prevention networks. This requires clear and comprehensible framework conditions for all actors involved in the networks. Moreover, a prerequisite for the success of freelance midwives’ involvement in early prevention is a trust-based working relationship with their clients. This requires sensitive handling of women’s trust through strict adherence to confidentiality, for instance. Otherwise there is a risk that freelance midwives’ involvement in early prevention networks will be at the expense of the relationship of trust between the midwife and her client. In order that midwives can develop their full potential in the early prevention networks, without jeopardising the relationship with their clients, they need to have an in-depth understanding of early prevention structures as well as an insight into the roles of all participating actors.

The data used for this study was collected as part of the research professorship entitled "maternity care” (Familienorientierte geburtshilfliche Versorgung, FageV) funded by the Ministry for Science and Culture of the State of Lower Saxony (Niedersächsische Ministerium für Wissenschaft und Kultur) ("Nds. Vorab"; FKZ: 11-76251-33-2/12). The research group “family health in the life course” (Familiengesundheit im Lebensverlauf, FamiLe), under the auspices of which this study was published, is funded by the Federal Ministry for Education and Research (Bundesministerium für Bildung und Forschung, BMBF) (FKZ: 01KX1113B).

The authors would like to thank the midwives who par-ticipated in this study.

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

There is no conflict of interest.