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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 66-72

The evaluation of ethics education in midwifery undergraduate programs in Turkey

1 Department of Midwifery, Faculty of Health Sciences, Kocaeli University, Umuttepe, Kocaeli, Turkey
2 Department of Nursing, Kocaeli University Faculty of Health Sciences, Umuttepe, Kocaeli, Turkey

Date of Submission30-Sep-2020
Date of Acceptance29-Aug-2021
Date of Web Publication16-Feb-2022

Correspondence Address:
Mrs. Suzi Ozdemir
Department of Midwifery, Faculty of Health Sciences, Kocaeli University, Umuttepe, 41380, Kocaeli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNMS.JNMS_138_20

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Context: Ethics education in midwifery leads to professionalism and good clinical practice. Lack of standards related to ethical education cause differences in implementation.
Aims: This study aims to collect comprehensive data about ethics education in undergraduate midwifery programs in Turkey.
Settings and Design: In the cross-sectional descriptive study, the sample of study was consisted of faculty members who gave ethics education in midwifery schools and undergraduate final year midwifery students in 29 universities in Turkey between 2017 and 2018.
Materials and Methods: This study was conducted on 17 faculty members and 1138 midwifery students recruited by simple random sampling. Data collection forms consisted of demographic characteristics and questionnaire of knowledge and opinions about the ethics courses.
Statistical Analysis Used: Descriptive statistics including mean, standard deviation, frequencies and percentages, and Chi-square were used.
Results: It was observed that ethics education was given as a 2-h theoretical course in all midwifery undergraduate schools, and ethics course was compulsory in 87.5% of them. There was statistically significant difference between the views of faculty members and students about necessity of ethics education (P = 0.000), sufficiency of content (P = 0.002), and the expertise of educators (P = 0.000).
Conclusions: According to the opinion of participants, there are lacks in ethics education for midwifery students in Turkey. Regarding the difference between opinions of faculty members and students, contents and the aims of the ethics education should be co-determined by the ethics experts, the midwifery teachers, and the midwives.

Keywords: Education, Ethics, Midwifery, Professional issues

How to cite this article:
Ozdemir S, Aydin Er R. The evaluation of ethics education in midwifery undergraduate programs in Turkey. J Nurs Midwifery Sci 2022;9:66-72

How to cite this URL:
Ozdemir S, Aydin Er R. The evaluation of ethics education in midwifery undergraduate programs in Turkey. J Nurs Midwifery Sci [serial online] 2022 [cited 2023 Jun 5];9:66-72. Available from: https://www.jnmsjournal.org/text.asp?2022/9/1/66/337784

  Introduction Top

Midwifery is an art of providing support, applying care and treatment for women in their all life stages.[1] Midwifery education, which was started to be given in 2-years courses opened in Turkey in 1843, started to be given at the 4-year graduate level in 1996, and it has been a program carried out only at the undergraduate level since 2008.[2],[3] These developments were followed by master education opened in 2000, and doctorate education programs started in 2013.[4]

Midwifery care is a complex profession by its nature. One of the reasons for this complexity is that the midwife has responsibilities toward at least two people, mother and baby, with different needs and values.[5] Another reason is the difficulties that the midwife may face by working with other health professionals with different personal or professional values.[6] However, having to deal with private problems such as preterm birth, the effect of the harmful habits of the mother on the fetus, domestic violence, and increasing diversity in societies and cultures due to the increase in the number of migration and refugees also makes midwifery care difficult.[7] In addition, midwives frequently encounter ethical problems due to the fact that midwifery practices concern the private life of women and are aimed at their privacy, assist reproductive techniques, and use of screening tests during pregnancy.[8]

The fact that health professionals have ethical competence makes ethics education necessary and indispensable during vocational education.[9] Ethics education is provided in midwifery education as well as medical and nursing education.[10] Ethics education in midwifery aims for midwives to know professional values, codes and principles, to think ethically in their professional practices, to act in accordance with ethic principles, and to develop solutions, to anticipate possible ethical problems, and thus to experience less moral distress.[11]

It is stated in the National Midwifery Core Education Program before Graduation that ethics education is important and necessary in midwifery undergraduate programs in Turkey. In this program, midwifery students are expected to provide necessary care by adopting midwifery ethics and values, among students need to be acquired competencies to embrace, respecting each and every individual and their privacy.[12] Although ethics education is given to gain these qualifications to students, the status of ethical education in midwifery programs is not known. Revealing the current status of ethical education in midwifery will contribute to the identification and development of the weak and strong aspects of the education.

