**4. Results**

112 graduates participated in the survey, 26 of them did not finish the whole questionnaire, however their answers were used, where given. That gave the survey the response rate of 65%.

The majority of the participants were satisfied with the subject, as shown in Table 1.


**Table 1.** General satisfaction of students with the subject Sexology in midwifery

The next complex of questions evaluated the organization and the form of the subject. The first question referred to appropriateness of that the subject is in the last year of the study. Again, the majority of the participants supported the inclusion of the subject in the last year of study, but some of them (one fifth) objected. The results are shown in Table 2.


**Table 2.** Participants' view regarding the instalment of the subject into the midwifery curriculum

Author asked students whether they think subject is comprehensive enough. One third of students thought it is not correctly emphasized, however the proportions of those who thought that it is too extensive and those who thought it is undervalued were evenly distributed (Table 3).


**Table 3.** Participants' estimation of the appropriateness of students' workload to the subject

Participants were also asked whether they think the subject should be mandatory for the midwifery students. The opinions of the participants were almost equally distributed as shown in Table 4.


**Table 4.** Participants' view about the mandatorily attendance of the subject

When discussing the size of the group, appropriate for the realization of the subject, half of the participants thought that the group of 30-35 students is too large. None of them thought it is too small, as shown in Table 5.

The group is very coherent, since all participants are midwifery students of the same genera‐ tion and they know each other very well; they are relaxed in the company of one another and do not feel restrain to express own thoughts. If conversation turns to intimate questions it is very important that participants feel reassured that nothing will be revealed outside the group.


**Table 5.** Participants' opinion regarding the size of the subject's group

the majority of the participants supported the inclusion of the subject in the last year of study,

Yes 84 81% No 20 19%

Author asked students whether they think subject is comprehensive enough. One third of students thought it is not correctly emphasized, however the proportions of those who thought that it is too extensive and those who thought it is undervalued were evenly

**Table 2.** Participants' view regarding the instalment of the subject into the midwifery curriculum

**Do you think subject is correctly evaluated (3 ECTS = 90 hours of student's work)? (N=101)**

**Table 3.** Participants' estimation of the appropriateness of students' workload to the subject

**Do you think the subject should be mandatory? (N=101)**

too small, as shown in Table 5.

**Table 4.** Participants' view about the mandatorily attendance of the subject

Yes 72 71% No, I would wish more hours 17 17% No, I would wish less hours 11 11% I do not know 1 1%

Participants were also asked whether they think the subject should be mandatory for the midwifery students. The opinions of the participants were almost equally distributed as shown

Yes 59 58% No 42 42%

When discussing the size of the group, appropriate for the realization of the subject, half of the participants thought that the group of 30-35 students is too large. None of them thought it is

**N %**

**N %**

**N %**

but some of them (one fifth) objected. The results are shown in Table 2.

**Do you think subject should be in the last year of midwifery education? (N=104)**

distributed (Table 3).

8 Sexology in Midwifery

in Table 4.

Since there is an interest for the subject also from other health professions (such as nursing students, occupational therapists etc.), author asked students whether they would agree for other students to join the class. More than half of the participants disagreed (Table 6). From the open ended comments, two major themes for disagreement emerged – one revealed participants' opinion that dealing with sexual issues is not relevant for other health professio‐ nals so much as for midwives; the other important issue expressed was that other (unknown) students would affect the openness and relaxedness of discussion within the group. Since there is also a tendency to open the subject for incoming students from other countries that come to the faculty via international exchange, the participants were also asked whether they would attend the subject if run in English language. 62% of students would join the subject even if lectured in foreign language.


**Table 6.** Participant's opinion about the appropriateness of multi-disciplinarity of the subject

The question that seemed even more important than general satisfaction with the subject was whether the gained knowledge seemed useful to participants for their clinical work. Only 11% of participants did not perceive information helpful, as seen in Table 7. In the open-ended section, the most often exposed general comment of these participants was that they already knew things that were discussed/lectured about and therefore they did not see the benefits.


**Table 7.** Participants' opinion regarding the usefulness oft he gained knowledge for their clinical work

When asking participants regarding the satisfaction with the specific content of the subject, it was obvious that majority of the participants were satisfied with all included contents; the satisfaction ranged from 69% to 89%, depending on the theme. Students evaluated as best the lecture about "sexuality through history", while the content "sexuality in art" was least appreciated. More details on the evaluation of the content of the subject can be seen from the Table 8.


