The first person most of us meet in this world is a midwife – even if we don’t remember her later. At the University of Cologne, a new generation of midwives has been undergoing training since the winter semester 2021/22. The first class has recently graduated. Right from the start, they have learned to develop the particular empathy which is essential to their profession. And their training is grounded in the latest research findings.

Anna Euteneuer and Hannah Reiter

The baby’s head is already visible. Suddenly everything comes to a halt. “One more hard push, Ms Lucina,” says Maria Rivera, a fourth-semester midwifery student, to the woman giving birth, but nothing happens. After another unsuccessful attempt at pressing, Rivera tries again to see if she can feel what’s happening. She suspects that it could have something to do with the child’s shoulder. Antonia Henninghaus, research assistant at the Institute of Midwifery Science, then removes the abdominal wall from Ms Lucina, a life-size, 80,000 euro birth simulator doll. Now the students can see what’s going on. The baby’s front shoulder is stuck in the mother’s pelvis – a so called shoulder dystocia. 

In this complication during labour, the baby’s shoulder cannot follow the rotation of the head through the convoluted birth canal. Dystocia means difficult birth. If the same situation had happened in a delivery room, Rivera would have immediately called for assistance to get things moving again. She knows: “The most important thing is to keep your nerve.” Even though shoulder dystocia is one of the most feared emergencies during a birth, a calm reaction from the staff can quickly defuse the situation.

“In the simulation, the future midwives become acquainted with the birthing process and all of its potential outcomes. They train to be well prepared for the reality that awaits. The constant practice is worth its weight in gold for the trainee midwives”, says Professor Dr Nicola Bauer. She has been the first professor of midwifery science at the Faculty of Medicine in Cologne since April 2022.

With Bauer’s appointment, the integrated degree programme ‘Bachelor of Science in Applied Midwifery Science’ was established at the University of Cologne as the first comprehensive university in North Rhine-Westphalia. The Midwifery Reform Act of 2020 provides for the academization of the midwifery profession, which is why the integrated degree programme is replacing training at midwifery schools throughout Germany. This creates a close exchange of information with researchers, allowing for the latest findings to be incorporated into the midwives’ training. The students learn about everything relating to childbirth under academic supervision – in theory, in lifelike simulations, in the VR lab and in practice. This year, twenty-three trainee midwives will be leaving the University of Cologne with a Bachelor’s degree and beginning their work.

The situation in delivery rooms is becoming increasingly complex

On average, women in Germany give birth once or twice in their lifetimes. These are exceptional situations in which expectant mothers and their children depend on professional help. However, in international comparison, the quality of obstetric care in Germany is no more than mediocre, even according to the latest data collected by the Organisation for Economic Co-operation and Development (OECD) in 2022. The infant mortality rate is in the mid range compared with other European countries. In the Scandinavian countries, but also in Slovenia and Spain, the infant mortality rate is particularly low. In terms of the low rate of stillbirths, Germany ranks only 28th out of 45 high-income countries.

According to a statement issued by the Government Commission for Modern and Needs-based Hospital Care in November 2024, Germany’s performance in terms of healthcare stems from a lack of human resources, regional care structures and demographic developments. 

At the same time, the situation in delivery rooms is becoming more complex. However, Nicola Bauer is convinced that this is not only due to the conditions prevailing within the healthcare system but also to changing living conditions: People are starting families later and women are becoming mothers further on in life. Thanks to improved medication, chronic illnesses such as heart disease are no longer a hindrance for people planning to have children. Reproductive medicine is also increasingly enabling couples to have children even at an advanced age or with pre-existing conditions.

The prevailing situation calls for a high degree of flexibility, professionalism and considered reflection on the part of doctors, midwives and other healthcare professionals working in the delivery room. These conditions will continue to apply despite the new integrated degree programme but the upgrading of the profession through academization could facilitate a degree of latitude for midwives.

Acting professionally, reacting compassionately

In addition to medical skills, future midwives at the University of Cologne learn all about respectful communication on equal terms – whether they are dealing with expectant parents or colleagues. “Involving the parents-to-be in decisions has a major impact on the birth experience and therefore on the further development of the couple’s relationship, the parent-child relationship and the self-perception and personal competence of the parents-to-be,” says Bauer. In contrast to large international surveys, such as the Birth Experience Study (BESt), which was originally developed in Australia and has been repeated in thirteen countries, there have only been a few studies in Germany investigating the birth experience.

