Midwifery 84 (2020) 102653

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Midwifery
journal homepage: www.elsevier.com/locate/midw

A theory of the aims and objectives of midwifery practice: A theory

synthesis ✩
Mirjam Peters a,b,∗, Petra Kolip a, Rainhild Schäfers b
a
Bielefeld University, Bielefeld School of Public Health, Germany
b
The Hochschule für Gesundheit, University of Applied Sciences (hsg), Department of Applied Sciences, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Every discipline has a dichotomous objective by which it recognizes whether its work has
Received 16 November 2018 been successful (Vogd, 2011). For midwifery care, no objective has been set in this way so far. This also
Revised 22 January 2020
has implications for measuring quality, because quality of care is only measurable if objectives have been
Accepted 23 January 2020
identified. This paper aims to contribute to theory formation in midwifery science by analysing exist-
ing concepts and theories and preferences of women to midwifery care to answer the question of the
Keywords: dichotomous objective of midwifery.
Midwifery
Theory synthesis Method and findings: The method of theory synthesis (Walker and Avant, 2011) was used to analyse ex-
Model isting theories and concepts of midwifery care and literature-based preferences of women to midwifery
Midwife care and synthesize them with regard to the objectives of midwifery care. The synthesis took place in the
Birth form of a means-end chain to extract the dichotomous target of midwifery care. In this way, the objec-
Antenatal care tives of midwifery could be compared and linked from both the scientific and from women’s perspective.
Postnatal care The resulting means-end chain model of the process of midwifery describes the aims and objectives of
midwifery from the point of view of women on three levels.
Discussion: The hierarchical model of the process of midwifery presented here is a first attempt to il-
lustrate the aims and objectives of midwifery practice in a means-end chain model in order to facilitate
discussion on the topic and to make the quality of midwifery care measurable. Measurement is a first
step towards improving quality of midwifery care and thereby improving women’s reproductive capabil-
ities.
© 2020 Elsevier Ltd. All rights reserved.

Introduction
According to Vogd’s sociological theory of organized medical
treatment (2011), every discipline has a dichotomous objective by
which it recognizes whether its work has been successful. In the
medical field, for example, this objective is whether someone has
been cured or not. So as a doctor, a good job was done when the
patient was cured. The objective of care is whether someone is
cared for, i.e. can be integrated into his family and his culture. As a
nurse, a good job was done when this objective has been achieved.
So this dichotomous goal is primarily aimed at why, at the purpose
✩
This article is based on the assumption that each individual woman defines the
term ‘family’ for herself. Subsequently, the term ‘woman’ refers to users of mid-
wifery services, including partners, other children and significant others defined by
a woman as family.
∗
Corresponding author.
E-mail address: mirjam.peters@hs-gesundheit.de (M. Peters).
of one’s own work (Vogd, 2011). For midwifery care, no objective
has been set in this way so far.
Making one’s own goals explicit makes it possible to better rep-
resent one’s profession in relation to other professions and users
(Vogd, 2011). In addition this has implications for measuring qual-
ity, because quality of care is only measurable if objectives have
been identified (Deutsche Institut für Normung e.V., 2015). Thus,
quality measurement requires comparable goals and objectives, if
possible also internationally. Because quality measurement is the
first step towards quality improvement. This is intended to provide
(even) better care for users (Hoope-Bender et al., 2014).
Very few middle-range or grand theories exist in midwifery sci-
ence (Dickson, 1997; Fleming, 1998; Kennedy, 20 0 0; Renfrew et al.,
2015; Thompson et al., 1989). They use similar and often overlap-
ping concepts, yet rarely identify the objectives of those concepts
with regards to midwifery practice.
This paper aims to contribute to theory formation in midwifery
science by analysing existing concepts and theories of midwifery
science and literature based preferences of women to midwifery

