Midwives as Adult Educators: An Investigation of Midwives’ Perceptions about the Educational Dimension of their Profession

This article deals with the educational dimension of Midwifery, as manifested in the context of perinatal education programmes in Greece. Despite the internationally recognized value of childbirth education in reducing perinatal mortality and morbidity, and despite the rich activity of midwives in terms of perinatal education, their role as adult educators has received limited scientific attention and support. The purpose of this study is to investigate whether and to what extent midwives teaching in perinatal programmes perceive their role as educators, as well as whether and in what way they are prepared for this role. It also investigates whether and what form of training midwives receive to their role in perinatal education. The study followed the specifications of qualitative design and data was collected through in-depth semi-structured interviews with twelve (12) midwives - trainers in perinatal education, as well as with eight (8) women and men who have participated in childbirth classes in Greece. The findings highlight the need to further support midwives in their educational role and to enhance their educational practice by integrating the principles of Adult Education .


Introduction
Perinatal education today involves a holistic approach to care and support, which actively involves the pregnant woman, the partner, and the family.It includes preparing women for childbirth, counseling/supporting breastfeeding mothers, building up for the transition to parenthood, and promoting family health (Polomeno, 2000).In essence, perinatal education has replaced the passing on of knowledge and experience surrounding childbirth and motherhood from woman to woman within the family-neighbourhood context.In this new context, the passing on of knowledge is performed by the midwife.
The move of childbirth from home to hospitals and the detachment of labouring women from their familiar surroundings as well as the transformation of pregnancy and childbirth from private to public affair, led to the need for informing and guiding women through a normalized framework.The midwife, already on the woman's side since antiquity, undertakes the role of satisfying the need for support, information and guidance through the educational dimension of her profession.The role of midwives, despite the intense medicalization of pregnancy and childbirth, is emerging as crucial in reducing perinatal mortality and morbidity (WHO, 2019).Appropriate midwifery education, both at the level of clinical practice and at the level of training as educators in childbirth/maternity programmes is underlined by a variety of international organizations.For instance, the International Confederation of Midwives (ICM), the World Health Organization (WHO) and the United Nations (UN) have detailed work plans for the training of midwives as educators, highlighting the contribution of professional competence in reducing maternal and neonatal mortality (Barger et al., 2019).
The integration of the principles of Adult Education is highlighted by the above organizations as a necessary element for the qualitative upgrading of perinatal education programmes.In particular, according to the latest guidelines of the WHO (2019), the role of midwives in health systems is essential and central, given that the informed practice of midwifery is proven to contribute towards women adopting more positive attitudes regarding health at such a critical moment in their lives.Emphasis is also laid on the importance of proper training and the development of midwives into knowledgeable health professionals, who will be able to cater fully and purposefully to the couples' needs for support and counselling.The literature review reveals that the educational role of midwives in the context of perinatal education programmes has received limited attention.The role of midwives as adult educators is usually approached indirectly, through the exploration of the various aspects of the programmes.Rarely are midwives-educators given a voice to talk about their role and how they experience it in practice.Nolan (2010) is one of the few researchers to highlight these programs as a prime form of adult education and to point out the deafening silence in the scientific field about the use and incorporation of the principles of Adult Education.Although the activity of midwives in perinatal education programs appears intense in Greece and beyond, it has not been investigated or associated with the field of Adult Education.Midwives in perinatal education programs, as will be seen below, are called upon to take on a much more substantial role than that of an informant.And their trainees are much more than mere "audience".

Theoretical Framework
The present study draws on Kegan's (2003) theoretical proposal to investigate the dimensions of the role of midwives as adult educators in the context of perinatal education.Kegan (2003), based on the theory of constructivism -according to which reality is not something that "happens to the individual" but rather is something created by her-in the context of the developmental theory, described a dynamic view of the evolution of individual's consciousness, which evolves through five stages:

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First stage (about 2-6 years old): Imagination plays a leading role in the way the person perceives reality.The subject, making irrational correlations through the prism of imagination, fails to produce logical cause-and-effect relationships.

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Second stage (around 7 years old until adolescence): The individual begins to clarify who she is and what she wants.Desires are perceived as objects with duration.She expresses an egocentric and short-sighted attitude as she tries to manipulate her environment to satisfy her needs.

