Status quo of Master’s programs in midwifery

As more countries worldwide develop Bachelor’s programs for midwives^8,25,26, it is essential to create opportunities for further academic qualification¹⁰. Compared to Bachelor’s programs, considerably fewer Master’s programs in midwifery are implemented^8,25 although it is recommended that midwifery education should be offered at Bachelor’s and Master’s level^26,27. Internationally, barely a quarter (26%) of the 74 included countries in the State of the World’s Midwifery (SoWMy) report indicate that a Master’s program is the highest qualification, while another quarter (27%) offer a doctorate for midwives⁸, mostly in high-income countries⁸. In Europe, all Bachelor’s, Master’s and doctoral programs are described and standardized by the European Qualification Framework (EQF)^28,29. To use these levels internationally, the International Standard Classification of Education (ISCED)³⁰³⁰ is used. Both EQF²⁸ and the ISCED³⁰ describe the Master’s degree at level 7. Programs at level 7 aim to enable participants for advanced academic and/or professional knowledge, skills and competencies³⁰. Despite these general standardizations, there are no further standards for Master’s programs in midwifery, as most standards apply for primary qualification of midwives^14-16. While some Master’s programs serve as primary qualification through post-nursing programs⁹, most of the Master’s programs in midwifery are designed as postgraduate qualification after a Bachelor’s degree⁹. The international lack of standardization or recommendations for Master’s programs in midwifery, leads to the fact that they differ at national, European as well as international level, especially in terms of duration, content and results^10,12,23,26. Nevertheless, studies show a trend of acquired competences in Master’s programs. Midwives with a Master’s degree have a higher level of pedagogical, management and research skills²¹, which is why these areas will be outlined in the following.

Master’s programs in midwifery: Leadership and management

The midwifery profession is traditionally predominantly practiced by women worldwide. To strengthen midwifery and to motivate and retain qualified professionals, the establishment of midwifery leadership opportunities are crucial. Still, challenges remain at both policy and clinical levels¹³. A lack of female leaders in the healthcare systems, as well as limited leadership opportunities for midwives often results in midwives not climbing the leadership ladder. At the same time, decisions about midwifery profession are often not made by leading midwives themselves. Especially, if midwifery is incorporated into the structures of nursing, midwives have limited leadership opportunities⁸. According to the SoWMy, 71% of the reporting countries state that at least one midwife holds a leadership position⁸. Nevertheless, midwives need to be supported when it comes to practicing their role as leaders¹³. To fulfil this role, learning management skills in midwifery education is necessary³¹. Studies show that midwives recognize the need for systematic education for high levels of management to enable the next generation of midwifery leaders³¹. Midwifery leaders are not only crucial in policy and clinics, but also in research and education¹⁸.

Master’s programs in midwifery: Research

Profession-specific research is fundamental for midwifery¹⁸. Midwives provide their practice based on the best available evidence. The WHO recommends an evidence-based midwifery education¹³. To enable evidence-based education and practice, a wide range of midwifery research is needed¹⁹. For woman-centered research, midwives themselves should be the researcher. Midwives can understand woman’s needs and the impact of research on them. They understand the practical aspects of midwifery and the reality of clinical research¹⁹. To become a midwife researcher, there are various options, e.g. Master’s programs in midwifery¹⁹. They allow midwives to enter a doctoral program, which further trains them as scientific leaders and promotes their academic careers². To pursue an academic career at university, the ability to teach as a midwife is equally important²⁰.