https://doi.org/10.1016/j.midw.2020.102653
0266-6138/© 2020 Elsevier Ltd. All rights reserved.
2 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653
care to answer the question of the dichotomous objective of mid-
wifery. The identification of the dichotomous objective of mid-
wifery care should promote the discussion and measurement of
quality in midwifery care.
Method
In this paper the following definitions according to Walker and
Avant (2011) were used: “A theory is an internally consistent group
of relational statements [about concepts] (…) that presents a sys-
tematic view about a phenomenon and that is useful for descrip-
tion, explanation, prediction and control”. (Walker and Avant, 1988,
p. 22). Concepts are a mental image of a phenomenon, an idea
or a construct. They allow us to classify our experiences mean-
ingfully (Walker and Avant, 2011). Theories are often graphically
represented by a model (Walker and Avant, 1988).
The formation of theories relating to a profession serves to de-
velop a logical, systematic and organised version of that profes-
sion and its aims (Meleis, 1999; Neumann-Ponesch, 2017). These
theories and models function as a melting pot for already existing
concepts, which are thus identified, analysed, clearly defined and
newly compounded (Meleis, 1999).
In order to bring together the existing theories and concepts,
the method of theory synthesis from nursing science according to
Walker and Avant (2011) was applied. It enables the organisation
and integration of a large number of findings in one single theo-
retical work. It was developed for theory construction in nursing
and has also been used in midwifery science (Halldorsdottir and
Karlsdottir, 2011).
Theory synthesis is a strategy to combine information about a
phenomenon. The method contains three iterative stages: (1) Spec-
ification of central concepts of the topic of interest and assump-
tions about how they may be interrelated in order to construct
an analytical framework. (2) Review of the literature to identify
concept-related variables and relationships between the concepts,
possibly using field observations or empirical research. (3) Integra-
tion of the concepts and statements into a new, more efficient rep-
resentation. Different strategies of theory construction may be ap-
plied within these three iterative stages (Walker and Avant, 2011).
The goal of this theory synthesis was to find a dichotomous ob-
jective for midwifery. Therefore, a model was sought that helps to
sort the results within the theory synthesis. The best transferable
model that was found and meets these requirements is the means-
end chain from the field of strategic management. The means-
end chain is a hierarchical model. It helps in structuring by ask-
ing the question why this objective should be achieved (from bot-
tom to top) and how this aim can be achieved (from top to bottom)
(Welge et al., 2017) (Fig. 1).
Fig. 1. Diagram of a means-end chain.
Aims within a means-end chain are systematically represented
by an objective or vision and several sub-aims or operational
aims. Each operational aim is a means towards the superior aim.
Since an aim or objective is difficult to measure, operational aims
are used to structure actions and make it easier to measure the
achievement of aims. The aims may be complementary, mean-
ing they may complement and reinforce each other mutually.
The means-end chain does not represent a chronological sequence
(Welge et al., 2017).
The following section is structured according to the three stages
of Walker and Avant (2011). For each stage the procedures and re-
sults are described. In stage three, the final hierarchical model is
presented.
Stage 1: Identifying key concepts
A systematic review of models, concepts, theories and frame-
works was performed to identify theoretical considerations of the
aims and objectives of midwifery practice. The aims and objectives
of midwifery care have been extracted from those concepts, theo-
ries and frameworks identified as relevant. This approach assumed
that most of the aims and objectives relevant to midwifery practice
have already been written about in midwifery science.
A systematic literature review was performed in June 2017. The
following electronic databases were searched for relevant articles:
MEDLINE via pubmed, The Cochrane Library, CINAHL Complete
via EBSCO, PsycINFO via EBSCO, SocINDEX via EBSCO, EMBASE
via OVID, MIDIRS via OVID, Web of Science, Livivo (incl. BASE).
The keywords used were: ((midwif∗ [Title] OR midwiv∗ [Title]))
AND (theor∗ [Title] OR model [Title] OR concept[Title] OR frame-
work[Title]). Included were scientific articles discussing the aims
and objective of midwifery from 1960 onwards.
The search yielded 1342 articles, 622 of which remained af-
ter removal of duplicates; these were then screened and 22 full-
text articles assessed, 11 of which were excluded. Those ex-
cluded involved studies solely concerning women’s experiences
(Carolan, 2009; Davis and Walker, 2010), the midwife as an indi-
vidual, the external circumstances of midwifery practice, the de-
velopment of the profession (Casey et al., 2015; Crozier et al.,
2007; Davis, 2010; Fullerton et al., 2011; Noseworthy et al.,
2013; Walsh, 2006), articles with no recognisable scientific
method (Rooks, 1999), and articles about implementing a concept
(Ryley and Middleton, 2016; Symon et al., 2016). 20 percent of the
articles were reviewed by a second person. There were no differ-
ences of opinion.
The 11 studies remaining are listed chronologically in
Table 1 (Berg et al., 2012; Bogossian, 2007; Dickson, 1997;
Fleming, 1998; Hermansson and Martensson, 2011; Kennedy, 20 0 0;
Lundgren and Berg, 2007; Ménage et al., 2017; Renfrew et al., 2015;
Thompson et al., 1989).
Most of the grand or middle range theories were developed
some time ago (see Table 1). Grand theories within a profes-
sion have a high level of abstraction. They describe the nature,
mission and objectives of a profession and provide an expla-
nation at the level of the entire profession. Middle-range theo-
ries have a medium level of abstraction. They describe a spe-
cific phenomenon that appears in different areas of a profession
(Walker and Avant, 2011). The development from a deductive ra-
tionalistic (Dickson, 1997; Thompson et al., 1989) to an induc-
tive empirical (Fleming, 1998; Kennedy, 20 0 0) theory formation,
as seen in the care profession, can also be observed in mid-
wifery science (Neumann-Ponesch, 2017). The latest and also most
comprehensive theoretical work resulted from a mixed-methods
approach (Renfrew et al., 2015). The other studies provide in-
sights into certain aspects of midwifery practice (Berg et al., 2012;
Bogossian, 2007; Hermansson and Martensson, 2011; Lundgren and
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 3

Table 1
Theoretical work in midwifery science.

First author, year Country Subject Method

Thompson et al. (1989) USA The care Theory building: Seven central concepts of nurse-midwifery:
process Middle-range theory nurse-midwifery care is safe, satisfying, respects human
dignity, respects cultural and ethnic diversity, promotes
self-determination, is family centred, and promotes health.
Dickson (1997) Australia Practical Model Review: Theory Women have physical, psychological, cultural and social
for midwifery, needs. Midwives’ respond to these needs through being
based on present (emotionally, communicating, touching, allowing,
caring concepts listening, reassurance), ensuring client control and building
capacities and capabilities, while respecting specific client
situations and beliefs.
Fleming (1998) UK, Scotland, Model of Grounded theory: The six major categories of this model were: attending and
New Zealand midwifery Conceptual model presencing, supplementing and complementing, reflection
practice and reflexivity, on the basis of reciprocity of the social
process in the midwife-client relationship.
Kennedy (2000) USA Exemplary Delphi Study Essential elements within three dimensions or outcomes:
Midwifery therapeutics, caring, and the profession of midwifery. The
practice process consists of vigilance & attention to detail, creates a
setting that is respectful & reflects the woman’s needs,
supports the normalcy of birth and respects the uniqueness
of the woman & family.
Lundgren (2007) Sweden Midwife- Phenomenological- ‘The relationship between the midwife and the woman is
woman hermeneutic approach: essential for a positive experience for woman during
relationship secondary analysis of childbearing period’ (p.220). Six pairs of concepts are
qualitative studies illuminated from the points of view of both the woman
and the midwife ‘surrender– availability, trust–mediation
of trust, participation–mutuality, loneliness–confirmation,
differentness–support uniqueness, and creation of
meaning–support meaningfulness’.
Bogossian (2007) Netherlands Social support Review and Midwives’ social support consists of emotional,
development of a informational, tangible and comparison support.
model
Halldorsdottir (2011) Iceland Professionalism Theory synthesis The professional midwife cares for the childbearing
in midwifery woman and her family; she has professional wisdom;
professional and interpersonal competence; she develops
herself professionally and personally.
Hermansson (2011) Sweden Empowerment Concept analysis Attributes: Developing a trusting relationship; starting an
awareness process, making it possible to reflect on the
changing situation; acting based on the parents’ situation
on their own terms, getting them involved and able to make
informed choices and confirming the personal significance of
becoming parents (p. 811).
Berg (2012) Sweden and Woman- Hermeneutic The midwife builds a Reciprocal Relationship (Presence,
Iceland centred care in approach: Synthesis of Affirmation, Availability, Participation) and A Birthing
Sweden and review and focus Atmosphere (Calm, Trust, Safety, Strengthening, Supporting
Iceland group interviews normality). For this she respects the woman’s cultural
context.
Renfrew (2014) USA Scope of Mixed-methods Definition of the components of a health system needed
midwifery approach: Scope of by woman and newborn infants: practice categories, the
care/Framework midwifery organisation of care, values, philosophy, and care providers.
Ménage (2017) USA Compassionate Concept analysis Compassionate midwifery is defined as the interrelations
midwifery of authentic presence, noticing suffering, empathy,
connectedness/relationship, emotional work, motivation to
help/support, empowering women and alleviating suffering
through negotiation, knowledge and skills (p. 558).

