Teaching to get Nurses and Midwives Empowering Women: Nursing Students’ Perceptions on Professional ́s Roles During Perinatal Care

Female empowerment is a key concept in the current healthcare environment, especially in perinatal care. The educational process offered by universities to train future nurses and midwives has a great influence on their professional attitude and performance. To be able to educate in a way that encourages empowerment, it is essential for higher education institutions to know the starting point relating to students’ opinions on the subject. It was conducted a cross-sectional descriptive observational study, at the University of Huelva. It used a self-developed, semistructured questionnaire, previously validated, to gather quantitative and qualitative data. A total of 117 nursing student were surveyed. Participants consider that general nurses supplement the work of the midwife and acts as a facilitator for the process of women’s empowerment in the perinatal period. They believe that the midwife is the professional figure of reference and the one in which they place greater trust. Improvement proposals for both types of professionals are based on improving training and resources. To encourage the development of the profession and improve the quality of care, it is essential to introduce features related to women’s empowerment in the undergraduate training of future nurses and midwives.

235 Martín-Bellido, C., Martín-Fiscal, F., Morano-Gómez, F. & González-Sanz, J.D. -Teaching to get Nurses and Midwives fter a long period in which a patriarchal model of perinatal care has predominated (Cahill, 2001), characterized by an unequal distribution of responsibilities among health professionals and women, during past decades women's empowerment is increasingly relevant to the field of perinatal care (Hsia, 1991;Kwee & McBride, 2015). The use of this term, and similar terms, such as womencentred care (Rijnders et al., 2019), is evidence of the change that these strategies of women's empowerment are producing (Prosen & Tavcar, 2019), as the experience of childbirth has repercussions on women's lives (Garcia & Yim, 2017).
Promoting respect and women's autonomy in their own reproductive process involves increasing their ability to make informed decisions, allowing them to influence and achieve change in health organization through an active participation (Mattison et al., 2020). Female empowerment during perinatal period lets professionals helps women dignifying theirs bodies and fighting to remove obstetrics violence, that it is considered such as mistreatment of women and a disrespectful maternal care. To empower pregnant and postpartum women consist of give emotional and physical support, giving the women the necessary tools and the capacity to make their decisions visible in a health care system where obstetric violence is visible yet (Martín-Bellido, 2020).
To increase women's empowerment, invite women to use more and better the health system perinatal services (Sado et al. 2014) and improve mothers and child´s well-being (Lagendijk et al. 2019). However, women's empowerment in perinatal care cannot be successful without the necessary involvement of healthcare professionals, especially nurses and midwives (Hadisuyatmana et al., 2020). More than the healthcare role of the nurse or midwife -although this is important-the empowering orientation emphasizes their work as educators, trainers, and companions of women. This empowering role is on the rise and appears before, during, and after the process of childbirth, and in very complex situations as abortion services (Ramsayer & Fleming, 2020).
Universities have an essential role to get possible this empowering orientation because nurses and midwives need not only to be motivated in this direction but also trained to identify the individual needs of each woman and A 10(3) 236 be able to respect her decisions (Higginbottom et al., 2012). This training includes the knowledge, skills, and attitudes that will enable or hinder this empowering role (Hamilton et al., 2020). Although role models at the clinical field are essential in nursing/midwifery education (Nieuwenhuijze et al., 2020), it seems clear for us that the educational process offered by universities for the training of future nurses and midwives also has a great influence on the acquisition of these skills and, especially, on the attitudinal component of them (Turkmani et al., 2013;Kuliukas et al., 2020).
At this point, it is essential to keep in mind that the nursing academic environment it´s quite different than others in the universities (Clynes et al., 2020). Many higher education institutions remain a non-small number of nursing academics with a "professional" orientation (Findlow, 2012) maintaining a "vocational" style, having difficult to introduce the best available results from research into their educational programs (Lopes et al., 2012) and to allow an adequate appreciation of research (Mitchell et al., 2020). This can be an obstacle to outpace an old vision on the women´s and nurses/midwives´ role during perinatal care. Thus, if advancing women's empowerment in the perinatal period is desired, it is essential to develop an undergraduate teaching that facilitates the acquisition of empowering skills by students of nursing and midwifery.
A real process of learning involves strengthening the students' creativity so that they can critically examine their previous opinions and points of view. It is not an easy way (van Wyngaarden et al., 2019) but it is the only one to lead our students to take a personal position on the key questions of their education, also about women's empowerment. To be able to educate these students in an attitude that favours women's empowerment, higher education policies must be based in a solid knowledge of the starting situationthat is to say, the students' perceptions of this matter.
Thus, the aim of this study is to describe and analyse nursing students' perceptions of the role played by both the general nurse and the midwife in women's empowerment during the perinatal period.