Master’s programs in midwifery: Midwifery educator

Midwifery educators educate midwifery students in theory and practice. This should include midwifery educators who teach in educational settings and clinical midwives who teach in practice, or both²³. The quality of the educators themselves has a huge impact on the quality of midwifery graduates. It is virtually impossible to train the practitioners, leaders and researchers that are needed if there are not enough well-trained educators in the programs (both Bachelor’s and Master’s programs)²⁰²⁰. It is already known that midwifery programs have a shortage of competent midwifery educators²⁰. To be a competent midwifery educator, advanced knowledge, skills and behaviors are needed²⁰. However, there is a disagreement about what qualifications and competencies midwives need to become midwifery educators³². The need for competent midwifery educators is supported by the WHO document ‘WHO Midwifery Educator Core Competencies’²⁰. Four of the eight formulated competence domains are at Master’s level²⁶. Therefore, the completion of Master’s programs in midwifery can raise the quality of midwifery educators worldwide and therefore improve the quality of care of future midwives²⁰. In accordance with the recommendations of the German Council of Science and Humanities, medical faculties can develop their strength here through the combined competencies relevant to the healthcare system³³. As many Master’s programs in midwifery meet the main areas of leadership and management, research, and midwifery educator^10,21, some programs go beyond these areas by focusing on a further approach: Advanced midwifery practice (AMP)²².

Advanced midwifery practice

AMP can be defined as: ‘A level of midwifery practice at which midwives use their expertise, management and clinical leadership skills to provide evidence-based, tailored care for woman and their families independently and autonomously. Professional leadership and research skills are used to evaluate practice and advance midwifery as a profession and science’²². It is particularly about midwives not only being clinical experts but fulfilling a variety of other roles: consultant, educator, researcher, innovator, clinical and professional leader, policy advisor, and ethical decision facilitator^3,34. Acquired competencies of AMP extend the areas of leadership and management, research, and midwifery educator by incorporating advanced assessment and intervention strategies, analysis of complex interaction, use of research findings in decision making and management of these, development of woman-centered care and inclusion of education³⁵. Studies show that the advanced practice role differs widely from those of clinical specialists. These include satisfaction with service delivery, emotional support and practical advice. Advanced practice roles offer strategic benefits, including better clinical and professional leadership, as well as more research and better service delivery³⁶. Education for AMP is structured differently internationally. The entry criteria differ^3,37, as some expect a Master’s degree for entry to AMP education³⁵. Other countries offer AMP education as a Master’s program³⁸.

Rationale of the review

As described above, there are some challenges that cannot be met with a Bachelor’s degree¹³. In fact, a Master’s degree is required for specific challenges that relate to management^13,14,18, research¹⁹ and teaching^20,21 tasks as well as for advanced practitioner roles²². As the Master’s programs in midwifery differ both at European¹² as well as international level²³, the question arises as to how the Master’s programs address these three areas and how AMP programs go beyond these areas.

To approach this, the review points out the competence goals of the Master’s programs. Competence goals provide a general statement about the expected abilities that graduates of a program should have³⁹. To illustrate how the programs address these competence goals, the learning outcomes are examined as well. These make a specific and measurable statement on what a student or graduate will be able to do. A competence goal usually comprises several learning outcomes³⁹.

Objective and research questions

The objective of this narrative review is to provide an overview of Master’s programs in midwifery in selected OECD countries. Besides organizational aspects, the focus lies on competence goals and learning outcomes of the Master’s programs. This provides an overview for the actors involved to develop or enhance Master’s programs in midwifery and to demonstrate the different approaches on how to educate midwives at Master’s level. The research questions were: 1) ‘Which commonalities and differences of organizational aspects in Master’s programs in midwifery occur?’; and 2) ‘On which competence goals and learning outcomes are the Master’s programs in midwifery based on?’.

The narrative review study design

The study design as a narrative review provides a broad overview of a specific topic as well as quickly inform about the current state-of-the-art⁴⁰. Narrative reviews are considered an important tool in medical education and are commonly used in medical literature syntheses⁴¹. Since the objective was to obtain an overview of a relevant topic in medical education, this study design was highly suitable. To ensure adequate quality, Scale for the Assessment of Narrative Review Articles (SANRA) was applied⁴². In addition, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement⁴³ was considered in the parts suitable for a narrative review (Supplementary file).

Inclusion and exclusion criteria

The criteria primarily focused on the Master’s programs. Included were Master’s programs localized at universities or universities of applied sciences in Organization for Economic Cooperation and Development (OECD) countries. This was due to fact that Master’s programs are mostly offered in high-income countries⁸, as well as to ensure that midwives have similar basic conditions for practising as midwives. Still, there are differences in the health systems in every country⁴⁴.