In July 2024, the Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR) at the University of Cologne participated in the publication of a study which investigated how obstetric interventions affect individual perceptions of childbirth. It analysed the birth experiences of around 1,000 women. The study shows that the women rated the birth overall as rather positive with 3.09 out of 4 points – especially if no obstetric interventions such as manual pressure on the abdomen (fundal pressure), an unplanned caesarean section, an episiotomy or an assisted vaginal birth (suction cup/forceps) were necessary. 

They were asked to rate their experiences of their ‘own abilities’, ‘professional support’, ‘perceived safety’ and ‘involvement’ during the birth. After obstetric interventions, women were less satisfied overall. However, it turned out that this feeling of dissatisfaction could be checked and even ameliorated if the expectant mother’s self-efficacy – her inner conviction that she could cope well with this difficult situation on her own – was strengthened, for instance by positive communication. 

“The fact that we now have these kinds of empirical results for Germany is a step in the right direction,” says Bauer. The Cologne Institute of Midwifery Science, other institutes at the university and the University Hospital are also currently conducting or planning studies on obstetrics. According to Bauer, the data allows for a change of perspective: In addition to the biomedical view of illness and health at birth, there is a growing awareness of the need to accompany expectant mothers, families and children well and safely through the birth process. This approach is also known as ‘woman-centred care’. It is at the heart of the World Health Organization’s recommendations for intrapartum care published in 2018 and is reflected in the content of the integrated degree programme.

From simulation to reality

The trainee midwives learn to apply their theoretical knowledge at an early stage. During the semester, they take part in practical exercises at KISS, the Cologne Interprofessional Skills Lab and Simulation Centre. There, students encounter a real-world learning environment in which they can practise acting in everyday routines or emergencies with medical equipment, models and simulated individuals – as in the case of the shoulder dystocia in ‘Ms Lucina’.

Since the winter semester 24/25, trainee midwives have also been able to experience the birth process in a virtual reality environment in the new Center for Medical Innovation and Technology of the Faculty of Medicine and the University Hospital, CeMIT for short, so that they can understand the mechanics of birth in all its details. In the ‘Virtual training for obstetric birth simulations’ (V.T.O.B.S.) project, students of human medicine and midwifery put on VR goggles to follow the birth process in a 360-degree video. A woman giving birth is shown in various positions and, in addition, the view inside the body enables a detailed visualization of the foetus during the birth process. Different perspectives show the process from pelvic entry to shoulder birth in a 3D animation.

Even if they are experienced by way of models or in virtual reality, the birth simulations feel very real for the participants. “Nothing and nobody can prepare you down to the last detail, because every woman and every birth is individual,” says Julia Carl, a 7th semester student. “What you can practise here, however, is logistics: Which tools do I have at my disposal? What are all the things I need for a birth? And the good thing is, it’s okay to make mistakes. You can discuss everything afterwards, return to the situation and practise.” 

In real-life birth scenarios, midwives are often confronted with situations in which decisions must be made quickly and there’s little room for discussion. One such situation for instance would be an unplanned caesarean section that needs to be performed in a hurry. “Many women report afterwards that nobody spoke to them in the emergency situation. This can have a traumatising effect,” says Bauer. The women experienced terrible fear, even mortal fear, for themselves and their child. The programme teaches how expectant parents can be reassured and informed in this kind of emergency situation. Even with an emergency caesarean section, there are still a few seconds to explain the necessity. Sometimes, according to Bauer, a simple “Look, we have to act quickly now” is enough to communicate with the families, and then to talk about what happed when there is time after the birth.

Here’s to many birthdays ahead!

With the academization of the midwifery profession, a new generation of midwives is advancing. “We have practitioners who reflect and ask critical questions, and who want to work in an evidence-based way in interprofessional collaboration,” says Nicola Bauer. Many students also enquire about continuing their academic education. “We need Master's programmes and doctoral programmes, because we still have too few academically qualified midwives who can also for instance become professors or go into research as postdocs,” adds the course director. That will soon change: the new Master of Science programme ‘Advanced Midwifery Practice’ will start at the Faculty of Medicine in the winter semester 25/26.

The newly qualified graduates of the integrated degree programme usually go into practice first, where they can play a decisive role in the healthcare of mothers and their newborns and families, not least in terms of the appreciation of this specialized medical profession in healthcare. Bauer sees the new graduates as ‘midwives 2.0’, as change agents who are not only highly trained in medical terms but also equipped to contribute on key issues relating to sexual and reproductive health and rights.