Study design
A cross-sectional descriptive observational participatory-action research, through self-developed surveys. This qualitative study tends to change women's healthcare model by identifying what are student's perceptions about female empowerment during perinatal period. The study site was the University of Huelva (a public entity), and it took place during 2015/2016 academic year.

Setting and study sample
The population selected for the study were all third-year students of the degree in nursing who took the subject Nursing of the Adult Person III, specifically the block of Women's Health (WH). The total number of participants were 117.
It is important to highlight that this is the first subject in their course directly related to perinatal care and that, when they take it, they have not yet performed care practices related to this content. The aspects related to women's empowerment are approached during the teaching of the subject through reading and critical commentary on various studies in Spanish and English (Biurrun & Goberna, 2011;Gibbins & Thomson, 2001;Kwee & McBride, 2015;Lila et al., 2012;Upadhyay et al., 2014).
It is important to highlight that in Spain, despite its epistemological differences (Gimenez, 2012), the study of nursing and midwifery are not separate. In Spain midwifery is a nursing specialty (over two years) that can be studied only by those with nursing degrees who, after completing the fouryear degree course, pass an annual national examination known as EIR (Zabalegui & Cabrera, 2009;Praxmarer et al., 2017).

Instruments
For the data-gathering, an anonymous self-completing survey answered online by the students after the end of the teaching of the subject was used.
The survey consisted of two questions about the participants' demographic data (age and gender) and four open questions on the role of the general nurse and the midwife in women's empowerment during the perinatal period and on proposals for improvements regarding this role (What do you think is the current role of the general nurse in the empowerment process of women in the field of perinatal health? In your opinion, how could this role be improved? What is the role of the specialist nurse in Obstetrics and Gynaecology (Midwife)? How could you improve midwife's role?).

Ethical considerations
This study follows the principles of the Declaration of Helsinki. All the participants were informed about the study orally and in writing. Informed consent to participate in the study was inferred from the voluntary completion of the online survey. The study has been sent and reviewed by a university's protection data expert that approve the investigation. The University Nursing Department approved the study too.
All data has been always treated confidentially, in compliance with the spanish law "Ley Orgánica 3/2018, de 5 de diciembre, de Protección de Datos Personales y garantía de los derechos digitales".

Data collection procedure
The survey was carried out using Google Forms, it was made available to the students through a link on the course's Moodle platform and could be completed in either English or Spanish.

Data analysis
The sociodemographic data were placed into an Excel worksheet in the Microsoft Office program the descriptive analysis of the collected variables is shown through frequencies and percentages.
The answers to the open questions were placed into an Excel sheet. After a detailed reading by the research team, considering the content of the answers, the relationships between units of meaning were identified and grouped according to subcategories, categories, and subjects, with their respective codes. This allowed the synthesis of information through reducing and grouping the data and facilitated the triangulation of the data, thereby extracting the maximum benefit from the information (Graneheim & Lundman, 2004). Two main themes emerged from the analysis (the role of the general nurse and the role of the midwife in women's empowerment in the perinatal period) along with four categories (the current role of nurses and midwives, and proposed improvements for nurses and midwives). Despite appearing the term empowerment in the questions asked to the students, this term was not coded. The reason is that to describe what students understand by empower is an extensive topic that need to be treated in another study. The participants' literal textual contributions are indicated with the letter E and the number assigned to each student.