Berg, 2007; Ménage et al., 2017). The grand or middle-range theo-
ries are described below followed by the concepts dealing with a
certain aspect of midwifery.
From these theories the following relevant and related con-
cepts were extracted: midwife-client relationship; interpersonal
competence; presence; availability; family-centred; trust; birthing
atmosphere; empathy; awareness process/changing situation; hu-
man dignity; respect (situation; culture, beliefs; uniqueness of
the woman/family); promotion of self-determination/ client con-
trol/ getting them involved; safety; health promotion / therapeu-
tics/ professional wisdom and competence; normalcy of birth/ ex-
pectant management; emotional work; is satisfying; have physi-
cal, psychological, cultural and social needs; building capabilities.
These concepts were used as an analytical framework for the next
stage.
Stage 2: Developing key concepts and relationships
In the first step, the analytical framework was created on the
basis of theories, concepts and frameworks from the midwife sci-
ences to identify possible aims and objectives. A further systematic
review was performed in the second stage to identify articles on
women’s experiences and preferences on midwifery care. The ex-
periences and preferences identified were used to specify the ex-
tracted concepts, examine their relationships and to ensure their
completeness. Empirical data was used to explore how the con-
cepts interact in practice.
The literature search was carried out in June 2017 using the
following databases: MEDLINE via pubmed, The Cochrane Library
(incl. NHS CRD - databanks DARE, HTA, NHS EED), CINAHL Com-
plete via EBSCO, Web of Science, Livivo (incl. BASE), EMBASE via
4 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653
OVID, PsycINFO via EBSCO, MIDIRS via OVID and socINDEX via
EBSCO. The following terms were used: (1) “Midwifery[Mesh] OR
midwife∗ [tiab] OR midwives∗ [tiab] OR “Nurse Midwives”[Mesh]
(2) “Prenatal Care”[Mesh] OR “Postnatal Care”[Mesh] OR “Perina-
tal Care”[Mesh] (3) “prenatal care”[tiab] OR “postnatal care”[tiab]
OR “perinatal care”[tiab] OR “maternal health service∗ ”[tiab] OR
“childbirth care”[tiab] OR “antenatal care”[tiab] OR “postpartum
care”[tiab] OR “intrapartal care”[tiab] or “maternity care”[tiab] (4)
Experience∗ [tiab] OR Perspec∗ [tiab] OR Expectat∗ [tiab] OR Satisfac-
tion[tiab] Or View[tiab] Opinion[tiab] OR Perception[tiab] OR “Per-
sonal Satisfaction“[Mesh] OR “Patient Satisfaction“ [Mesh] (5) #1
AND (#2 OR #3) AND #4.
Studies with an empirical background which were conducted in
industrial countries in the last 15 years and dealt with the pref-
erences or experiences of women regarding general provision of
midwifery care were included. Studies which referred to particular
target groups or specific situations were excluded. Study quality
was assessed using the Critical Appraisal Skills Programme - qual-
ity assessment tool for qualitative studies (CASP, 2013). Ten percent
of the articles were reviewed by a second person. There were no
differences of opinion.
6181 hits were obtained. Those from before 2002 were re-
moved, as were those, in accordance with the exclusion criteria,
from non-industrial countries and studies referring to specific sit-
uations or target groups such as stillbirth or teenage pregnancies,
in a pre-screening with keyword search. After removing duplicates,
2163 studies remained which were screened and 26 studies were
included (Table 2).
Stage 3: Organising and presenting
In the first and second stages, possible aims and objectives were
identified and specified. Possible relationships between aims and
objectives were observed. The identified aims and objectives were
brought into the model of the means-end chain. For each object,
the question was asked as to why this concept is carried out in
midwifery care (relation to the superordinate aim) or which re-
quirements are required for this (relation to the subordinate aim).
Based on these questions, the identified aims and objectives were
brought into the hierarchical form of the means-end chain in or-
der to define a primary aim. Within the iterative process, steps one
and step two were repeated to validate the results. In the follow-
ing, the newly synthesized theory is described and illustrated using
Fig. 2: Hierarchical model of the means and targets of midwifery.
In the third stage the concepts and their relationships were or-
ganised into one objective and four aims of midwifery on three
levels. The constructs extracted in the first stage were reflected in
the empirical articles, which also made it possible to answer the
Fig. 2. Hierarchical model of the means and targets of midwifery.
questions of why and how and to structure the existing constructs
hierarchically. Further, a proof of concept was conducted in a work-
shop with five academic midwives in January 2018. The model was
presented in its former version and explained on the basis of lit-
erature. It was discussed which ambiguities appeared. One of the
main results was that the literature was once again undermined
with regard to physical health promotion, as this seemed to be un-
derrepresented, but according to the workshop participants should
be emphasized more.
The hierarchical model of the process of midwifery shows that
midwifery care is based on a trusting relationship (Level 1). In or-
der to establish such a relationship, certain midwifery skills and
practices are required. Based on this relationship, the midwife may
achieve three operational aim on the second level, which them-
selves enhance a trusting relationship. Target 1: The midwife pre-
serves and promotes both mental and physical health of women
during the reproductive phase of life. This improves women’s
health and offers them a sense of security. Target 2: The mid-
wife cares for the woman in a respectful and dignified manner
and promotes participation in her own care. Both aspects allow the
woman to stay in control. Target 3: The midwife gives practical ad-
vice and guides the women. She offers information regarding the
change of life circumstances, enabling orientation in a new phase
of life.
The three operational targets on the middle level and the trust-
ing relationship itself support the reproductive capabilities of the
woman (Level 3). Midwives therefore empower women to con-
struct this phase of life on their own terms. The concepts are de-
scribed individually below:
Level one
Trusting relationship
If the midwife is empathetic and accepts to the individual sit-
uation of a woman, the woman feels she is being seen and heard.
The woman gains confidence that she has the leading role and her
preferences will be considered; she can let go of her anxieties and
relax. This is easier if the woman has had the opportunity to get
to know the midwife and/or her care and has had time to build
an emotional bond. The woman finds it easier to bring up difficult
topics and the relationship feels safe and predictable for her. If the
midwife is a good communicator, the woman can ask questions
and understand the answers. She is thus empowered to take re-
sponsibility for herself and her child and feels supported and taken
seriously. Prompt attention results in less stress and facilitates de-
velopment of maternal confidence. If attention is not prompt dur-
ing labour, the woman can feel left alone and ignored. If these
requirements are met well, a reciprocal relationship of autonomy
and mutual cooperation results, facilitating reassurance and trust
in the midwife for the woman and enabling shared responsibil-
ity. On this basis health promotion and respectful care has more
capacity (Beake et al., 2005; Berg et al., 2012; Boyle et al., 2016;
Dahlberg et al., 2016; Dickson, 1997; Hermansson and Martens-
son, 2011; Karlstrom et al., 2014; Mattern et al., 2017).
‘People that I knew and who knew my history and I was able to
be absolutely frank with them and I didn’t feel that I was wasting
their time about anything’ (Beake et al., 2005) (online, no page)
Trusting relationship: individual and woman centred care
Every woman is in a unique situation, with specific ex-
periences and wishes; this includes a specific culture, reli-
gion or disability. The midwife accepts and promotes this in-
dividuality. She is non-judgmental, interested in others and
flexible in care. She listens actively and identifies the physi-
cal, psychological, cultural and social needs and preferences of
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653 5