Included were Master’s programs that focused on midwifery science or equivalent as well as advanced midwifery practice. Master’s programs were included that served as pre-service or postgraduate education for midwives. Excluded were Master’s programs that exclusively focused on nursing or related discipline without specific midwifery relation.

Search strategy and selection procedure

A comprehensive literature search was conducted from June to December 2023. The process was divided into three phases.

Literature and database search

In the first phase, the focus lied on a sensitive literature search approach. The aim was to search as comprehensively as possible in different databases with general keywords⁴⁵. Therefore, the following databases were screened: PubMed, ScienceDirect, Educational Resources Information Center, Academic Search Premier and Wiley Online Library. The used search terms were: midwif*, academic education, higher education, master’s degree, master’s program, master*, postgraduate education, advanced practice*, and international*. These search terms were combined in different search strings, which were assembled with the Boolean operators (Supplementary file Tables 1–5). Articles published from the year 2000 onwards and written in English or German were included. In addition, the snowball method was applied (screening the reference list of relevant publications) as well as a free web search on Google to further identify Master’s programs in midwifery.

The search strategy was conducted by two independent researchers. Both researchers documented their search strings and the number of results. After screening relevant articles, each researcher listed their included articles as well as identified Master’s programs. Subsequently, one of the two researchers reviewed the results, which overlapped considerably. This ensured inter-rater reliability⁴⁶. If there were any results that did not correspond, these were verified by a researcher and included if appropriate. The search strategy was documented in a PRISMA flow chart (Figure 1).

Figure 1

PRISMA flowchart for narrative review (2024)

Selection of Master’s programs in midwifery

After the search for literature, the relevant Master’s programs in midwifery were extracted according to the inclusion and exclusion criteria. These programs were identified by the described process of two independent researchers. The Master’s programs were selected through the identified literature (Figure 1), that referred to institutions of higher education in midwifery. Subsequently, one of the researchers screened the official websites of these institutions for Master’s programs in midwifery. A free web search for Master’s programs in midwifery was conducted by the same researcher in the countries identified through literature search. The described approach to select Master’s programs in midwifery tried to filter relevant programs, as not all OECD countries could be screened in the free web search separately due to insufficient personnel resources. If several relevant study programs were identified in one country, the following procedure was followed: the competence areas and organizational aspects of the study programs were screened. If the programs competence areas differed, both were included. However, if the programs had alike competence areas and differed little in terms of organization, one of the programs was selected at random. This finally led to the selection of Master’s programs in midwifery that met the inclusion and exclusion criteria.

Identifying the characteristics of the included Master’s programs in midwifery

In the third and final phase, the included Master’s programs in midwifery were analyzed by one researcher according to the defined educational characteristics. These were synthesized in tabular form for the extracted Master’s programs in midwifery. For the first research question, the following organizational characteristics were extracted: program name, academic degree and institution; entry requirements; course length, full-time or part-time; in person or online; language; tuition; and clinical practice, pre-service education pathway for midwives. Tuition fees were listed in local currencies at the official websites. To ensure comparability, tuition fees have been consistently converted to euros (at the exchange rate on 14th August 2023) and rounded to whole numbers. Focusing on the second research question, the following characteristics were extracted: competence goals and learning outcomes of the Master’s programs. The official websites of the study programs as well as the websites of national midwifery associations were screened for the necessary information.

Selection of relevant studies

The PRISMA flow chart summarizes the search process (Figure 1). A total of 1867946 results were identified from the databases PubMed, ScienceDirect, ERIC, Academic Search Premier and Wiley Online Library as well as the free web search. In the pre-selection process, 42 abstracts were screened and 10 duplicates removed. After assessing 37 full texts for eligibility, 28 texts were excluded due to non-compliance with the inclusion and exclusion criteria as well as the research questions. Finally, 9 articles and 6 additional websites were included in the narrative review. After reviewing the extracted literature (Figure 1), 12 countries and 15 Master’s programs in midwifery were included in the narrative review (Tables 1 and 2).