Results
There was no refusal to complete the questionnaire, so 100% of the population invited to participate responded to it. The total number of people surveyed was 117. Of the total sample, 97 were women and 20 were men. The ages of the population in the study ranged from 20 to 32 years. There are ninety women between 20-25 years old and seven from 25-32. For men, there are seventeen whose age are between 20-25 and 3 older than 25 years.

Current role of the general nurse
The main feature identified by the students is that the current role of the general nurse in the perinatal area consists mainly in filling in for the midwife, especially in primary care: "The general nurse often plays a big role because as occurs in some villagesin many health centres where many pregnant women have their pregnancy monitored there is no midwife" (E4).
The students believe that there has been a positive evolution in the figure of the general nurse, allowed to take on new responsibilities, and they identify general nurses as professionals able to provide adequate care in situations of health-disease. However, they note that in many cases their caregiving is still centred on the biomedical model: "I think that the role of the current general nurse is very centred on the biomedical model that has long accompanied the process of childbirth." (E33).
In relation to women's empowerment, there are students who observe a lack of involvement in this subject by general nurses, while others expressed the opinion that nurses act as facilitators of women's empowerment: "I consider that today the role of general nurse and that of other health professionals are not aimed at encouraging the empowerment of women" 241 Martín-Bellido, C., F.,. In this respect, future nurses think that psychological support during the perinatal period is the responsibility of the nurse and argue that this professional can establish a suitable relationship with the woman to approve and understand her state and needs, making her feel comfortable, safe, and accompanied. They also believe that nurses encourage women's knowledge about their process so that they have the power to take decisions: "The general nurse is the one charged with promoting women's empowerment through factors that encourage autonomy, self-care, participation, and the capacity to take decisions, among other factors" (E19).
The participating students consider that the main activities of the nurse in the perinatal area are to inform, to support and accompany, to advise, to prevent complications, and to offer health education.
In terms of their knowledge and skills, the future nurses consulted considered that the general nurse has the basic knowledge necessary for the care of patients in the perinatal period but, in comparison with midwives, they claim that general nurses have more knowledge gaps. The students comment that general nurses should improve their ability to communicate and to listen to the mother, and that they need to learn how to show themselves to be impartial in order to respect the mother's decisions: "On the other hand, I also think that the general nurse should be impartial and if, for example, the woman wants to give birth at home, the nurse should respect this and at no point try to convince the woman that she will be better cared for in hospital, but should offer her both the advantages and the disadvantages of all the possible options (E53).
Among the main deficiencies indicated by the participants is a specific lack of knowledge regarding women's empowerment. A lack of enthusiasm in terms of the involvement and encouragement of women's participation was also identified, as well as paying little attention to the emotional aspect of perinatal care (which they related to a lack of motivation due to working conditions, lack of resources, etc): "These days, I think that not all nurses are involved in the right way given the situation we are going through where salaries have been cut, they are working longer hours, and there are fewer staff. Because of this, many professionals feel frustrated, and the patients end up suffering as not all professionals perform their job correctly" (E94).

