gms | German Medical Science

Women are legally entitled to midwifery care during pregnancy and the postpartum period under the contract on the provision of midwifery services in Section 134a of Book V of the German Social Code (SGB V) [11]. Due to the Covid-19 pandemic, additional special arrangements were made which made it possible, for the first time, to provide digital midwifery services. From March 2020, freelance midwives in Germany were permitted to conduct initial consultations and provide advice on pregnancy complaints, conduct antenatal and postnatal courses and provide postpartum care digitally and charge for these services [10]. Just a year earlier, in 2019, in a survey of midwives on midwifery care in the federal state of Hessen, 54% of the midwives surveyed could never imagine using telemedicine to provide women with care. At that time, only 9% of those surveyed could definitely imagine providing this type of care [1].

Unlike Germany, other countries already offered digital midwifery services before the pandemic and experiences with this type of service provision have been described [6], [7], [9]. The studies published on telemedicine specifically in the midwifery context show that digital midwifery care was primarily rated positively both by the women surveyed and the midwives and doctors themselves. However, the model of home-based postpartum care, as provided by midwives in Germany, is unique in the world. It is therefore difficult to find studies from the international context that can be drawn on to compare home-based postnatal services with postpartum care via videotelephony, as any conclusions regarding digital postpartum care in other countries cannot necessarily be transferred to Germany.

The aforementioned scepticism of midwives regarding digital services, the rapid introduction of these services and the limited transferability of the findings of studies from other countries, as well as the likely permanent establishment of digital midwifery services, which did in fact happen in June 2021 with the Act for the Digital Modernisation of Care and Nursing (DVPMG) [3], were all reasons to conduct a timely evaluation of the implementation of digital services in Germany. As part of a collaborative project between the German Midwives Association (DHV), the University of Health Sciences, Bochum, and the BARMER Institute for Health Care System Research, a survey of mothers and midwives was conducted, the results of which are presented here [2]. The aim of the survey was to collect information on the provision of digital services by midwives and utilisation behaviour as well as to find out more about how the services were evaluated by mothers. Based on statements regarding satisfaction as well as assessments of opportunities and challenges the aim is to derive pointers for the further development and improvement of these services. A distinctive feature of this study is the fact that two perspectives are surveyed at the same time, on the one hand the views of midwives and, on the other, those of mothers.

To acquire an overview of the literature on the subject of digital midwifery services, an exploratory literature review was conducted in the Embase database using the search blocks “telemedicine” (63,722 hits) and “obstetrics or midwifery or midwife” (174,360 hits). Combining these two search blocks and excluding the duplicates yielded 239 studies. However, screening the abstracts for these studies only revealed a small number that were suitable to be used for the theoretical classification in the introduction and for the discussion of the results.

To survey the views of the service providers (midwives) and service users (mothers) within the cross-sectional study described, two questionnaires were developed, each tailored to the respective target group. The questionnaires were designed in collaboration with experts from the fields of questionnaire development, healthcare research, midwifery and health sciences, and from the professional perspective of midwives as well as from the perspective of mothers. Since there are no validated instruments to draw on, the experts contributed the relevant questionnaire content which was then structured for the survey. The decision was made not to develop a comprehensively validated instrument as it is not envisaged that the survey will be used regularly. Throughout the process of developing the questionnaire, members of the BARMER Institute for Health Care System Research, members of the team Outpatient Care and the German Midwifery Association regularly provided internal feedback on drafts of the questionnaire. Moreover, both questionnaires underwent a pre-test for clarity and completeness. The cognitive pre-tests were conducted in written form in February 2021. The questionnaire for mothers was tested by representatives of the national parents’ initiative Mother Hood e.V. and the pre-test of the midwife questionnaire was conducted by freelance midwives. Following the pre-tests, minimal adjustments were made to both questionnaires.

The midwife questionnaire comprises blocks of questions covering personal details and general information about the respondent’s professional life and experience, about digital and in-person services, about their attitudes towards technology/technical facilities, as well as the opportunities and challenges of providing digital services, including prospects for the future of digital service provision in the post-Covid world. The questionnaire for the mothers included question blocks on the individual respondent and on the course of their pregnancy and labour, on their utilisation of midwifery digital and in-person care, their attitude towards technology and technical facilities, as well as their assessment of digital midwifery care, including the opportunities, challenges and future prospects.