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Third stage (end of adolescence onwards): Development of the individual's perception of the social whole to which she belongs.This awareness is expressed through the pursuit of commitment to individuals or ideologies.Egocentrism gives way to subordination to the group, its interests, and values.The actions and perceptions of the individual are oriented towards the "meeting" with the community.

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Fourth stage (conquered by few adults): The individual can be accountable and in control of her internal state.Experiences are now perceived outside the self, as objects of observation and reflection as the subject has now constructed a Self, which is not defined by the individual's relations with the people around her but is self-determined.However, an encounter with elements of an opposite value system poses a challenge to the subjects' composure.

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Fifth stage (conquered by a minimum of adults): Weakening of dichotomous thinking.
The individual can combine the opposites but also find the unity that pervades them on a universal level.This ability allows the adult to deftly navigate between opposing elements.Kegan argues that the transition from one level to another presupposes the objectification of experience, that is, its view beyond and outside of ourselves, not as subject -that is as a state of being-but as an object under observation and contemplation.As Kokkos (2019) points out, what matters in the transition from one stage to another is not the change in what the subject learns but the change in how she learns.The change of epistemological structures does not take place suddenly and completely.Instead, the process develops through constant regressions in which the individual uses elements of the previous and/or next stage in order to re-frame the new reality and to achieve balance.This theory is useful in the context of the present study for the following reasons: Pregnancy and the transition to parenthood are a pivotal moment in life, characterized by gradual changes in the individual's life -what Mezirow (2000) refers to as "disorienting dilemma"which requires the revision of previously accepted viewpoints and presuppositions.In other words, it is a period of life in which the person seeks tools to reconstruct her reality, as described by Kegan.Thus, the educator-midwife is called upon to assume a very important role: To understand the level of development which the adult learner has reached and to adapt the educational programme accordingly.She is called to create those conditions which will support the individual in the reconstruction of her consciousness, taking into account the stage of development which the learner has reached at that moment.The mere provision of information, therefore, according to Kegan, proves ineffective for the adult learner, as it does not contribute to their development and transformation.However, Kegan's theory is also important in terms of the educators' level of consciousness and the degree to which they can identify their own dysfunctional perceptions (or elements of the subject according to Kegan) that are inserted into the educational process.

Literature Review
The literature review refers to studies investigating perinatal education courses within the context of adult education and the role of midwives as educators respectively.Some studies focus on the perinatal programs' participants' educational needs.Such an example is the study of Norling-Gustafsson et al., 2011).Although oriented towards the investigation of the degree of satisfaction of couples who have participated in perinatal education programs, in demonstrating the degree to which the programs respond to the learning needs of the participants, it also highlights the importance of midwives being informed concerning their role as educators and reveals the processes that evolve in the context of perinatal courses as adult education programmes.Other studies demonstrate the need for perinatal education programmes to be more adapted to the participants' learning needs, as those needs are highlighted in the theories of adult learning (Fabian et al., 2005).
Other studies look into the educational methods and the content of perinatal programmes.What is found in research is the prevalence of a teacher-centred approach.With the aim of sterile information transmission, the educational methods in perinatal programmes tend to include lecturing and a limited use of active / participatory learning techniques (Nolan, 2010).The lack of acquaintance of midwives with participatory learning strategies and teaching methods, as well as of organizational educational principles (e.g.appropriate number of participants) are reported as common causes for adopting this approach (O'Sullivan et al., 2014).
The evaluation of perinatal education programs is another important part of the educational process, which as pointed out in the literature, has been largely neglected (Stamler, 1998).In this way, there is often a discrepancy in the degree of satisfaction reported by the participants in the courses and the midwives' perceptions (Norling-Gustafsson et al., 2011;Renkert & Nutbeam, 2011;Stamler, 1998).Theodoridou (2005) is the only author in the Greek literature, who refers to the importance of self-evaluation of the midwives' work in perinatal education through critical reflection, indeed suggesting its integration into the midwives' training curriculum.
O' Sullivan et al. (2014) underlines the limited interest of the scientific community in exploring the preparation that midwives receive to respond to their educational role in perinatal education programs.In their study, they note the lack of preparation and support that midwives receive in preparation for their educational role and emphasize the need to introduce continuing training in this area.According to Theodoridou (2005), the relevant training in Greece often takes on an informative character, thus deviating from its purpose, i.e. the enrichment of the knowledge and skills of the trainees.She points out the noncorrespondence of the content of the training programs with the midwives' learning needs, as they perceive and articulate them.In addition, she points out that this discordance suggests a significant deviation from the principles of Adult Education, where the identification of content and learning methods according to the needs of the adult learner is central to the success of education (Papageorgiou, 2022).