The main purpose of the research is to collect comprehensive data about the ethics education conducted in midwifery undergraduate degree programs in Turkey.

  Materials and Methods Top

Design and participants

Research data were collected between April 2017 and July 2018 in Turkey. Participants of this descriptive and cross-sectional research were determined according to the 2013 OSYS Higher Education Programs and Quotas Guide.[13] According to this guide, 33 schools give education at undergraduate level midwifery in Turkey. The research was carried out at 29 universities since there was no senior midwifery student at one university, and the midwife department manager at three universities refused to participate to the research. The participants of our research consisted of two groups. One of our research groups consisted of faculty members who are giving ethical education in midwifery (n = 33). Our other research group consisted of senior midwifery students who took ethics courses at these universities (n = 2135). It was determined that a minimum of 28 faculty members and 326 senior midwifery students should be interviewed under 95% confidence and 5% error of margin using the sampling formula with a known population.[14]

By simple random sampling method, 23 faculty members and 1140 senior midwifery students enrolled in the study.

Data collection

The data were collected through study forms by the researchers and pollsters in a way that would not disrupt the educational activities. These study forms were created based on the issues highlighted by researchers in previous studies and assessed by two professionals in the field.[7],[10] Two separate study forms were used for faculty members and students. The study form for faculty members included questions on demographic characteristics, professional knowledge, and opinions about the ethics courses were included. Besides, we got information about reveal the name, period, duration, and type of the course related to ethical education in midwifery programs from their. In addition, were asked to write five ethical values that they tried to adopt to faculty members midwifery students. Study forms for students; questions on socio-demographic characteristics, midwifery department, professional development, and their views on ethics courses were included. In addition, students were asked to write five ethical issues that they thought were related to midwifery. It took about 15–20 min to complete each form.

Ethical considerations

Ethical approval for the study was granted by the Kocaeli University Ethical Committee in Turkey (Approval Number: KÜ GOKAEK 2017/5.14). Research participants were informed in writing and verbally about the subject that the purpose of the research and their personal information would be kept confidential. The participants were stated that participation to the study is voluntary, and they would be accepted as giving consent to participate in the study if they responded by submitting the data collection forms.

Data analysis

Data were analyzed using the statistical software SPSS version 20.0 for Windows (IBM Corp., Armonk, NY, USA). Descriptive statistics including mean (M) and standard deviation (SD) were used to define the variables “age,” “time working as an educator,” and “mean duration of clinical experience.” Other responses to all questions are reported as frequencies and percentages. Chi-square test was used to test the relationships between the statements of faculty members and students regarding ethics education in midwifery. P <0.05 was accepted as statistically significant.

  Results Top

Six faculty members who did not want to participate in the study and two midwifery students who filled out the questionnaire incompletely were excluded from the study. Eventually, 17 faculty members and 1138 senior midwifery students were included in the sample. The socio-demographic and professional characteristics of the faculty members, who are all women, are given in [Table 1]. In addition, faculty members with clinical experience reported that they mostly worked in adult and neonatal intensive care units (17.6%). [Table 2] shows the socio-demographic characteristics of midwifery students and their answers about midwifery.
Table 1: Sociodemographic and professional characteristics of faculty members (n=17)

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Table 2: Sociodemographic and professional characteristics of the midwifery students (n=1138)

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The answers given by the participants to the research questions about ethics are given in [Table 3]. Accordingly, a statistically significant difference was found between the views of the faculty members and students about ethics education in midwifery education (P < 0.05).
Table 3: The faculty members' and students' issues about ethics education for undergraduate midwifery students in Turkey (2017-2018)

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The faculty members stated that the name of the ethics course they carried out in the midwifery program was Midwifery History and Ethics/Deontology (n = 7) and Ethics and Deontology in Midwifery (n = 5). They said that the ideal ethics course name was Ethics in Midwifery (n = 4), History of Midwifery and Ethics (n = 3). In [Table 4], the evaluations of the faculty members regarding the current situation of ethical education and the education they think are ideal are given. In addition, it was stated by a faculty member that the ethics course was integrated to the other courses in the midwifery program and it was ideal to give the course both separately and integrated to the other courses, and 1 h of practical ethics courses should be added to the content of applied midwifery courses in midwifery programs in terms of reinforcing ethical issues.
Table 4: Evaluations of faculty members on the current and required status of ethical education in midwifery programs (n=17)

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The ethical values that the faculty members aimed to adopt to midwifery students; justice, equality and respect for individual/autonomy (n = 9), nonharm/utility (n = 8), privacy, honesty (n = 4), all ethical principles and rights (n = 3), morality, empathy, definition of ethics, human dignity, respect for life, trust, confidentiality (n = 2), conscience, professional identity, solidarity and cooperation, developing moral sensitivity, trustworthiness, taking responsibility, professional ethics and information (n = 1).