**Table 8.** Participants' satisfaction with the content of the subject

Only few participants gave concrete answers on the open comment, where they were asked what else they think should be added as a content in the subject. Some of them proposed themes such as: sexuality of disabled people, more about the relaxed conversation with couples regarding the sexual issues. Some did not see the relevance of lectures like "sexuality through history" or "sexuality in art"; this didn't seem relevant to them for their professional work. On the other side, some of the participants would like the listed themes to be debated in much more details.

Author asked participants also how they liked different approaches to teaching that were used. The evaluation of the study methods by participants is presented in Table 9. The most negative response was to seminar work and they liked debates the most. The majority (90%) were satisfied with lectures. It might be concluded from the results that they prefer conventional teaching methods.


**Table 9.** Participants' satisfaction with teaching methods of the subject

**Do you think knowledge gained was useful for midwifery practice? (N=94)**

**Were you satisfied with the content of the subject? (N=90)**

Sexuality in different cultures and effect

Individual aspects and prejudices regarding

Interconnections among love, sexuality,

Sexuality during pregnancy, birth and

**Table 8.** Participants' satisfaction with the content of the subject

Approach and communication regarding sexual

Table 8.

10 Sexology in Midwifery

Gained information were helpful for my midwifery work 63 67% Gained information were not helpful for midwifery work 10 11% Otherwise: 21 22%

When asking participants regarding the satisfaction with the specific content of the subject, it was obvious that majority of the participants were satisfied with all included contents; the satisfaction ranged from 69% to 89%, depending on the theme. Students evaluated as best the lecture about "sexuality through history", while the content "sexuality in art" was least appreciated. More details on the evaluation of the content of the subject can be seen from the

> I was not satisfied et all

Sexuality through history 0 (0%) 7 (8%) 52 (58%) 28 (31%) 3 (3%)

of the religion 1 (1%) 14 (16%) 34 (38%) 39 (43%) 2 (2%)

Sexuality in the postmodernism 2 (2%) 6 (7%) 32 (36%) 44 (49%) 6 (7%) Sexuality in art 4 (4%) 14 (16%) 43 (48%) 26 (29%) 3 (3%)

sexual issues 0 (0%) 6 (7%) 34 (38%) 43 (48%) 7 (8%)

issues 0 (0%) 4 (4%) 32 (36%) 46 (51%) 8 (9%)

Midwives role in management of the sexual issues 1 (1%) 9 (10%) 24 (27%) 47 (52%) 9 (10%)

partnership, parenthood 0 (0%) 6 (7%) 27 (30%) 48 (53%) 9 (10%)

Sexuality in different periods of woman's life 1 (1%) 9 (10%) 27 (30%) 46 (51%) 7 (8%)

puerperium; 1 (1%) 11 (12%) 27 (30%) 45 (50%) 6 (7%)

Women's sexual problems and midwifery care 1 (1%) 8 (9%) 26 (29%) 47 (53%) 7 (8%)

I was not satisfied

I was satisfied I was very satisfied

I was not satisfied et all

**Table 7.** Participants' opinion regarding the usefulness oft he gained knowledge for their clinical work

**N %**

Next question asked participants, which method do they think would be the most appropriate to teach and learn about sexuality. Their responses are presented in Table 10 – again it was confirmed that they would like more debates and guided conversations on the topics. In the category other, they exposed also field work. Again it is very clear that they do not estimate seminar work as useful in gaining knowledge on the topic.


**Table 10.** Preferable teaching methods of the participants for learning about sexuality

Since the aim of the subject is that participant gets the insight into their own attitudes and believes and that they relax in conversation about the delicate theme such as sexuality, the author questioned whether the exam is needed at the end of the subject. However, as presented in Table 11, only 12% of participants thought the subject should not be marked. The majority thought that the most appropriate would be to mark the exercises and home works they were assigned to.


**Table 11.** Participant s' opinions about the most appropriate examination at the end of the subject

In the category other, where students had an opportunity to explain their selection, the majority of propositions contained the idea of combining the above mentioned methods of evaluation. The most common combination was the mark of the assignments and the consideration of student involvement in the debates.