Purpose -Research Questions
Based on the above, the need to understand how midwives perceive their role in the context of perinatal education programs is highlighted.Specifically, the following questions are investigated in the context of this article: • How do midwives understand their role in perinatal education courses?
• To what extent do they understand their role as an educator?
• Do they receive trainers' training and what kind to fulfil this role?
For the study, we will focus on midwives and perinatal courses in Greece.

Methodology
The present research follows a qualitative approach.According to Creswell and Guetterman (2020), a qualitative approach proves to be extremely useful for the holistic examination of a phenomenon.The aim is to deeply understand and investigate a phenomenon -the role of midwives as adult educators and how they experience teaching in perinatal courses.The chosen methodological approach allows for greater flexibility (Robson, 2011), as it allows the research tools to be adapted during the research and to include emerging dimensions to be explored.In Greece, the role of midwives as adult educators remains invisible.Therefore, a quality design allows the emergence of unknown variables that are included in this dimension of the obstetric profession.
As a data collection method, the semi-structured interview was chosen.According to Robson (2010) and Creswell & Guetterman (2020), the semi-structured interview permits more flexibility in the course of the interview, it encourages the development of participants' thoughts and feelings and consequently, it allows the emergence and exploration of new themes and dimensions.Because of the above, the interview guide's questions revolved around how midwives perceive their role but also encouraged them to explore topics (e.g.challenges, dilemmas, participation, and exclusion issues).
The research involved twelve (12) midwives with experience in the private sector and voluntary providers of perinatal education, in the organisation and conduct of perinatal education programmes.Four (4) of these midwives are also midwife educators.The research also involved eight (8) participants/trainees in such programs.The interviews of this target group were designed and implemented after the analysis of the midwives' interviews.

Limitations -Reliability of the Research
To ensure the validity and reliability of the research, the method of triangulation was applied, drawing data from different types of informants (midwives-educators and participants in perinatal education courses) (Cohen et al., 2018).The purpose of investigating the dimensions of the trainees' participation was on the one hand to determine whether the aims of the perinatal education courses, as described by the midwives, are communicated to the trainees.On the other hand, the aim was to investigate whether the midwives' perception of the effectiveness of the programs is verified in the views of the participants.The midwives who participated in this research come from private and voluntary sector organizations in Athens and thus, the resulting conclusions cannot be generalized.

The Purpose of Perinatal Programs and the Role of Midwives
For many midwives in the study, their role in perinatal education is inextricably linked to the obstetric dimension of their profession.In fact, in many cases, the same midwife who trains a pregnant woman will assist her in childbirth and during breastfeeding.They are therefore called to act simultaneously in both dimensions, the educational and the obstetric, which usually develop in the environment of a maternity centre or hospital.In this light, the role that almost all midwives identified themselves with was that of "supporter".As Margarita1 points out, "midwifery means being next to the woman, with the woman, that is our role".Also, empowerment emerged as an important purpose of the courses."I empower.Empowerment.This is my role.I strengthen their will to breastfeed", said Eleni.
Most midwives interviewed do not think they are educated.They believe that education is not directly related to the content of their programs.For Alexandra, the concept of education seems to be negatively charged, perceived as a process that is permeated by strictness and alienation.The midwives therefore seem reluctant to uptake the role of the educator, which they have associated with negative schooling experiences."I think it is education but not in the strict sense.It's a relationship with a woman.It is a deep relationship beyond the sterile knowledge that is made in formal education".It has to be noted here that midwives' perception of not having an educational role in their perinatal courses stems not only from their negative experiences in education but also from their perception of education only in its formal form.The lack of training in Adult Education seems to affect the midwives-educators' view of their role in the context of perinatal programs, as they are not aware of non-formal education as part of education.
On the other hand, there are midwives' interviewees who do realize their educational role.For example, Stella identifies herself partly as an educator, but cannot fit her work regarding guidance and empowerment into the image she holds for the educator's role."Initially you are an educator but later, when you establish a closer relationship with the woman, you coach, empower, and give psychological support."Indeed, when it comes to the interviewed participants in perinatal programs, they tend to view them indeed as educational.Accordingly, during the interviews, prospective parents refer to these programs using words related to learning.Indicatively, Faye states that the "lessons" she attended in a perinatal provider "got her learning one level higher" while Anna feels that she was "educated in breathing techniques".
The context in which midwives practice their profession -in all its dimensions -presents Greece with some important particularities.Specifically, the perinatal period in Greece is extremely medicalized.This fact is reflected in the excessive number of caesarean sections (WHO, 2016), as well as in the significantly large number of women who choose to give birth in private maternity hospitals.The rate of caesarean sections in public maternity hospitals in Greece is 40% and in private ones 60%, when according to the WHO ( 2016), the medically acceptable rate is 15%.This inevitably affects the success of breastfeeding to the extent that a caesarean section can negatively affect the establishment of breastfeeding (Iliodromiti et al., 2018).Therefore, for most midwives in this study, the context surrounding childbirth in Greece suggests the first and greatest challenge.As they state, "women leave empowered" from perinatal courses and then give birth in a maternity hospital where none of what they have learned is validated" (Dorothea), where "their power is being stolen" (Nota).In light of this, midwives seemed reluctant to see themselves as "educators", considering themselves to be "much more" than that: Supporters providing courage and empowerment in a struggle.From the above, it can be seen that the lack of training in the principles of Adult Education prevents midwives from recognizing the complex role that they perform as educators of adults (Jarvis, 2010), which includes teaching, guidance, and empowerment.