Organizational aspects of the reviewed Master’s programs in midwifery

The review included 15 Master’s programs (Table 1) in midwifery from 12 OECD countries: Australia, Austria, Germany, Ireland, Malta, Netherlands, Norway, Portugal, Switzerland, Türkiye, UK, and USA. Australia, Austria and Ireland each include two Master’s programs. Similarities and differences within organizational characteristics of the Master’s programs are identified: all 15 Master’s programs award the title Master of Science^38,47-60; 13 of the programs focus on Master in Midwifery (or equivalent)^47-52,54-60, while two of them pursue AMP^38,53. Six of the programs require a minimum knowledge of English^{48-50,54,55,59}. Seven of the programs teach in English^{47,51-53,57,58,60}, which is their official language or mother tongue. Eight programs teach in their native language other than English^{38,48-50,54-56,59}. In addition, seven of the programs offer their courses both online and in person^{47-49,52-54,60}. Major differences between the programs are the admission requirements and qualification. Three of the analyzed Master’s programs are pre-service education for midwives, requiring a Bachelor’s degree in nursing as well as practical experience for admission. These post-nursing Master’s programs allow a first-time registration as a midwife after completion^47,50,56. 12 of the Master’s programs serve as postgraduate midwifery education. They require a Bachelor’s degree in midwifery and a registration as a midwife for admission^{38,48,49,51-55,57-60}. Five of the study programs integrate clinical practice^{47,50,53,56,59}, while four allow projects or internships in different intuitions^48,49,55,60.

Two of the programs recommend working in clinical practice alongside the study course^38,54, whereas four of the programs do not require any clinical practice at all^51,52,57,58. Differences are identified in the study length, as durations of 1–4 years in part-time or full-time in six programs^{38,47,51,52,57,60}, only part-time with 2–3 years in five programs^{38,49,53,54,58}, or only full-time with 1.5–2 years in four programs^50,55,56,59 are possible. Another central difference is found in the tuition fees that differed enormously between the countries, e.g. more than €40000 per academic year for domestic students in the USA⁴⁷, up to no fees at all for domestic students in Norway⁵⁶.

Competence goals and learning outcomes of the Master’s programs in midwifery

Similarities and differences can be identified in terms of the competence goals and learning outcomes of the Master’s programs (Table 2). The ability to undertake research is a central competence goal in all 12 programs^38,47-60. This is accomplished in the different study programs through various learning outcomes. Graduates should be able to apply research methods after completing their studies^{48,51,53,57-60} or have the ability to integrate professional knowledge into a scientific, evidence-based context^{38,48,50,54,59} as well as to promote evidence-based practice^38,50-52,54. Furthermore, graduates should be able to verify evidence and conduct one’s own research project^{38,49-52,57-60}. In this context, seven of the programs educate for the ability to think and reflect critically^{47,51,52,55,57,59,60}. Six of the programs also integrate scientific and midwifery theories in their studies^{48,49,52,55,56,60}. Ultimately, all these competence goals and learning outcomes in the area of research, aim to enable their graduates to further develop midwifery practice^38,47-60.

Twelve of the programs focus on abilities for leadership and management^{38,4848,49,51-57,59,60}. This is addressed by the learning outcomes of graduates being able for effective teamwork^48,51,55-57 as well as effective communication^{38,48,49,51,53,55-57}. Graduates should be able to take on (clinical) management tasks^{38,48,49,52-56,59,60}, such as quality management^{38,49,53-55,60} and/or project responsibilities^{38,48,52,53,55}. Moreover, graduates should be able to take on leading positions^{38,48,49,52-56}.

A central key competence in seven programs is to enable graduates to educate midwives^{38,48,49,51,55,56,59} in theory and practice^{38,48,55,56,59}; for example, in clinical education^51,55,56 but also for further professional qualifications⁴⁸. In addition, the ability to educate patients based to their informational needs is enabled⁵⁹. To address the mentioned abilities for education midwives, graduates should be able to apply theories of teaching as well as theories of learning^48,49,55,59.