Table 2
Studies included in the second phase (PNC = postnatal care; ANC = antenatal care).

Author, year Country Subject Study aim Sample, method and reflection

Aaserud (2017) Norway PNC, home, 1–6 Experiences of short stay the maternity 9 women; convenience sampling;
day postnatal ward Semi-structured interviews; hermeneutic
approach; Based on theory of: empowerment,
coping, autonomy and relationship
Baas (2015) Netherlands Maternity Care Explore suggestions for improvement of 3499 women; Purposive sampling; Question:
maternity care; Part of DELIVER study ‘Do you have any suggestions on how your
midwife could improve his/her provision of
care?; Qualitative thematic content analysis;
Presupposition: Care has a long-lasting effect
on women’s wellbeing
Bäckström (2016) Sweden ANC; incl. classes Perceptions of professional support; 15 women; 36–38 SSW; semi-structured
understand needs of pregnant women interviews, the questions were: What types of
professional support have you received for
childbirth and parenting? How has the
support been, in your experience? What has
the support meant to you?;
Phenomenography approach; Gap between
need und received care
Beake (2005) UK PNC: home and Exploring women’s views 22 women; In-depth semi-structured
hospital interviews; grounded theory; data was
reviewed by co-researcher
Blackwell (2002) USA PNC Women’s perceptions, experiences and 20 women; face-to-face interviews
needs
Bondas (2001) Finland Maternity care Women’s experiences 40 women; Phenomenological approach:
semi-structured interviews, dialogical
interviews and non-participant observation;
Reflective accounts
Borelli (2016) UK Midwifery care First-time mothers’ perspectives of a good 14 women; semi-structured interviews;
midwife; conceptualised in the context of grounded theory; Reflective accounts
different birthplaces
Boyle (2016) UK Maternity Care Explore whether the UK Government 16 women; diary interview method; social
agenda for partnership working and constructivist; hermeneutic approach
choice was realised
Dahlberg (2016) Norway Early PNC, home Deeper understanding of women’s 24 women; Six focus group interviews;
experiences Phenomenological analysis.
Fawsitt (2016) Ireland Maternity care Exploring pregnant women’s preferences 196 women; focus groups; thematic analysis
for alternative models of maternity care
Feeley (2016) UK Birth Exploring why women choose to freebirth 10 women; narrative, semi-structured
interview; hermeneutic-phenomenological
Howarth (2011) New Zealand Birth First time mothers’ experience of birth 10 women; face-to-face interviews;
Phenomenological form of thematic analysis
Karlström (2015) Sweden Birth Meaning of a very positive birth 26 women; focus group; thematic analysis
Kurth (2010) Switzerland PNC Exploring the experience of hospital care 15 women; Participant observation and 2
narrative interviews; phenomenological
approach; Discussion was used
Larkin (2012) Ireland Birth Women’s experiences 25 women; focus groups; evolutionary
concept analysis
Lundgren (2005) Sweden Birth Important aspects of midwifery care 10 women; Phenomenological approach
Luyben (2005) Scotland, ANC Women‘s needs 23 women; Interviews; grounded theory
Netherlands,
Switzerland
Malacrida (2014) Canada Birth Women’s expectations and their birth 22 women; Qualitative semi-structured
experiences narrative interviews;
Mattern (2017) Germany Midwifery care Experiences and wishes of women 50 women; focus groups; hermeneutic
approach
McKinnon (2014) Australia Maternity care Consumer evaluations of maternity care 150 women; Open-text survey: ‘Is there
anything else you’d like to tell us about
having your baby?’; thematic analysis
McLachlan et al., Australia PNC, hospital and Explored participants’ experiences and/or 50 women; Eight focus groups and four
2009; Melender, home expectations, views of alternative interviews; step-by-step approach; Analysis
2006; O’Hare and packages of postnatal care was conducted by two authors and
Fallon, 2011; crosschecked
Parratt and Fahy,
2003; Schneider,
2002; Shu Fen et
al., 2014; Deutsche
Institut für
Normung e.V. 2015
Melender (2006) Finland Birth Women’s perceptions of a good birth 24 women; Semi-structured Interviews;
content analysis
O‘Hare (2011) Irland Birth Experience of control in labour and 9 women; Semi-structured interviews;
childbirth analysed using frameworks influenced by
Smith et al. (2009) and van Manen (1990)
(continued on next page)
6 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653