Challenges
Despite the individual differences, all midwives identify "the Greek reality" mentioned above as a great challenge in their role as educators.As Eri explains, "I feel like I have an invisible enemy somewhere ... you want to work properly, to support childbirth with safety and respect and love.But you are called to accomplish this in a country and a system where things are very very bad, very invasive, without respect ... the opposite ".For some midwives, the Greek reality "is inextricably linked to the "unclear role of midwives in the health system" (Matina).In addition, Dora explains that the position of perinatal education in Greek society, and in particular in the Greek health system, contributes to the limited understanding of its importance.The result of this, as she states, is the perception of perinatal education by obstetricians as competitive or even hostile.The above perception also appears in the interviews of the participants.For example, Anna describes "..the Greek system as far as pregnant women are concerned is rotten and fragile.This is what I experienced in my first birth and this is what the midwives gave us to understand: How we will cope with this system during labour".
Interviewed midwives at the beginning of their professional life, considered the setting of boundaries with trainees as being particularly challenging for them.Characteristically, Eri refers to "the limits... that also require training, you have to know how to set limits with love and generosity, it is difficult and you have to handle this gently because if you fail let's say to start the session at 7: 30p.m you'll end up going back home at 2: 00a.m ... ».And this is another element that stresses the need to further acquire skills related to adult education.
Another issue that emerged from the analysis of the data relates to the characteristics of the participants as well as the composition of the groups.Sophia, for example, refers to issues related to the management of gender differences within the groups: "For me, the challenge is the dad.Fitting men into the group is a challenge because men ... because we live in this patriarchal society, have more taboos and should ... Because in the average Greek family, they have learned, you are a boy, do not cry, you are a boy, you are strong, you are a boy so you do not change diapers, you do not wash dishes so in general ... I generally feel, or I may be biased I don't know, that it is difficult ". Once again, this highlights the need for midwives undertaking perinatal education programmes to demonstrate the knowledge, skills and competences pertaining to adult learning, such as knowledge of the characteristics of adults as learners, participatory teaching techniques and group dynamics (Karalis & Papageorgiou, 2012).
The importance of Kegan's (2003) theoretical proposition on the developmental stages of adult consciousness and on the role of the educator in distinguishing the level of consciousness the adult learner has reached that particular moment and her readiness for transformation is reflected in Stella's description, who states that "Sometimes I meet people who are steadfast in their views and they try in every possible way to challenge what I say.So I find myself doing the job of a browser let's say.I try to prove to them, using this or that research, that what they are telling me is not true and this is a challenge for me because I am trying to prove the obvious, what is self-evident to me but not to the other person.Some of the participants often react ... ".

Educational Methods
Several interviewed midwives apply active educational methods (such as role play, experiential exercises, and storytelling) as a way to support, on the one hand, the building up of their groups and on the other hand to encourage their active participation.Respectively, interviewees who were participants in such groups emphasized the importance of active educational methods and their contribution towards learning through the perinatal course.As Maria describes: "... we did everything… dancing, singing, experiential activities, everything.It was an incredible experience; it all got me one level ahead".In contrast, different interviewees, participants in perinatal courses, pointed out their experience of perinatal courses where there is a prevalence of lecturing and of accumulating "useless" information (Vaso).Once again, this confirms the importance of midwives knowing and implementing adult education participatory methods and, when this is not the case, of the need to train midwives in the principles of adult learning.