Another competence goal that can be found in nine of the Master’s programs are abilities for ethical aspects in midwifery and healthcare^{38,48,50,52,53,55-57,59}, whereas only four programs enable graduates skills for legal and judicial aspects in midwifery and healthcare^52,53,55,59. Moreover, eight of the programs focus on the competence goal of abilities for psychological as well as sociological dimensions of midwifery care^{38,49-51,54,55,59,60}. A further competence goal of eight programs is to enable graduates’ advanced clinical skills^{47-49,52-54,57,60}. Whereas ten programs focus on woman-centered care^{38,48-52,55,57,59,60}, five programs focus on family-centered care^48-50,57,59. Another competence goals in three of the programs is to enable skills in cultural competence^38,51,57. Competence goals that can only be identified in Master’s programs focusing on AMP are abilities for obstetric emergency situations and peripartum monitoring³⁸, trauma psychology³⁸, fault management³⁸, dealing with power conflicts³⁸, prescribing medicinal products and ionizing radiation⁵³, as well as abilities to practice with the highest professional level throughout the entire spectrum of care⁵³. In general, overlapping competence goals can be identified, whereas the learning outcomes differ to address these competence goals.

Summary of the findings and answers to the research questions

The narrative review includes 15 Master’s programs in midwifery from 12 OECD countries (Australia, Austria, Germany, Ireland, Malta, Netherlands, Norway, Portugal, Switzerland, Türkiye, UK, and USA). Considering the organizational aspects of Master’s programs in midwifery (answering research question 1), several similarities can be identified. The awarded title Master of Science in midwifery (or equivalent)^38,47-60 is common to all of the programs, although two especially focus on AMP^38,53. Basic knowledge in English is required in 13 of the programs^47-55,57-60. Differences can be identified, among other things, within admission requirements and qualification level (primary qualification^47,50,56 or postgraduate program^{38,48,49,51-55,57-60}) and the integration of clinical practice (from no clinical practice^51,52,57,61 to integrating clinical practice or projects^{38,47,48,50,53,55,56,59,60}).

Analyzing the competence goals and learning outcomes of the Master’s programs (answering research question 2), commonalities can be found within the competence goals. The objective for research competence underlies all 15 programs, with the overall purpose of further developing midwifery practice^38,47-60. Another competence goal of 12 the programs is the ability for leadership and management^{38,48,49,51-57,59,60}, which is mostly addressed by graduates being able for effective teamwork^48,51,55-57 and effective communication^{38,48,49,51,53,55-57}. Furthermore, seven of the programs aim for the ability to take over tasks in midwifery education^{38,48,49,51,55,56,59}. Other competence goals are the ability to deal with ethical aspects of midwifery and healthcare^{38,48,50,52,53,55-57,59}, as well as psychological and sociological skills^{38,49-51,54,55,59,60}. In addition, graduates are enabled for advanced clinical skills^{47-49,52-54,57,60}, mostly focusing on woman-centered care^{38,48-52,55,57,59,60}. Although the overarching competence goals mostly align, differences can be identified within the learning outcomes to address these competences. For example, while five of the programs educate research competence by graduates being able to promote on evidence-based practice^38,50-52,54, 10 of the programs focus on graduates being able to implement a research project^{38,49-52,57-60}.