According to the answers given by 53.1% of the students, ethical issues were respectively privacy (n = 302), individual/autonomy respect (n = 162), nonharm/non-maltreatment (n = 118), law (n = 85), and usefulness (n = 73). Loyalty, moral values, conscience, understanding, ethical principles, newborn ethics, smiling face, maternal-infant duo, ethical codes, end of life, research ethics, ethics in midwifery, patience, ethics in practice, benevolence, and paternalism/maternalism were stated by a small number of students (6.6%). However, a small percentage of the students (16.5%) stated that women/violence/social problems, midwifery practices, occupational problems, and malpractice issues were the subject of professional ethics.

  Discussion Top

It is emphasized that ethics education in midwifery should be conducted in a way to improve students' ethical competence.[9],[15] At this point, evaluating the status of the current ethical education in midwifery is important in terms of guiding the development of ethical education. In Turkey, the results of our study we thought that was the first research on this subject have been reached to important data.

In our study, all the faculty members conducting ethics education in midwifery stated that ethics education is necessary in midwifery education and the majority of them stated that the content of the current ethical education was sufficient. Almost all of the faculty members who gave the ethics course had different expertise other than ethics, but all thought that this education should be given by faculty member with ethics expertise. In 2014, a similar study was conducted examining the characteristics of the ethics courses given in nursing education in Turkey, and the researchers showed that; all the faculty members conducting ethics education in nursing deemed this education necessary, and more than half thought that the ethics course should be given by an expert in the field.[16] In a study conducted in 25 medical schools in 18 European countries, it was found that ethical education was generally carried out by physicians (29.7%), ethics/bioethics experts (19.8%), and philosophy department faculty members (15.8%).[17] All these results indicate that professional ethics education is intended to be given by a specialist in the field, but the current education situation in health sciences is different. Although ethical principles and values of health professionals are similar, differences in the duties and responsibilities of midwifery profession require that ethical education be specific to midwifery.[18] For this reason, it is considered that conducting ethical education in midwifery by midwife academicians specialized in ethics will increase the effectiveness of education.

Similarly, to the faculty members, almost all of the students who participated in our research stated that ethical education is necessary in the midwifery education and that education should be given by a specialist in the field of ethics. Although not statistically significant, one of the remarkable results of our study was that the midwifery students found the content of ethical education to be insufficient more than the faculty members. In another study conducted in Turkey, researchers showed that 40.4% of midwifery students did not find ethics education in the curriculum sufficient.[19] The negativities such as the lack of ethical education conducted in midwifery programs by the experts in the field, and the inability of the course to be integrated into midwifery issues, may be the reason why students find the content of the ethics course inadequate.

In accordance with the evaluation of faculty members participating in our study in the midwifery program in Turkey, a mandatory ethics course is conducted as a separate subject and determined that it was ideal. In the study conducted in Turkey with 30 faculty members, it was determined that the ethics education is compulsory in all nursing schools, half of them (50%) are conducted as subjects in different courses, 30% are carried out together with the history of nursing course and 20% as a separate course.[16] In a study conducted with 44 medical schools in Spain, it was found that 47.73% of the medical schools were taught together with the other courses, 45.89% were given as a separate course and 7.14% were given by both methods.[20] In Korea, ethics courses were taught as a separate course in six of the eight nursing schools and integrated into the other courses in two schools.[21] All these results suggest different opinions about the inclusion of ethics course in education curriculum in health professions. One of these views argues that ethics should be taught as a separate course since it provides an in-depth discussion of ethical issues. Another opinion suggests that ethical issues should be integrated into other courses because it provides an understanding of the ethical relationship between the profession.[22] Another view emphasizes that besides ethical education as a separate course in health-related professions, ethical issues should be distributed in accordance with the content of other courses.[23],[24] This idea shows the need to more researches. However, the reasons of different opinions may be related to different curriculums and differences between modality of the majors. In addition, a statistically significant difference was found between the views of the faculty members and students about ethics education in midwifery education. This difference is thought to be due to the difference in the number of participants between the two groups.