Proposals for improvements in the role of the general nurse
The main improvement proposals from the nursing students surveyed focuses on the training, activities, and resources available to general nurses.
In terms of education and training, most students consulted proposed a better education in nursing skills and strategies to encourage the comprehensive care of women. This could be done through a programme of continuous training, given by specialist nurses, around empowerment and humanization of childbirth: "General nurses should attend classes, consultations, and talks given by midwives to acquire experience in this field and to know what needs to be done at any time or how to approach the problems that mothers can experience" (E14). The students surveyed also propose strengthening training about empowerment in the degree courses but ensuring that this training does not focus exclusively on theories or technical activities and saying that it would also be desirable to tackle attitudinal, cultural, emotional, and psychosocial features: "To ensure that general nurses are able to empower women about their perinatal health, they need to have adequate prior knowledge. I believe that it should be based on introducing a specific competence in this subject into the curriculum of the nursing degree. I also believe that it is necessary that all subjects give us guidelines or methods for achieving women's empowerment or gender equality in all aspects, and I am not referring exclusively to the domain of perinatal health." (E79).
In terms of activities, many participants propose basing care on scientific evidence, focusing care on women's decisions, and working in a multidisciplinary way. The students indicate that it is necessary to include the general nurse in the process of childbirth to provide the woman with support and confidence, as they believe that this would facilitate empowerment. The use of community interventions for prevention and for promoting women's health is supported as an improvement in the activity of the general nurse. In addition, they indicate that, in the absence of the midwife, the general nurse should be the reference for the pregnancy, informing mothers and asking about their preferences for the process of childbirth: "The general nurse needs to have some minimal knowledge about how to act in childbirth and what to do so that the woman does not feel she is a sick person, and also knowledge about psychology to be able to try to help or resolve the emotional conflicts that women can experience during this whole process" (E96).
On the resources available to nurses, the students consider that it is necessary to increase the team of general and specialist nurses both in primary care and in hospitals. They also consider that the health system needs to change in terms of the perinatal care provided. "Principally, this role could be improved through a possible restructuring of the health system, which would include the number of midwives necessary according to the number of women to be cared for. If this is not possible, then the role of the general nurse would be enhanced" (E37).

Current role of the midwives
The students believe that the current role of the midwife goes beyond care during childbirth, involves following the woman throughout the whole process, and is more important than the role of the general nurse during the perinatal period. Along these lines, they believe that the midwife is the professional figure in whom mothers place most confidence, creating a relationship that provides security: "They have a very important role in the process of empowerment, I believe it's the most important role, because it is the midwife who spends most time with the mother and gives her most confidence, which makes them a great support for mothers" (E15).
In relation to women's empowerment, there are students who observe that midwives perform care that is humanized and centred on empowerment. They think that one of this profession's aims is that women are the protagonists of their own pregnancies, childbirth, and postpartum, which means increasing their participation and control of their own care. To this effect, they say that midwives allow women to be able to take informed decisions and they identify the midwives as responsible for encouraging the empowerment of the mothers during the perinatal period: "It is they who give the appropriate information to the pregnant woman so that she herself can be self-critical and can take her own decisions" (E45). Despite this, some participants indicate that midwives rarely consider the decisions of the pregnant woman.
The participating students consider that the main activities of midwives are: helping ensure that the pregnancy, birth, and postpartum occur normally, performing the necessary care and detecting risks and alarm situations (both physical and emotional); creating a bond of confidence and respect with the mother; informing and counselling the woman; performing sessions of childbirth preparation and maternal education; as well as care during birth and the control and monitoring of the new-born child and the mother after childbirth.
In terms of their knowledge and skills, the future nurses consulted consider that midwives possess specific knowledge about perinatal health and that this is based on the scientific evidence: "It is the obligation of all midwives, in my opinion, to know what, for example, the NICE guidelines say about the process of pregnancy, birth, and postpartum. They will thus offer the best care that can be provided, not only from the opinion of a midwife but backed up by rigorous scientific information" (E23).
Among the deficiencies indicated by the participants was the lack of time that many midwives have for carrying out all their tasks properly. They also C.,F., indicate that there is still a certain subordination to doctors and that there are midwives who dedicate themselves only to routine techniques and tests without working with the woman in a comprehensive way: "The midwife may be the person who does the routine visits and evaluations, but I believe that all the time she is supervised by the doctor and is never able to exercise her own free will. It seems the pregnancy continues being a biomedical model" (E39).