Competences of midwives with a Master’s degree: Management and leadership

The SoWMy states that investment in midwifery leadership and governance are urgently needed to improve quality and safety of maternity care⁸. To enable strong leadership, the roots are already planted in the education of midwives¹⁸. The integration of leadership and management skills is recommended for undergraduate and postgraduate education⁶². However, many midwives are not able to find appropriate leadership and management positions after their primary qualification due to a lack of leadership opportunities⁸ or not having enough specialized leadership skills⁶³. In addition to professional work experience⁶⁴, further education that develops specific management and leadership skills is useful⁶⁵. This is reflected within the analyzed Master’s programs, as many of them focus on abilities for management and leadership^{38,48,49,51-57,59,60}. To fulfil management and leadership tasks, midwives should have knowledge about cooperate management issues to integrate and understand policy direction and commissioning. Moreover, midwives in leadership and management positions should have the ability to understand the wider healthcare system. Midwives need to develop negotiation, persuasion and influencing skills as well as political astuteness to take on leadership and management roles. To build these competences, midwives need to understand the structure as well as the language of the systems they are working in, especially focusing on safety and quality, finances and resources as well as workforce planning and modernization⁶⁶. In general, these competences are found in the Master’s programs examined as their learning outcomes focus on graduates being able to take on clinical management tasks^{38,48,49,52-56,59,60}, but it is not clear within the scope of the review to what extent these abilities are developed.

In addition to contextual understanding, professional experience is equally important. This includes, for instance, experience in project management⁶⁴, which is also a central learning outcome of many Master’s programs examined^{38,48,52,53,55}. Furthermore, the ability to communicate effectively is a central component of midwifery leadership. Another central ability is to lead teams towards visions and goals they share⁶⁴. Both effective teamwork^48,51,55-57 as well as effective communication^{38,48,49,51,53,55-57} is trained within the Master’s programs. After all, midwifery leadership and management is about changing the future of midwifery⁶⁴, which many of the analyzed Master’s programs refer to^38,47-60.

Competences of midwives with a Master’s degree: Midwifery research

Research is an integral part of midwife’s role¹⁹. Internationally, research opportunities and careers in research for midwives are increasingly expanding. This is necessary to provide efficient and cost-effective care that adapts to changing needs of consumers and society⁶⁷. In its ‘International Code of Ethics for Midwives’, the ICM describes that midwives use up-to-date data and professional evidence-based knowledge for safe midwifery practice as well as actively participate in research⁶⁸. However, evidence-based practice and research are seen as a challenge for midwifery students⁶⁹ as well as practitioners²¹. A tension between evidence-based practice as well as research and practice is reported⁶⁹. Reasons for this include the lack of clinically active midwives with solid scientific training in many places have⁶⁷ and their lack of influence on the framework conditions and the control of these via management positions⁸. Embedding elements of evidence-based practice and research in the primary qualification of midwives is not enough to ensure that evidence-based practice can be implemented within the actual work as a midwife^69-71. Rather, to prepare midwives for research activities, they should complete Master’s or doctoral programs^19,67, where comprehensive research abilities are developed. A highly relevant ability for midwifery research is the ability for interdisciplinary cooperation. The reason lies within the fact that the contribution from other disciplines and interdisciplinary exchange are seen as extremely valuable source of knowledge to midwifery research⁷². This is enabled by most of the analyzed Master’s programs by the learning outcomes of graduates being able for effective teamwork^48,51,55-57 as well as for effective communication^{38,48,49,51,53,55-57}. However, despite the relevant contribution of other disciplines, it is necessary to find a separate identity for midwifery research with a perspective on midwifery care. Therefore, midwifery researchers should be familiar with appropriate qualitative and quantitative methods and balance these approaches carefully⁷². The analyzed Master’s programs address this by the learning outcome of graduates being able to apply different research methods^{48,51,53,57-60}. Despite the abilities to conduct research⁷², transferring findings into evidence-based practice is an essential ability for midwives. Studies show that this is enabled by reading and reviewing literature as well as translating these findings into evidence-based practice^19,73. Moreover, midwives should be able to disseminate literature to health professionals in a purposeful way⁷³. Many of the Master’s programs analyzed here focus on the named abilities for transferring findings into evidence-based practice^{38,48,50-52,54,59}. After all, midwifery research refers to how midwives work and how midwifery practice can be improved⁷², which is why qualified midwives with a Master’s degree are needed¹⁹.