In our study, it was found that ethics education conducted in midwifery programs was given 2 h a week (approximately 30 h) as a compulsory course in the third academic year. In 25 US midwifery schools, the duration of ethical education (36%) was found to vary between one and ten hours.[10] Compared with this study, it said that midwifery education at the undergraduate level in Turkey have more ethics training time. In the study conducted in 18 European, the researchers reported that the average annual ethical training in medical education was 44 h and that the training was given before and during clinical practice.[17] Ethical education in medical schools in Spain was reported to be compulsory (78.6%) and mostly in the second (35.7%) and third (26.8%) years of education.[20] The results of these studies showed the differences in the duration of ethical education in medical, nursing, and midwifery education. These differences may be due to the competencies that both countries and different health professions aim to gain regarding ethical education. Detailed studies can be conducted in which the quality of ethical education and the achievement of educational objectives are evaluated in the education of different health professionals.

The ethical values that the faculty members primarily wanted to adopt to the students were the principles of justice, equality, and respect for individuality. In a study conducted with 30 faculty members in Turkey, researchers showed that the ethical values that faculty members primarily try to adopt to nursing students are primarily nonharm, utility, respect for human rights, respect for autonomy, and justice.[16] In Finland, it was stated that the ethical principles and values that academic nurses try to adopt to students are the principles of justice, equality and honesty, followed by respect, individuality, responsibility, patency, reliability, and autonomy.[25] When our study results are compared with these results, there are similarities and differences in ethical issues that are tried to be adopted. It can be thought that this may be due to differences in duration, methods, and content of ethical education as well as cultural differences.

Approximately half of the students who participated in our study often on ethical issues they think are relevant to midwifery wrote one or two issues. The most frequently mentioned issue was privacy. Other topics frequently expressed by the students are; respect for autonomy/individual, nonharm/non-maltreatment, rights, utility. Respect for privacy, one of the important ethical rules; it includes the right to respect the privacy of the individual and to expect the protection of secrets.[26] Although health professionals are expected to respect the privacy of the individual/patient they serve, more attention should be paid to this issue, especially in the midwifery profession. Because violations of privacy during procedures such as obstetric and gynecological examinations, or at birth, increase shame and fear levels in women.[27] In our study, the students' stating about the issue of privacy related to ethics showed that the students developed awareness about this issue. However, in our study, it was thought that some of the students had difficulty in defining or understanding ethical issues as they often mention social problems, midwifery practices, and professional problems as ethical issues. As a result of a joint project carried out in midwifery schools in Finland, Estonia, and Switzerland, similarly, it was found that midwifery students had difficulties in defining and understanding ethics. In the same study, it was found that students' ethics were compared with their own moral systems, the contribution of ethical education to the development of ethical competence was low and theoretical courses were not sufficient by themselves.[7]

The results of the study examining the ethical sensitivity of midwifery students can give an idea about the effectiveness of ethical education given in midwifery education. According to the studies, the moral sensibilities of midwifery students were found to be moderate.[19],[28],[29] In our study, students had difficulty in defining ethical issues, and the research results showing that students had moderate ethical sensitivities showed that the current ethical education should be developed specifically to midwifery.

Our research had some limitations. First of all, our study results cannot be generalized for all midwifery students, as our study was conducted only on senior midwifery students. Other research limitations are the inability to reach the targeted sample number of faculty members and the research findings in line with the answers given by the participants to the study form.

  Conclusions Top

Ethics education in midwifery degree programs in Turkey is conducted by faculty members who have their expertise outside ethics. The current ethics education is insufficient for midwifery students to comprehend basic ethical issues related to midwifery. Our results show that it is necessary to set standards regarding the duration, goals, and content of ethical education in midwifery. For this purpose, ethical education programs should be developed by bringing together ethical experts, academicians, and midwives working in the field. The developed ethical education programs should be conducted by spreading all of the midwifery undergraduate education by using innovative centered education methods, and learning effectiveness should be evaluated. Finally, we suggest to conduct a qualitative study that will enable us to understand the reasons why the midwifery students find the content of the ethical education they receive insufficiently.

Conflicts of interest

There are no conflicts of interest.

Authors' contribution

Suzi Özdemir and Rahime Aydın Er contributed with the design, concept development, literature search, manuscript preparation, and manuscript editing. Suzi Özdemir contributed to the data collection. Rahime Aydın Er contributed with the definition of the intellectual content, statistical analysis, manuscript review and supervised the work.

Financial support and sponsorship



We would like to thank the Professor Doctor Canan Baydemir for her assistance in the analysis of the data, all midwifery department heads who helped in the realization of the research, the academicians who supported the data collection process, and all the faculty members and students who participated in the research.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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