Proposals for improving the midwives´ role
The main improvement proposals of the nursing students surveyed focused on the training, activities, and resources that are available to midwives. In terms of education and training, the students consulted propose rewarding the continuous training of midwives so that their knowledge is based on scientific evidence, and this allows them to improve their professional performance. The content of this training should include, according to the participants, everything related to birth, as well as the new techniques available and sociocultural and psychological considerations. They consider that this will thereby ensure that the majority of midwives know how to respect the decisions of the users and provide women-centred care: "So that midwives perform their work correctly, although they are already considered experts in the subject, they should also be trained and informed continually regarding the new scientific evidence that emerges and thereby provide the mother with up-to-date evidence-based care and information" (E24).
In terms of activities, the participants think that midwives should listen to and respect the decisions of mothers during the perinatal process and support them in their decisions. Informing the pregnant women throughout the perinatal process and providing maternal education are two of the other activities indicated as improvement proposals: "On the other hand, the time that a midwife dedicates to maternal education is very important so that women acquire the knowledge they need. For this, what is needed is good organization by the midwife when establishing schedules with the mothers, as it is very common that women cannot attend because of their working hours or because they are unable to travel to attend" (E67).
In terms of material, administrative, and management resources, the students consider that it is necessary that the same midwife follows the mother throughout the perinatal process, that the number of midwives in primary and specialist care should be increased, and that more autonomy should be given to the midwives in relation to doctors, as they have the necessary knowledge and skills for this: "The midwife should follow the woman's whole process and should establish a very intimate relationship with the pregnant woman, although to do this it will be necessary that this work position has more consistent working hours so that each woman is always looked after by the same midwife" (E77).

Discussion
The first aspect to highlight is that our participants did not have a direct experience of the care offered by nurses and midwives in contexts that are strictly perinatal, such as consultations with midwives in primary care or in maternity, paediatric, or birth units in hospitals. Thus, what is expressed in their answers to the survey is very closely related to their own beliefs, to the training they have received during their degree, and to care practices in general nursing. This distinguishes them from participants in other studies carried out with midwifery students (Janighorban et al., 2016;Nieuwenhuijze et al., 2020).

On the role of the general nurse
The students consider that the general nurse has the capacity to provide adequate care in the perinatal period in primary care, highlighting physical and psychological support and health education. However, they allude to a lack of knowledge about care during the perinatal period in comparison with the midwife and a lack of involvement, communication with women and enthusiasm. This coincides with other studies including pregnants (Barkensjö et al., 2018;Jardim et al., 2019). 247 Martín-Bellido, C., Martín-Fiscal, F., Morano-Gómez, F. & González-Sanz, J.D. -Teaching to

get Nurses and Midwives
On improving the role of the general nurse Our participants insist that improving the empowering role of general nurses in the perinatal period requires a great effort in training based on scientific evidence. This is consistent with opinions from other nursing collectives, as educators (Lopes et al., 2014) and with the results from studies on the continuing education´s influence in nurses' empowerment (Samedy et al., 2012). About the previous mentioned lack of involvement, our participants coincide with other studies calling to keep in mind the needs and desires of the pregnant women, as well to increase the knowledge of both the pregnant women and the health professionals involved in perinatal care (Artieta-Pinedo et al., 2017;Hoffkling et al., 2017;Kempe et al., 2020). On the other hand, they consider that women's empowerment in the perinatal period is being compromised by a lack of nurses in clinical practice.

On the role of the midwife
Among the main activities performed by midwives mentioned by the students we find the preparation of childbirth, information, and psychological assessment and support. As already shown in earlier studies, the students highlight the importance for women´s empowerment of prepartum classes (Artieta-Pinedo et al., 2017;Hunter et al., 2019), psychological support from the family, the partner, and healthcare professionals (Feijen-de Jong et al., 2017;McLeish & Redshaw, 2017;Demirci et al., 2019;Patterson et al., 2019), and the interaction between family and health service for good family integration. On the other hand, the students highlight the importance of the role of the midwives in perinatal health and in women's empowerment during this period, claiming that they are the professionals with the specific knowledge about perinatal health. This corresponds with results from other studies with midwifery students (Binfa et al., 2017;Hamilton et al., 2020).
The students consulted coincided with other studies in the view that there persists a certain focus on the biomedical model of care by midwives (Andina & Siles, 2016;Duarte et al., 2020), and that to advance towards women's empowerment a change in the organization of the system is needed (Speakman et al., 2014;Warmelink et al., 2017;Hunter et al., 2018;Patil et al., 2017). The participating students' perceptions also coincide with those of other students in the appreciation of certain disrespectful attitudes by midwives towards their users and on the need to pay more attention to the psychosocial aspects of women (Richards et al., 2015;Nieuwenhuijze et al., 2020).