Table 2 (continued)

Author, year Country Subject Study aim Sample, method and reflection

Parratt (2003) Australia Birth What features of childbirth have a 6 women; In-depth interviews; Telephone,
positive effect on women’s sense of self also some written statements; thematic
analysis
Schneider (2002) Australia Maternity care This paper explores which models of care 13 women; phenomenological interviews;
the women experienced and also how grounded theory
useful the women found the information
disseminated at antenatal education
classes.
Shu Fen (2014) Singapore Early PNC Postnatal experiences and support needs 13 women; Semi-structured interviews;
thematic analysis; Three researchers analysed
the data

the woman, recognising the level and type of support each
woman needs and tailoring her care accordingly (Beake et al.,
2005; Borrelli et al., 2016; Dickson, 1997; Feeley and Thom-
son, 2016; Halldorsdottir and Karlsdottir, 2011; Hermansson and
Martensson, 2011; Lundgren, 2005; Lundgren and Berg, 2007;
Mattern et al., 2017; Renfrew et al., 2015; Thompson et al., 1989).
‘It was important that the midwife considered the woman’s
uniqueness and vulnerability, and took her worries seriously what-
ever they were.’ (Bondas, 2002) (p.65)
Trusting relationship: interpersonal communication
Women need time and a relaxed atmosphere which allows
them to talk and ask questions. They want to be taken seriously
and to feel that the midwife engages with them. Women want to
discuss their experiences, anxieties and worries. Midwives need
to have good communications skills. This means listening care-
fully to each woman, explaining things so women can understand
and allowing time to ask questions. Communication can be ver-
bal, tactile or aural. The midwife needs pedagogical creativity to
make it easier to share information in classes (Baas et al., 2015;
Backstrom et al., 2016; Dickson, 1997; Halldorsdottir and Karlsdot-
tir, 2011; Hermansson and Martensson, 2011; Mattern et al., 2017;
O’Hare and Fallon, 2011; Renfrew et al., 2015).
‘I want to tell her how I am_ _ _ When she asks and listens she
looks me in the eye and I can feel that she listens.‘ (Bondas, 2002)
(p.65)
Trusting relationship: choice and continuity
Women want to choose a midwife who suits them. They feel
better if the midwife knows their personal circumstances and
they feel they can trust her. They don’t like repeated examina-
tions by different examiners and different opinions make them
feel insecure. The midwife enables women to choose their mid-
wife and offer continuity of care or carer (Aaserud et al., 2017;
Baas et al., 2015; Beake et al., 2005; Bondas, 2002; Boyle et al.,
2016; Dahlberg et al., 2016; Fawsitt et al., 2017; Feeley & Thomson,
20 16; Kurth et al., 2010; Mattern et al., 2017; McLachlan et al.,
2009).
‘Furthermore, an awareness that it was a ‘lottery’ as to who at-
tended their homebirth, meant that they did not want to take the
risk of having a fearful or unsupportive midwife look after them in
labour: ‘ (Feeley and Thomson, 2016) (p.6)
‘The hospital setting was perceived to provide 24-h midwifery sup-
port, with access to immediate medical care if needed. These fac-
tors helped alleviate women’s anxiety, with continuous access to
midwifery support seen as essential to building maternal confi-
dence.’ (McLachlan et al., 2009) (p.6.)
Trusting relationship: empathy attitude
Women find themselves in a vulnerable situation during preg-
nancy, childbirth and postpartum, so midwives need to be em-
pathetic. Many adjectives are used to describe the qualities re-
quired in a midwife: friendly, nice, warm, kind, personal, sensi-
tive, considerate, peaceful, humane, not tense, not stressed, nearby,
patient, nurturing, trustworthy, calm, positive, supportive, gen-
tle and genuinely interested. These qualities also describe the
‘mothering role’ and are reflected by avoiding disturbance and
creating a relaxed, homelike and cosy atmosphere (Baas et al.,
2015; Backstrom et al., 2016; Berg et al., 2012; Bondas, 2002;
Feeley and Thomson, 2016; Hermansson and Martensson, 2011;
Howarth et al., 2011; Karlstrom et al., 2014; Kennedy, 20 0 0;
Mattern et al., 2017; Ménage et al., 2017).
‘Try not to use a childish “tone of voice.” In everyday life I am a
mature professional and despite my upcoming motherhood I would
like to be approached that way.’ (Baas et al., 2015) (p. 373)
Level two
Security
Midwives promote women’s psychological and physical health
and wellbeing and help them to navigate the psychological and
physiological processes of the changes they and their bodies
are undergoing. Competent medical and psychological knowl-
edge and skills increase trust and give a feeling of safety
and reassurance, allowing women to relax (Baas et al., 2015;
Backstrom et al., 2016; Beake et al., 2005; Berg et al., 2012;
Blackwell, 2002; Bogossian, 2007; Bondas, 2002; Borrelli et al.,
2016; Feeley and Thomson, 2016; Halldorsdottir and Karlsdot-
tir, 2011; Hermansson and Martensson, 2011; Karlstrom et al.,
2014; Kennedy, 20 0 0; Lundgren and Berg, 2007; Mattern et al.,
2017; Renfrew et al., 2015; Thompson et al., 1989).
Many participants felt lonely and unsupported at this time in
the ‘twilight zone” between ‘being in labour and ‘not in labour”’
(Larkin et al., 2012) (p. 101)