The random sample of women surveyed was drawn from all women insured with BARMER who gave birth between May and November 2020. Inclusion criteria were legal age, live birth and place of residence in Germany. Around 9 million people are insured with BARMER and the insurance fund covers the costs of more than 60,000 births per year. The pool from which the sample was drawn was reduced due to the months the mothers had given birth and the months in which they gave birth and the fact that women who had already participated in another questionnaire on the topic of pregnancy were not approached again. Ultimately, 18,784 women were asked by BARMER to participate in the online questionnaire using a QR code. The questions on pregnancy and postpartum period were asked at the same time. Filter questions steered participants towards the relevant question blocks. The midwife survey was based on a sample of midwives put together for this specific purpose by approaching midwives via the German Midwifery Association in the form of a call for participation in the Association’s magazine, in the electronic newsletter and through social media. Inclusion criteria were legal age, place of residence in Germany, professional license and at least one month of freelance midwifery practice in 2020. The written online questionnaire took place for both survey groups at the same time, from 17 February to 15 March 2021. Participation was anonymous and required participant consent. For data collection, the platform Unipark Questback EFS Fall 2020 Release was used, and data analysis was conducted at the University of Health Sciences, Bochum using the IBM SPSS Statistics 27 program.

The personal characteristics of the mothers were age, number of own children, highest educational qualification, number of inhabitants in place of residence, federal state, migration background, first language, as well as self-assessed digital competence and/or technical skills. The purpose of the questions about the federal state and size of the place of residence was to capture possible regional differences and differences between urban and rural regions.

A total of 1,821 fully completed questionnaires for mothers were included in the analysis. This sample predominantly comprised mothers between the ages of 30 and 39 (n=1,348, 74.0%). The share of mothers from the 30–39-year age category in the group of respondents is thus significantly higher than the share of mothers in the general population (Destatis: 55.3%) and of all mothers insured with BARMER (59.1%) during the same period. More than half of the women surveyed (n=983, 54.9%) were primipara. Similarly, more than half of the women in the sample had a general or a subject-specific higher education entrance qualification (n=1,015, 55.7%). Women from North Rhine-Westphalia (n=375, 20.6%) and Bavaria (n=300, 16.5%) made up the largest group. Overall, 100 women with a migration background took part in the survey (5.5%). A total of 76.8% of women (n=1,398) reported finding it easy to use a computer, laptop, tablet etc. (Table 1 [Tab. 1]).

A total of 1,551 fully completed midwife questionnaires were received. The participating midwives were roughly equally distributed across the age groups 30–39 (n=394, 25.4%), 40–49 (n=450, 29.0%) and 50–59 years (n=429, 27.6%). A total of 150 midwives under the age of 30 participated (9.7%), 127 were aged 60 or older (8.2%). A total of 92.5% of the participating midwives (n=1,434) had completed midwifery training, 3.7% had completed a university degree in midwifery (n=57) and 3.9% had obtained a degree in addition to their midwifery training (n=60). North Rhine-Westphalia (n=420, 27.1%) and Baden-Württemberg (n=291, 18.8%) were the most strongly represented federal states, while Mecklenburg-Western Pomerania (n=7) and Bremen (n=3) provided the smallest number of participants. A total of 95.6% of the participating midwives (n=1,483) were born in Germany and for 1,504 (97.0%) German was their mother tongue. Overall, 68 of the midwives had a migration background. A total of 1,044 midwives (67.3%) reported finding it easy to use a computer, laptop, tablet etc. (see Table 2 [Tab. 2]).

Two-thirds (67.1%) of the midwives reported having to purchase new equipment in 2020 to be able to provide digital care. This mainly comprised computers/laptops (n=456), webcams (n=276), microphones/headsets (n=455) and videotelephony programs (n=797). A total of 48.6% of the midwives (n=753) changed the services they offered in 2020. The majority (59.4%) of respondents stated that they did this because of the Covid-19 pandemic. Yet even during the pandemic, the vast majority of midwives managed to maintain in-person care. This particularly applied to the one-to-one services offered. The range of in-person courses offered was reduced. Of the participating midwives, 146 (9.4%) reported no longer offering in-person antenatal courses and 133 midwives (8.6%) said they had discontinued their privately paid midwifery services.

Table 3 [Tab. 3] shows the range of statutory services, both in-person and digital (via messaging services and live videotelephony), provided during pregnancy and the postpartum period.

Of the participating women who used midwifery services during pregnancy (n=1,551), 37.3% (n=579) said they had (also) accessed digital services. During the postpartum period, the corresponding figures were 28.8% (n=495) of 1,717 women. These two groups partially overlap as the same women were asked about the services they used during pregnancy and the postpartum period at the same time.