On improving the role of the midwife
As in the case of general nurses, our study's participants repeatedly indicate training as one of the most important ways to improve the role of the midwives in terms of empowering women. This coincides with what has been indicated by other research on the necessity perceived by midwives from different geographical contexts to maintain competence to address some of the needs of the women with whom they work (Calvert et al., 2017;Anyichie & Nwagu, 2019) and the need to improve their communications skills (Jardim et al., 2019;Kuliukas et al., 2020).
In terms of improving the empowering role of midwives, our results coincide with those of other studies in indicating that the empowering capacity of midwives is closely related to their own professional empowerment (Hildingsson et al., 2016;Binfa et al., 2017;Jomeen et al., 2020). This also coincide with other studies on the own nurses student's empowerment and their capacity to act as advocates for patients disempowered (Bradbury-Jones et al., 2007). Dependency in relation to the doctor and the midwives' lack of autonomy do not facilitate women's empowerment (Rodriguez-Garrido et al., 2020). On the other hand, the students consider that it would be beneficial for the pregnant woman to be attended always by the same midwife, a feature highlighted in another research (Jefford et al., 2020).

Limitations
Our study's sample is localized in Spain as it corresponds to a single course of the Faculty of Nursing at the University of Huelva, for which the data could not be extrapolated to other educational contexts. More studies are needed on this subject to provide a deeper insight, such as focus groups.

Conclusion
This study shows that when given information about the subject and when helped to process it critically, nursing students recognize the role that general nurses and midwives play in women's empowerment during the perinatal period and can value it and propose improvements. Regarding general nurses, the participants highlight their work in the emotional support of women, although they identify a lack of knowledge related to perinatal care and women's empowerment during the reproductive process. For this reason, it is essential to recognize and satisfy general nurses' need for good initial and continuous training on women's empowerment in the perinatal period. It seems to us that higher education institutions should be called to action to improve their undergraduate nursing programs including wider and better education in this sense.
The participants see midwives as having a greater training and capacity to resolve problems, as well as a greater ability to respond to the needs of women and inform them about the key aspects of the reproductive process. These professionals are recognized as having a greater responsibility in empowering women and in creating a climate of confidence between the woman and the professional. To develop these capacities, proposals include providing incentives to those midwives who carry out continued education and, among other measures, a reform of the Spanish healthcare system so that the same midwife can follow each woman's entire process of pregnancy, birth, and postpartum. It is important to keep in mind that the postgraduate training of midwifes take place into hybrid (Hospital/University) educational units, allowing a better perinatal care research and teaching connection. It is necessary to explore in depth the factors that are blocking and delaying this connection in the undergraduate level.
Considering the results obtained, we conclude that universities have and essential role to introduce features related to women's empowerment into the undergraduate education and training of future nurses and midwives. These contents could be able the educational process to encourage the development of the nursing and midwifery profession, to motivate the future professionals, and to improve the quality of care and, as a result, the women´s autonomy and health during reproductive process.

Authors contributions
GS-JD and MB-MC designed the study and conducted the analysis. MF-FJ, MG-FJ and MB-MC performed the data collection with input from GS-JD. MF-FJ, MG-FJ and MB-MC drafted the manuscript. GS-JD supervised the whole process. All authors contributed to revising the manuscript and approved the final version.