Trusting relationship: prompt attention Security: physical health promotion

Women would like the midwife to be available and to pro-
vide prompt attention when needed during labour. Some women
want the midwife to be continuously present during birth. Mid-
wives provide clear information on their accessibility and con-
tinuous access to support. They are reliable (Boyle et al., 2016;
Lundgren and Berg, 2007; Mattern et al., 2017; McLachlan et al.,
2009; Renfrew et al., 2015; Shu Fen et al., 2014).
The reproductive life phase is a normal phase in a woman’s
life, but it may be associated with health problems or risks.
Women may need help in this period, although midwives be-
lieve in the capacity of women to give birth. Midwives have
scientifically based professional competence. They employ expec-
tant management and intervene only when indicated. Midwives
help women to find and trust their body, to get a new sense
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653
of normality and encourage them to promote their own health.
They support physiology and avoid intervention, at the same time
preventing injury and death. To this end they perform screen-
ing and risk assessment, identify problems, intervene appropri-
ately and evaluate their care. The midwife is vigilant, gives at-
tention to detail and provides first line management of compli-
cations. She knows her own limits and refers women to a doctor
if necessary (Berg et al., 2012; Blackwell, 2002; Bogossian, 2007;
Bondas, 2002; Borrelli et al., 2016; Feeley and Thomson, 2016;
Halldorsdottir and Karlsdottir, 2011; Karlstrom et al., 2014;
Kennedy, 20 0 0; Lundgren and Berg, 20 07; Mattern et al., 2017;
Renfrew et al., 2015; Thompson et al., 1989).
‘I was a very normal case, I didn’t have any particular problems, I
didn’t actually need any help as such, but I just felt like I wanted
someone to come and sort that out’ (Beake et al., 2005) (online)
Security: mental health promotion
Becoming a mother is a significant transitional process. Mid-
wives believe in the mother’s capacity and ability and strengthen
women’s self-esteem. Talking about birth, emotions and experi-
ences helps a woman navigate her changing situation. Prepar-
ing women mentally and being unhurried and serene reduces
women’s anxiety. Midwives give emotional and professional sup-
port, especially after an early pregnancy loss, stillbirth or traumatic
birth experience. If necessary they also perform a psychosocial
risk assessment and intervene/refer as required (Baas et al., 2015;
Backstrom et al., 2016; Beake et al., 2005; Halldorsdottir and Karls-
dottir, 2011; Hermansson and Martensson, 2011; Kennedy, 20 0 0;
Lundgren and Berg, 2007; Mattern et al., 2017; Renfrew et al.,
2015; Thompson et al., 1989).
‘In cases where the woman had a traumatic birth experience, she
pointed out that it was very important that the midwife during
the home visit appeared calm and left the impression that she was
interested in the woman’s birth experience: I felt that she was so
calm and that she gave me time to talk. I could hardly speak after
birth because I was so distant, and that she now had time to listen
while not looking at her watch felt really good. I thought the birth
was going to be easy, but I was shocked. In that way, it was very
nice that she came home to me afterwards as I felt that I needed
to talk more about my feelings and birth experience. It was lovely
to talk to someone about It, not just my husband. (Dahlberg et al.,
2016) (p.59)
Personal control
Being treated with respect facilitates women’s sense of control.
They feel accepted and able to do what they want. When women
have the feeling they have a choice and are supported in this
choice, they gain confidence and feel they have control. If women
feel disrespected, that their privacy has been violated, or that they
have no choice, they get stressed and may feel humiliated. Feeling
accepted and being in control facilitates self-responsibility and let-
ting go in the birthing process (Baas et al., 2015; Beake et al., 2005;
Berg et al., 2012; Bondas, 2002; Boyle et al., 2016; Dickson, 1997;
Feeley and Thomson, 2016; Hermansson and Martensson, 2011;
Karlstrom et al., 2014; Kennedy, 20 0 0; Larkin et al., 2012;
Lundgren, 2005; Lundgren and Berg, 2007; Luyben and Flem-
ing, 2005; Malacrida and Boulton, 2014; Mattern et al., 2017;
McLachlan et al., 2009; Melender, 2006; Ménage et al., 2017;
O’Hare and Fallon, 2011; Parratt and Fahy, 2003; Schneider, 2002;
Shu Fen et al., 2014; Thompson et al., 1989).
‘At the same time as the women tried to release control, they
wanted to retain control over the situation and the course of
events. This may seem contradictory, but, according to the women,
a feeling of having control was important when they were releas-
ing control and letting themselves go’ (Lundgren, 2005) (p.349)
7
Personal control: respect and dignity
This refers to respecting the woman, her situation and hu-
man dignity. The midwife’s actions demonstrate her acceptance
of the woman and her decisions. The midwife is empathetic, es-
pecially during physical examinations. This also means respect-
ing the woman’s privacy, her vulnerability, her individual needs,
and taking her concerns seriously. If care is mechanical, judging
or rough, women can feel hurt and ashamed (Baas et al., 2015;
Beake et al., 2005; Bondas, 2002; Feeley and Thomson, 2016;
Hermansson and Martensson, 2011; Kennedy, 20 0 0; Larkin et al.,
2012; Lundgren, 2005; Lundgren and Berg, 2007; Mattern et al.,
2017; McLachlan et al., 2009; Melender, 2006; Ménage et al., 2017;
Parratt and Fahy, 2003; Thompson et al., 1989).
‘luckily, it was quick but if it wasn’t quick that I was going to be
forced into having something that I didn’t want. I had this fear all
the time’ (Larkin et al., 2012) (p.102)
‘When the woman is not empowered by the midwife to accept un-
inhibited behaviour, the woman may also not accept the spontane-
ity required in the bodily response that allows‘releasing the body’
during labour.’ (Parratt and Fahy, 2003) (p.20)
Personal control: participation