Education -Training -Professional Development
Although all midwives-interviewees have attended vocational training, no midwife has received training specifically for her role as an adult educator.Most, however, seem to be looking for training programs to acquire tools that will help them meet the multidimensional challenges of their role as adult educators.This latter dimension is by no means at the level of the conscious.In other words, midwives do not seem to connect the emerging challenges that they try to meet through training with their role as adult educators.The training concerns the organization of perinatal education programs, counseling, psychology, pedagogy, group development and management, yoga, etc.
Those educators-midwives who have participated in training after the completion of their undergraduate studies in Midwifery on their initiative to expand their scientific knowledge about their educational role consider the preparation they received at the undergraduate level for teaching in perinatal courses as non-existent.On the contrary, for those midwivesinterviewees who have not participated in professional development courses, the basic elements of verbal communication included in the undergraduate Midwifery curriculum are considered as useful enough for their educational practice.This finding is in agreement with O' Sullivan et al. (2014), who found that midwifery educators who have pursued further training offer a more holistic approach to pregnant women and their partners without focusing on a sterile transfer of information.

Midwives' Perceptions of their Role in Perinatal Education
The role of midwives in perinatal education and the way they perceive it is considerably influenced by two elements: The obstetric and clinical dimensions of their profession as well as the context in which they are called upon to unfold these dimensions.The unfavourable medical context in which they are called to practice their profession significantly affects the way they perceive their role.The participating midwives see themselves mainly as a «supporter» of the woman, as being "with the woman", or "on the side of the woman".For most it seems that childbirth is a continuation of the lessons but also the point where their success is evaluated.After all, as most midwives-interviewees report, the success of breastfeeding and a good start in parenting presupposes a positive childbirth experience.A very similar approach of midwifery educators about lessons and childbirth is also found in other research (e.g.Nolan & Hicks, 1997, Otogara et al., 2017).
However, in the present study, achieving a "dignified" delivery and success in nursing after the end of the course is a bold move.Midwives in Greece seem to link the lessons with childbirth outcomes and nursing much more intensely and with significant anxiety, due to the unfavourable medical context within which they are called to educate and in which pregnant women give birth.
Still, the interest and dedication that midwives in this study show to their group participants is a key asset that, accompanied by the necessary training in adult education, would make midwives particularly good educators, as this element encourages adult educators to take on person-centered approach and to be open to the voice and needs of their learners (Papageorgiou,

Midwives' Perceptions of their Educational Role
From the data analysis emerged the feeling that midwives, despite teaching adults, do not consider their role in perinatal programs as educational or they seem reluctant to define their role as such.In addition, it seems that their personal experiences from school life and how they perceive and define learning themselves constitute an unprocessed element, which as Kegan (2003) argued remains at the level of the subject, i.e. it is not a critically considered experience.This ultimately affects the way they perceive their role.In this light, there is an ambiguous attitude towards how they approach their adult audience, sometimes taking on the role of "parent" and sometimes "of the peer", trying to "persuade" and sometimes "giving the stimulus" for the participants to pursue their quest.This contradicts the perception of participating women and men in the courses, who regard these programs clearly as educational.They consider that they are being educated.Bron's and Jarvis 's (2008) theoretical proposal on "multiple identities" and the fact that the adult educator can now work in different contexts, as long as she has a conscience and dedication to her educational work, could be helpful at this point.
The need for midwifery educators for training in the field of Adult Education permeates the collected research data whether explicitly or implicitly.This need is manifested implicitly through their active participation in professional development.They tend to spend significant time and money on seminars and programs seeking essentially -although not consciously-Adult Education tools to meet the demands of their role as educators.

Conclusion
Midwifery educators, therefore, are looking for tools that will enable them to meet the challenges accruing from their role as adult educators.In the absence of a coherent framework that would provide all the tools an adult educator needs, midwives borrow tools from the field of Psychology and Pedagogy.It could be argued that the participating midwives in the present research seek Adult Education without knowing it.They seek to meet with the wealth of the theoretical and practical tools of the field without this pursuit taking place on a conscious level.But all their needs and their educational aspirations verify this very presumption.