### **5. Discussion and conclusions**

Midwifery is, as shown in the literature, closely connected to sexuality. Midwives should be those in the relationship that give woman permission and stimulation to raise also questions regarding the topic. In order to promote women's sexual health, there is a need for improved dialogue between patients and health professionals; midwives and clinicians have the main responsibility to initiate this dialogue. Communication between patients and professionals is an important part of health care [21]. Women, however, seldom raise questions regarding sexual problems [39]. And as seen from the literature, midwives and clinicians might fail to raise questions due to a series of obstacles [20].

Wendt et al. [21]. claim that one of the problems can be also that only a minority of clinicians, midwives and nurses have vocational training in sexology, and suggest that increased knowledge, support and opportunities for reflection concerning dialogue regarding sexual issues might evoke the interest and intent of health professionals to approach these issues. Authors [40], albeit considering other aspects of midwifery care connected with sexuality, suggest that critical thinking around the cultural and moral dimensions of sexuality should be emphasised in undergraduate training and continuing education, to help nurse-midwives and other health practitioners to deal more empathetically with the sexual matters.

Since the aim of the subject is that participant gets the insight into their own attitudes and believes and that they relax in conversation about the delicate theme such as sexuality, the author questioned whether the exam is needed at the end of the subject. However, as presented in Table 11, only 12% of participants thought the subject should not be marked. The majority thought that the most appropriate would be to mark the exercises and home works they were

Written exam 11 12% Oral exam 12 13% Mark of the exercise (seminar, project etc.) 33 37% Collaboration in the debate 12 13% Subject should not be marked 11 12% Other 10 11%

**Table 11.** Participant s' opinions about the most appropriate examination at the end of the subject

student involvement in the debates.

**5. Discussion and conclusions**

raise questions due to a series of obstacles [20].

In the category other, where students had an opportunity to explain their selection, the majority of propositions contained the idea of combining the above mentioned methods of evaluation. The most common combination was the mark of the assignments and the consideration of

Midwifery is, as shown in the literature, closely connected to sexuality. Midwives should be those in the relationship that give woman permission and stimulation to raise also questions regarding the topic. In order to promote women's sexual health, there is a need for improved dialogue between patients and health professionals; midwives and clinicians have the main responsibility to initiate this dialogue. Communication between patients and professionals is an important part of health care [21]. Women, however, seldom raise questions regarding sexual problems [39]. And as seen from the literature, midwives and clinicians might fail to

Wendt et al. [21]. claim that one of the problems can be also that only a minority of clinicians, midwives and nurses have vocational training in sexology, and suggest that increased knowledge, support and opportunities for reflection concerning dialogue regarding sexual issues might evoke the interest and intent of health professionals to approach these issues. Authors [40], albeit considering other aspects of midwifery care connected with sexuality, suggest that critical thinking around the cultural and moral dimensions of sexuality should be

**N %**

**Which type of the evaluation do you think is appropriate for this subject? (N=89)**

assigned to.

12 Sexology in Midwifery

The described subject "Sexology in midwifery" that was included in the undergraduate study programme of midwifery, aimed that midwifery graduates would understand the connection between sexuality and midwifery. However, the goal was not only to raise the awareness, but also to reflect upon students' individual perceptions and attitudes. When woman experiences problems in sexuality it is of great importance that midwife is capable to act as an emphatic professional. And there is a close relationship between attitude and behaviour [41]. Therefore it is important that student midwives are aware of their own beliefs and how these attitudes affect their professional acting and judgement.

WHO [11] identified three necessary stages in educating health professionals regarding the sexuality:


The contents of the teaching about the sexuality can be extracted from the above WHO's suggestion. WHO [11] document also warns that "where sexology is a part of the health study programme, emphasis is frequently on deviancy and pathology rather than on normal sexual development and behaviour". It can be claimed that normal sexuality is satisfactory covered in the midwifery curriculum. It is also obvious that the contents of the subject "Sexology in midwifery" are not prone to pathological sexual behaviour. The contents also do not deal only with the topics, relevant to manage sexual issues in perinatal period, but are more spread in order to give graduates the broader insight. Some of the participants did not see the relevance of certain contents, however attitudes and believes can be changed also with the subtle impressions that sometimes are not directly connected [42].