Women are self-responsible. They have the right to partici-
pate and to make decisions which affect them and their child.
Each woman wants to participate to a varying degree in her
care, depending on her situation. Midwives allow room for desires
and preferences, accepting and supporting women’s decisions and
choices. To promote participation, midwives involve the woman
through continuous dialogue, by listening to her, offering alterna-
tives, informing her about what is going on and supporting her
in making decisions. Through this process the woman feel more
responsible and can take control. Participation can also involve
the delegation of choices or giving the midwife the role of ad-
vocate. If their decisions are not respected, women get stressed,
or feel manipulated or bullied (Berg et al., 2012; Boyle et al.,
2016; Dickson, 1997; Feeley and Thomson, 2016; Karlstrom et al.,
2014; Lundgren, 2005; Lundgren and Berg, 2007; Luyben and
Fleming, 2005; Malacrida and Boulton, 2014; Mattern et al., 2017;
Melender, 2006; O’Hare and Fallon, 2011; Schneider, 2002; Shu Fen
et al., 2014; Thompson et al., 1989).
‘Ultimately, if I have made the decisions and things go wrong, the
bus stops here. Yeah.. If they have made the decision and things
go wrong, how, how do you deal with that?’ (Luyben and Flem-
ing, 2005) (p.219)
Orientation
Women feel uncertainty about the new situation and worry
about whether they are doing everything right. Knowledge, skills,
and guidance help women feel orientated and empowered. They
can better judge what is normal and act autonomously. If women
know what can happen and how to respond, they feel prepared
and can relax. The information provided therefore needs to be
realistic, timely and tailored to each woman. Women feel dis-
tressed when information does not correspond to their situa-
tion (Aaserud et al., 2017; Backstrom et al., 2016; Beake et al.,
20 05; Blackwell, 20 02; Bogossian, 20 07; Borrelli et al., 2016;
Dickson, 1997; Hermansson and Martensson, 2011; Howarth et al.,
2011; Karlstrom et al., 2014; Lundgren, 2005; Luyben and
Fleming, 2005; Mattern et al., 2017; O’Hare and Fallon, 2011;
Schneider, 2002; Shu Fen et al., 2014).
‘I think in hindsight I probably needed to prove to myself I was ca-
pable of doing it before contemplating doing it alone.’ (Feeley and
Thomson, 2016) (p.7)
8 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653
‘A kind of support thing, you know, because if you weren’t sure
you always know that she will be coming sometime today and
you can ask her’ (Beake et al., 2005) (online)
Orientation: practical help
Women worry about their ability to give birth and care for the
baby. Besides information, women need practical help and hands
on practice. They want to learn how to breathe, to relax and to
breastfeed and care for the baby. During labour midwives give in-
structions about breathing, positions in labour, relaxing, and han-
dling the pain as well as providing practical assistance. In ad-
dition, they facilitate new social contacts, promote partner in-
volvement and inform women about social and financial resources
(Aaserud et al., 2017; Backstrom et al., 2016; Beake et al., 2005;
Bogossian, 2007; Mattern et al., 2017; O’Hare and Fallon, 2011;
Shu Fen et al., 2014)
‘I was prepared, I knew how to breath (during birth) and how to
breastfeed.’ (Karlstrom et al., 2014) (p.10)
‘When you read all these things on the internet, books, most of the
things you already know. I think I would prefer something more
practical, more useful.’ (Shu Fen et al., 2014) (p.775)
Orientation: information
Women find themselves in a new situation. They need edu-
cation, information about resources, and advice. Midwives pro-
vide information about physical changes, the normal process, de-
viations and how to respond them. During birth they continu-
ously provide information about what is happening and guide
women through the labour process. Education may include role
playing, illustrations and humour to be better able to imag-
ine what it is like to give birth and feel mentally prepared
(Aaserud et al., 2017; Backstrom et al., 2016; Beake et al.,
20 05; Blackwell, 20 02; Bogossian, 20 07; Borrelli et al., 2016;
Dickson, 1997; Hermansson and Martensson, 2011; Howarth et al.,
2011; Karlstrom et al., 2014; Lundgren, 2005; Luyben and
Fleming, 2005; Mattern et al., 2017; O’Hare and Fallon, 2011;
Schneider, 2002).
‘Yeah, yeah, yeah she was really good. Yeah, and also, um, quite
respectful of our wishes and wants with different things, like she
would often, she was slow to offer advice but very quick to of-
fer sort of information or resources um, but with perhaps a heavy
emphasis on us making the decision or us trusting our intuition,
or um, or reading up and finding out, but she would, she would
be there to offer information and I, I don’t think she ever would’ve
made a decision on our behalf.’ (Howarth et al., 2011) (p.8)
‘In particular, most women found the onset of labour distressing
because it did not correspond with what they had been told - a
unanimous complaint was that ‘it didn’t happen at all like they said’.
(Schneider, 2002) (p.36)
Level three
Reproductive capabilities
The objective of midwifery care is the facilitation of women’s
Reproductive capabilities. These capabilities are multidimensional
and not limited to physical health, but include social and psycho-
logical needs. This implies that the midwife offers the aids and
competencies described. The woman decides which are relevant
for her, and the midwife enables the woman to have the best
birth possible (Berg et al., 2012; Dickson, 1997; Feeley and Thom-
son, 2016; Hermansson and Martensson, 2011; Kennedy, 20 0 0;
Lundgren, 2005; Renfrew et al., 2015).
‘All occasions of birth trauma occurred during a hospital birth.
Repeated incidents of women ‘being ignored’, ‘left alone’ or con-
versely ‘harassed’ by hospital midwives and doctors left the
women feeling ‘abandoned’, ‘disempowered’, ‘out of control’ and
‘frightened’. Non-consensual acts were carried out including vagi-
nal examinations and IV lines being inserted where the women