Competences of midwives with a Master’s degree: Midwifery educators

To educate competent midwives and enable midwives for careers in research, leadership and practice, it is essential to have competent midwifery teachers^20,74. Of the 15 analyzed Master’s programs in this review, only seven explicitly refer to the competence goal of midwifery educator^{38,48,49,51,55,56,59}. However, when considering the midwifery educator competency domains defined by the WHO²⁰, many of the programs prepare graduates for those competency domains, even without making explicit reference to midwifery educator. According to the WHO, midwifery educators should base their knowledge and skills of midwifery on the best available evidence²⁰. All analyzed programs refer to the competence goal of research abilities^38,47-60 as well as to the learning outcomes of graduates being able to promote evidence-based practice^38,50-52,54. Another research-related competency domain of the WHO refers to midwifery education and practice being informed and developed through research²⁰. All the analyzed programs aim to enable graduates to further develop midwifery practice through research competence^38,47-60. In addition, another competency domain of the WHO focusses on effective communication, acting as advocates, change agents, and leaders²⁰. This is also reflected in many of the considered programs, as they enable graduates for leaders^{38,48,49,51-57,59,60}, as well as for effective communication^{38,48,49,51,53,55-57}. However, there are other competency domains of the WHO, referring to pedagogical and didactical skills, such as creating an environment for facilitating teaching and learning²⁰. These areas are not met within many of the analyzed programs, as only a few train abilities for teaching and learning^48,49,55,59. This can be seen critically, as adult education requires specialized teaching skills. These include knowledge in adult education theories, the ability to apply teaching methods effectively, and therefore support students and their individually needs⁷⁴.

Competences of midwives with a Master’s degree: AMP profile

As some of the analyzed Master’s programs qualified for AMP, the question arises to what distinguishes them from the other programs examined. The competence areas of leadership and management, research and education are also represented within the AMP Master’s programs. However, AMP programs emphasize an explicitly focus on leadership and research^38,53. Literature shows that research skills are an essential attribute of AMP, which is why AMP Master’s programs place major focus on this competence²². Moreover, leadership skills of advanced practitioners are highlighted as an increasingly important factor for improving patient outcomes. Although, as already argued, all midwives with a Master’s degree should be suitable for management positions, advanced practitioners are particularly well-suited as have additional responsibility for professional development and a high level of expertise. Moreover, they have complex decision-making skills^73,75. That is also reflected within the analyzed AMP Master’s programs as they specialize on the entire spectrum of care by educating clinical decision-making as well as emergency strategies^38,53. AMP programs develop skills that enable a higher level of judgement, discretion and decision-making in all practical settings³⁷. They also educate for specific diagnostic skills³⁷, which can be found in one of the analyzed Master’s programs as competence goals³⁸. In conclusion, AMP Master’s programs extend the other programs by enabling specialization and expansion of knowledge, abilities and autonomy in the named areas and beyond²².

Post-nursing and postgraduate Master’s programs in midwifery

There were two different types of Master’s programs included in this review (post-nursing and postgraduate Master’s programs in midwifery). On the one hand, it is known from related disciplines that postgraduate Master’s programs improve knowledge and skills as well as improve patient outcomes⁷⁶. With postgraduate Master’s programs midwives have further career opportunities, such as in research, education, management or consultancy. Moreover, besides personal benefits for graduates, Master’s programs in midwifery provide the necessary skills to maintain the autonomous professional role of midwives⁷⁷. Studies also show that midwives have a higher level of pedagogical, management and research skills after completing a postgraduate Master’s program. However, there is still a lack of opportunities to apply these skills in practice²¹. On the other hand, it is known from nursing that a four-year primary qualification is associated with better performance and patient outcomes⁷⁸. The post-nursing qualifications for midwives usually have a longer duration. As a result, a high amount of flexibility of graduates is reported⁷⁹. Studies indicate that graduates of post-nursing Master’s programs benefit from changes in attitudes, perceptions, knowledge and skills as well as their application in practice⁸⁰. Overall, there is very little evidence on how competencies, costs, career paths or other outcomes differ from each other considering the different educational pathways of midwifery⁹.