Already in the document of WHO was acknowledged that different methods in teaching about sexuality can be used to attain the best outcome: "in the more developed programmes there is a considerable amount of methodological experimentation and innovation; among the methods being tried are: panel discussions, male-female teaching teams, videotape case presentations, guest speakers from the community, and survey questionnaires for assessment of sexual attitudes and knowledge. A number of teaching methods have been selected because they oblige students to confront their own attitudes, values, and feelings regarding sexuality. Examples of these are the use of frank sexual films followed by small group discussions; interviews with homosexuals; role playing; and other methods requiring the active involve‐ ment of the learner" [11]. Especially meaningful are the methods, which enhance student's active involvement, like debates and role playing. That was identified as beneficial also from the opinions of participants in the study presented. However the debate must be grounded on the solid theoretical base that defines the theme. In order to achieve that, author often used combination of lectures and discussion.

Some of the methods, suggested by WHO [11] are in details described by Haeberle [26]: "in the USA they provide special programme for health professionals to enlighten them with different sex behaviours and prepare them to work confident but still with sensitivity with different sort of patients". These approaches certainly provide experience that leave a strong impact on the students' minds; however some of the described methods would be impossible to use in Slovenia, due to different cultural context, and lack of options. Nevertheless, both references give very clear idea that the main goal of this education is not only to teach health practitioner the approaches to discuss sexual health with clients, but aim at affecting partici‐ pants' believes and prejudices. Similar than in foreign studies [43], it was exposed also by Slovenian participants that they would want more practice-based educational methods. Foreign authors acknowledge that this is hard to provide, because of the ethical barriers [43] and therefore suggest a model, where theoretical knowledge is reinforced practically with practice based scenarios and mentor emulation as staging points, which help to develop confident practice. Other authors [44, 45]. agree that problem-based scenarios can successfully replace lack of concrete situations and stimulate critical thinking.

The subject "Sexology in midwifery", taught in the undergraduate midwifery programme was overall good accepted by the students and almost all the graduates were satisfied with it. It seems that majority support the decision to put the subject in the last year of midwifery study; students are more mature, they already gain clinical experience and are well theoretically versed into the midwifery matters. Results confirmed the authors' anticipation that partici‐ pants feel more relaxed in a homogenous group of midwifery students; many expressed restrains to be a part of the group of different unknown students.

Overall it seemed that subject covers the contents they expected (they did not give a lot of new suggestions to be included), however it could be improved via different and more various teaching methods. The very obvious message that derived from the results was the fact that participants would like more discussions. In parallel with this goes also their suggestion of dividing students into smaller groups. WHO [11] allows that human sexuality is taught as a required or an elective component of education. What is important is that the course organizers develop programmes that are appropriate, in both curriculum content and educational method, to sociocultural factors, the needs of students, and the health needs of the local population. It seems that the decision to alter the subject from mandatory to selective in 2007 was justified, since not all the participants are prepared to attend it and not all see the benefits of the contents for their clinical expertise, as proven from the participants' answers.

The dilemma regarding the evaluation in the subject still remains; author is aware that the theoretical exam undervalues the real aim of the subject, since the goal is to affect individual's thoughts. The final examination is however always a teacher's judgement of value [46]. Estimation of student's input in the case of revealing personal and intimate experiences, thoughts and perceptions can be also a matter of ethical question; the students might feel that a bad mark is a reflection of their unconventional opinions and expressed negative thoughts during the study. Therefore the authors' opinion is veering in the way of not marking the subject at all, however it seems that participants do not perceive that kind of hindrances as author.

The presented study has its limitations. For the in-depth information qualitative approach would be more appropriate, however for the first step of the study of evaluation of the subject, only a general overview was sought. The author is aware of the web-survey limitations [47, 48], but this approach also has major advantages – it is more economical, time effective and since it is adjusted to the population that was researched (students frequently use technical equipment) can improve response rate [49]. The main limitation of the research tool was that participants had to answer all the questions otherwise they were not allowed to move to the next question, which resulted in the loss of participant when progressing through the ques‐ tionnaire. Still the study provides useful information how to improve the subject and gives the author the confirmation that these topics are relevant to midwives and that the general form of the subject is solid and fair.