reported being ‘done to’, rather than being a part of an in-
formed process. These experiences often evoked ‘shame’ wherein
the women seemed to internalise the actions of the maternity staff
and blamed themselves for not stopping the’ (Feeley and Thom-
son, 2016) (p.5)
‘Information about how the women could prepare for childbirth
contributed to mental preparedness When the women perceived
that they had received satisfactory information about how best to
prepare for birth and parenting, this information contributed to
their mental preparedness. The information might involve practi-
cal tips for handling pain or tips on how to think during labour;
such tips could help the women create an individual goal that they
could then use during difficult parts of pregnancy or labour: It
means very much, because then I know that. . . if I have reached
that goal, then I have managed to give birth. . . and. . . it is very
important for . . . getting rid of my fear. . . well, I can’t completely
get rid of it, but I can make my goal bigger than my fear. . . so . . .
it is very important . . . it means a lot.’ (Backstrom et al., 2016)
(p.115)
Discussion
The hierarchical model of the process of midwifery practice
presented here is based on known concepts in midwifery science
and research into women’s preferences and experiences. It illus-
trates the multidimensional and complex work of midwives in sup-
porting women’s reproductive capabilities. The model illustrates
that prevention of morbidity and mortality are not the only aims of
midwifery practice. An equally important aim is the preservation
of personal control of a woman by supporting participation and
offering respectful care. Additionally, the midwife provides orien-
tation in a new phase of life by informing and guiding the woman.
Finally, the model illustrates the importance of a trusting relation-
ship, which needs time to take effect. Thus a step has been taken
here to describe the dichotomous goal of midwifery care and thus
to explain the “why,” the purpose of one’s own work, explicitly.
This work could be a step towards better explaining and clari-
fying one’s own work to other professions and to users. This could
also apply to teaching. It can also help to clarify one’s own goals
and thus contribute to the reflection of one’s own work. For exam-
ple, the question can be asked whether midwifery care with un-
known women is more challenging, because the midwife has to
build a trusting relationship in a very short time. It is also possible
to argue for more time for midwifery care, to enable the devel-
opment of a trusting relationship, and to meet women’s wish for
prompt attention. It also potentially highlights neglected areas of
midwifery care.
The main aim was to make the quality of midwifery work mea-
surable. A primary objective was identified and in addition some
sub-aims or process steps to the primary objective were identified.
The primary objective remains relatively abstract, so that the ques-
tion arises whether the primary objective can be used to measure
quality or rather the sub-objectives identified. If this work can be
used as a basis for quality measurement, it could serve quality de-
velopment and thus better care. In this study theoretical work is
perceived as a continuing discourse requiring constant adaptation
and change. The possibilities of this work therefore also depend on
its further development.
Walker and Avant (2011) theory synthesis seems to be a suit-
able method for theory development in midwifery science. It en-
 M. Peters, P. Kolip and R. Schäfers / Midwifery 84 (2020) 102653
ables the inclusion of theories and empirical data regarding mid-
wifery practice and from women’s point of view. The theoretical
and practical perspectives were found to concur and complement
each other.
Limitations
The fact that secondary sources were used to analyse the pref-
erences and experiences of women is one limitation of this study.
A distortion of secondary data may therefore exist and have been
adopted by the present study. The methods of the selected studies
weren’t always comprehensively outlined, especially regarding data
analysis, meaning the quality of the studies should be viewed criti-
cally. As midwifery science is a fairly young scientific field, chances
are that not all theoretical papers have been published and/or are
accessible via systematic research.
External validity depends on the data used to develop the the-
ory. Only sources from western, industrialised countries were used
in the present study. Applicability to other countries must be fur-
ther examined. In addition, only women’s perspectives were in-
cluded, not those of other family members. This was motivated by
the fact that women are the main users of midwifery care, and the
present study is based on the assumption that a woman defines
who belongs to her family. This theory is broad and therefore not
deep. A further deepening of the mentioned sub-aims is therefore
useful and partly already available in the literature.
Conclusion
The hierarchical model of the process of midwifery presented
here is a first attempt to show the aims and objectives of mid-
wifery practice hierarchically to facilitate a discussion about those
aims and objectives and make midwifery care measurable. Measur-
ing is a first step in improving quality of midwifery care and thus
improving women’s reproductive capabilities.
The next step in theory development is the empirical validation
of the model. The model was also intended as a basis for devel-
oping a scale for measuring the quality of midwifery care from a
women’s perspective. This scale has already been successfully de-
veloped on the basis of this theory and is currently being validated.
Ethical approval
None.
Funding
None declared.
Declaration of Competing Interest
None Declared.
Acknowledgements
The authors gratefully acknowledge all midwives who gener-
ously participated in our workshop and who are a continuously
inspiration for this work.
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