Adaption of Master’s programs to country-specific characteristics

While there are many standards for undergraduate midwifery education^14-16, much fewer standards exist for postgraduate education as they only refer to general classifications of education^28,29. There were clear patterns in terms of competence goals and learning outcomes of the analyzed Master’s programs that could also be embedded in literature (see above). Nevertheless, is should be noted, that country-specific adaptions for postgraduate education are necessary. The reason lies within the fact that there are considerable differences in the integration of the midwifery profession into healthcare systems, both within and between countries^8,44. This ranges from regulation and scope of practice to involvement in care^8,44 as well as different educational systems^8,9. The influence of the professional organizations on the curricula and the different educational programs also varies from country to country⁸¹. Considering the analyzed competence areas, it is clear that midwifery research is a country-specific phenomenon, as each country approaches midwifery research differently, especially in terms of addressed topics and integration of research in the professional role for midwives⁷². As the career opportunities for midwifery researcher differ internationally^19,72,82, the country-specific characteristics of midwifery research is needed to be considered in the various Master’s programs. Considering the competences of midwifery educators discussed^20,26, some of them are specifically aligned towards national healthcare systems. For example, midwifery educators should be able to understand and demonstrate the ethical and legal principles of midwifery²⁰. Whereas the ethical principles of midwifery are recognized in official international documents of the ICM⁶⁸, there are country-specific characteristics especially in terms of regulatory and legal aspects of midwifery⁸. For effective midwifery leadership, the ICM recommends focusing on the structures of each country and its specific healthcare system¹⁸. Consequently, it is clear, that a systematic adaption of the Master’s programs and their competence goals to country-specific characteristics of their healthcare systems^8,21, their integration of the role of midwives²¹, as well as educational systems^8,9,81, is considered reasonable and necessary.

Recommendations for research

Similarities and differences of organizational aspects as well as of competence goals and learning outcomes were identified. Three research gaps emerge from this review: 1) The analyzed similarities and differences can serve as an indication for further research as Master’s programs of many countries need to be analyzed in detail to collect more data. The purpose of further research is to find the core elements of Master’s programs in midwifery that are equally important for each program; and 2) This review has also shown that in addition to these core elements, there are relevant country-specific characteristics each Master’s program has to address differently. To fully understand which organizational aspects as well as competence goals and learning outcomes need to be adapted to individual circumstances, further research is necessary; and 3) Finally, it is important to examine the impact of Master’s programs, especially regarding the educational pathways, on health outcomes and national healthcare systems.

Limitations

A central limitation of this review is the study design. The narrative review follows a systematic approach^42,43, nevertheless, it is possible that relevant Master’s programs and publications have been missed. In conducting the search for identifying Master’s programs in midwifery, the primary source of information was academic literature. A free web search was consulted only secondarily. Consequently, it can be assumed that a number of relevant programs were overlooked. Some countries, e.g. Greece, have a number Master’s programs in midwifery⁸³ that were not identified through the aforementioned method. Moreover, the needed information on the characteristics of the Master’s programs is mostly found on the official websites of their institutions, rarely in scientific articles. Still, it can be assumed that the universities have trustworthy websites. As the search was mainly conducted in English, and partly German, study programs which maintain their websites only in their native language (if not English or German) and do not have corresponding publications, could not be identified. Another limitation is the different health systems and midwifery roles as the Master’s programs originate in different countries⁴⁴. By focusing on OECD countries, up to a certain point a comparison is possible, nevertheless significant differences exist in the health and education systems even within these countries⁸⁴. However, this can also be seen as being positive, as the countries can learn from each other. Beyond these limitations, the study did perform a systematic approach to the literature search (as far as possible). Two independent researchers conducted the literature search, and each listed separately their search strings, number of results, relevant articles and Master’s programs. The results overlapped considerably, which increases the inter-rater reliability⁴⁶. The results were, however, analyzed by one researcher only. Overall, the generalizability of the results is limited by the named aspects. Still, the results allow a solid overview and provide indications for practitioners, researchers and other involved actors.