Figure 1 [Fig. 1] provides an overview of the respective parent population of the women surveyed.

Table 4 [Tab. 4] shows that not all digital services were used to the same extent. The initial consultation, in particular, is something women preferred to have in person, and when it comes to postpartum care, too, women tended to opt for the in-person version. In contrast, around half of the women surveyed (also) resorted to digital midwifery services if they needed advice on pregnancy complaints. Course participation was divided roughly equally between digital and in-person options, while women who had already given birth predominantly participated in digital postnatal classes.

The questionnaire also included questions about the use of private midwifery services, such as pregnancy yoga, hypnobirthing, homeopathy, bach flower remedies and aromatherapy, as well as individual courses on infant care, babywearing, courses on supplementary feeding and baby massage. During the pandemic timeframe depicted here, the in-person version of these offerings, depending on the course, were used by one in four or five women, while very few participated in such courses in digital format.

Of those women who used digital midwifery services during pregnancy (n=579), the overwhelming majority were very satisfied: 74.1% (n=429) rated the care provided as “very good” and 18.8% (n=109) rated it as “good”, according to the German school grading system, which ranges from 1 (very good) to 6 (fail). When it comes to the digital care provided during the postpartum period, 75.4% of the mothers surveyed (n=373 of 495 women) gave it a “very good” score and 15.6% (n=77) a “good” score (see Table 5 [Tab. 5]). The average score for both digital prenatal and postpartum care was 1.4 (where 1.0 is the highest score and 6.0 is the lowest). Thus the digital services were ranked higher than the in-person care. Of the 972 women who exclusively used in-person prenatal care, 59.6% (n=579) gave that care a score of “very good” and 24.2% (n=235) rated it as “good”. Of the 1,222 women who exclusively received in-person postpartum care, 65.5% (n=800) gave their care a “very good” score and 20.5% (n=250) a “good” score. On average, women gave in-person prenatal care an overall score of 1.7 and postpartum care, 1.6.

One special feature of this study was that both mothers and midwives were asked about the opportunities and challenges of digital service provision at the same time.

Table 6 [Tab. 6] shows that, on some points, women and midwives had different opinions.

Moreover, midwives identified advantages in terms of flexible working practice but also challenges when it comes to data protection and invoicing. One disadvantage they mentioned was the inability to carry out a physical examination.

The overwhelming majority of women (84.4%) did not see digital midwifery care as posing any challenges, though they did perceive limitations when it came to interaction and networking with and getting to know other women.

Overall, 62.7% of midwives (n=972) are in favour of continuing to provide digital midwifery services after the Covid-19 pandemic during pregnancy and 50.4% (n=781) see this as an option for the postpartum period. Accordingly, more than half of all the midwives considered the provision of care in digital form during pregnancy (64.5%, n=1,000) and in the postpartum period (53.4%, n=828) to be a useful addition to in-person care. Here, affinity for technology was significantly positively correlated with the desire to see digital services continued after the pandemic and for this to be effectively combined with in-person care. That said, over 85% of the midwives agreed, regarding both prenatal (85.2%, n=1,322) and antenatal care (87.4%, n=1,356), with the statement that an expansion of digital care should not have a negative impact on the amount of home-based care offered.

The responses of the women surveyed were similar Table 7 [Tab. 7]). In answer to the overarching question regarding the future provision of digital services for both prenatal and antenatal care, 250 women (34.2%) responded with “the services offered were exactly right” and 132 women (18.1%) said “the services should be expanded further”. In contrast, just 125 women (17.1%) said they did not need any digital services.

Those women who would like to see digital services expanded further felt this would be needed in all areas, in other words, both for the courses offered and the individual advisory services and private services. Women were also asked about their wishes regarding future antenatal and postnatal courses. What they wanted most, and this answer was given by almost half of the women who responded (46.4%), was an opportunity to network more with other course participants, followed by 24.8% who wanted to see more interaction during the course. While 17.1% felt there was room for improvement when it came to technical implementation by the service providers, 37.0% said everything was perfect. Women see digital care as a good service and as a valuable addition but would like to continue having direct contact with the midwife, particularly during the postpartum period.

One limitation of the study is the lack of representativeness of the samples, which is due to the specific characteristics of women insured with BARMER. Women insured with BARMER tended to give birth at a slightly older age than women in the general population who gave birth during the same time period and, among those who responded, there was also a considerably higher share of women over the age of 30 (74.0% vs. 55.3% according to Destatis). This result may have been further distorted by the fact that the responses of those women who did not participate in the survey would have been different (nonresponse bias). The response rate of just under 10% for the survey of mothers was on the low side. This could be attributed to the use of the QR code. It was not possible to send the invitation to take part by email or electronic newsletter. Previous surveys among mothers insured with BARMER conducted by means of paper questionnaires had much higher response rates. It can be assumed that the survey mainly reached those women who are familiar with digital technology. This would also explain why digital services were, in some cases, rated even higher than in-person services by the women who participated in this survey.

No conclusions can be drawn regarding the sample and response rate for the midwives as it is not known how many midwives are actively working in Germany and because the midwives were not contacted in a targeted manner.

Overall, these first results of the evaluation show that the digital midwifery services offered during the pandemic were quickly established and were well accepted by the women who used them. This rapid establishment was, to a certain extent, in contrast to midwives’ scepticism regarding digital services, which had been identified in 2019 in a survey of midwives on the state of midwifery care in Hessen. At the time, 54% of the participating midwives said that they could never imagine using telemedicine to provide women with care and a mere 9% could definitely imagine providing this type of care [1]. With the caveat that the midwives surveyed in 2019 were obviously not the same as those surveyed here and the 2019 survey was also limited to midwives in Hessen, this study nevertheless suggests that midwives’ attitudes towards digital care have changed compared to the period before the Covid-19 pandemic. In this survey, those midwives who actually provided digital services expressed a largely positive opinion. Here, however, a “good” self-assessment when it comes to digital literacy or technical skills was significantly positively correlated with the wish to continue with digital service provision and to effectively combine it with in-person care. Mothers barely experienced any problems operating the digital tools, while just under 29% of midwives reported having had difficulties – presumably due to the fact that technical implementation is more complex for the provider than the user. Midwives were not asked to evaluate the digital services in the same way as the women participating in the survey. A comparison is therefore not possible as the focus was slightly different in the two surveys. For women, satisfaction with the care provided was at the forefront, while for midwives, the focus of our inquiry was on obstacles to implementation.

Looking at digital midwifery services abroad reveals that in other countries, digital midwifery care was, in some cases, implemented earlier and used more widely than in Germany. In Sweden, a study conducted as early as 2009 looked at postpartum care of women who left hospital less than 72 hours after giving birth. The parents were very satisfied with the service offering [6] and the feedback from the midwives was equally positive [7]. In the USA and Japan, women were provided with various devices/pieces of equipment (such as, for example, scales, blood pressure monitors, dopplers or cardio or foetal monitors) so that antenatal care could also be provided using telemedicine. Multipara, in particular, were attracted to the idea of having every third check-up via telemedicine [9]. A Japanese study also came to the conclusion that safe and high-quality antenatal care can be provided by means of telemedicine [8], [9].

A worldwide survey on digital care for all aspects of pregnancy and birth during the Covid-19 pandemic shows the widespread adoption of this approach: 58% of respondents used telemedicine so they could continue to provide care despite the necessary infection control measures. The main challenges listed were problems with technical implementation, lack of support, e.g. through training and guidelines, as well as an increase in the existing inequality of access. Other aspects mentioned were difficulties building trust and lack of non-verbal communication in the therapeutic relationship [4]. In the survey presented here, the latter aspects were only mentioned as concerns by the midwives but did not prove to be problematic for the women who participated in the survey. Despite its limitations, this worldwide study also found that telemedicine was seen as an important alternative to in-person care [4]. Switzerland, too, provided digital midwifery care during the lockdown. There, almost 40% of midwives viewed digital care positively, though almost 58% rated digital care negatively or largely negatively. The fact that it is harder to assess complex situations, there are no opportunities to conduct examinations and therapies, and there are disadvantages for clients with psychological problems, language barriers or limited technical know-how, were all seen as problematic here. Respondents also complained about the lack of training opportunities in this area [5].

In Germany, the Act for the Digital Modernisation of Care and Nursing (DVPMG) regulated digital midwifery care for the first time, thus also making it permanent. Digital midwifery care is now no longer part of an emergency plan for Covid-19, but instead the long-term digital provision of services is part of standard care. In light of this, high-quality implementation, both in terms of technology and content, must be ensured by means of the appropriate support and/or training courses as well as through the development of quality standards. The study presented here also shows that it is important to make sure the right services are being offered digitally and to effectively combine this with in-person care, as not all midwifery services are considered to be equally suited to digital implementation.

The authors declare that they have no competing interests.