A Cross-Sectional Study of Midwives’ Proactive Behavior in Midwifery Practice

Research Article

Ann Nurs Res Pract. 2019; 4(1): 1031.

A Cross-Sectional Study of Midwives’ Proactive Behavior in Midwifery Practice

Mestdagh E1,2*, Timmermans O2,3 and Van Rompaey B2

¹Bachelor in Midwifery, Department of Health and Social Work, Artesis Plantijn University College Antwerp, Noorderplaats, Antwerp, Belgium

²Centre for Research and Innovation in Care, University Antwerp, Universiteitsplein, Antwerp, Belgium

³HZ University of Applied sciences, Lectorship Healthy region, Edisonweg, NW Vlissingen and The Netherlands

*Corresponding author: Mestdagh Eveline, Head of the Midwifery Department, Artesis Plantijn University College Antwerp, Belgium

Received: January 11, 2019; Accepted: February 12, 2019; Published: February 19, 2019


Objective: To support midwives in coping with the continuous state of change of midwifery practice by studying proactive behavior in midwifery.


Objective: To support midwives in coping with the continuous state of change of midwifery practice by studying proactive behavior in midwifery.

Design: A cross-sectional study investigated associated antecedents of proactive behavior in a group of Belgian and Dutch midwives.

Setting: Midwifery practice in Belgium and the Netherlands.

Participants: Belgian and Dutch midwives (n = 139).

Intervention: Midwives answered a questionnaire, from September 2017 until December 2017, regarding six personal, seven individual and three contextual antecedents possibly associated to two types of proactive behavior: proactive idea implementation and voice speaking. A proportional odds logistic regression analyses was executed describing the association between these antecedents and the probability to observe proactive behavior.

Findings: Of all tested prognostic factors, job autonomy, control appraisal and role breadth self-efficacy, referring to the midwives’ commitment to perform tasks that go beyond the expectations, were significantly positively associated with proactive behavior.

Conclusions: Midwives having more job autonomy and higher role breadth self-efficacy are positively associated with proactive behavior. Additionally, independent midwives more likely behave proactive. Midwives, more than midwifery students, need a high level of control appraisal in order to show proactive behavior. Midwives tend to lose partly their level of proactive behavior after one working year.

Implications for Practice: In the quest to support midwives in turbulent times, this study uncloses additional insights of proactive behavior in midwifery. Anticipating the various significant antecedents, could strengthen the level of proactive behavior of midwives. The awareness for proactive behavior could positively contribute to the work efficiency and coping attitude of midwives and indirectly contribute to the quality of care for mother and child.

Keywords: Proactive Behavior in Midwifery; Job Autonomy; Role Breadth Self-efficacy; Work Experience; Advanced Practice; Organizational Success; Nursing


Researchers of this study focused on possible tools supporting midwives in the process of continuous changes in midwifery practice. A previous concept analysis by Mestdagh et al. [1] revealed possible benefits of proactive behavior in midwifery. Midwives behaving proactively notice changes as an opportunity, are always one step ahead, anticipate future possible barriers, adapt easily, work autonomously and in a constant quest for efficient, effective and qualitative care strongly leaning to the state-of-the-art. Additionally proactive behavior could result in an increased job satisfaction, workefficiency, commitment and higher coping strategies in increasing resistance of stress [2,3]. On top of that, improved team productivity and organizational success may occur [4,5]. Proactive behavior is possibly associated to several individual and/or contextual antecedents who were recently tested in a pilot study within a group (n = 98) of midwifery students [6]. Two antecedents, being control appraisal and role breadth self-efficacy, were identified as important predictors of proactive behavior. This study aims to confirm and/or supplement recent insights on antecedents of proactive behavior by studying a group (n = 133) of midwives and compare their characteristics and their antecedents on proactive behavior with the results of our earlier study with student-midwives as population.


Health care practice is characterized by rapid evolutions, the need for cost-effective and accessible health care and constantly changing practices [7,8]. In recent years, the context of midwifery practice presents a growing complexity, due to rapid evolutions, such as centralization of care, medicalization of childbirth as well as an overflow of new insights, innovations and availability of evidence on interventions [7,8,9]. Births also became increasingly complex. For example, older women are giving birth, more women that are pregnant are obese and more women are living in very difficult social situations. Midwives are expected to adapt quickly to changes in particular by modifying themselves to keep pace with the continuous changes in their specific working area or in the structures in which they provide care [10,11]. Up until now, the qualifications of midwives do not fully meet the needs of labor market and society. Employers report an increasing difficulty in finding staff capable of coping with the developments and innovations. This calls for a new generation of midwives, who proactively move along and possess the characteristics of a reflective practitioner [12]. In the quest for an answer to the developments and innovations in midwifery and midwifery education, health care organizations, universities and governmental institutions mainly focus on operational directly visible matters, e.g. restructuring of protocols, work areas, financing et cetera. Yet, less emphasis is given to underlying, not directly visible aspects of work (processes). We should move the focus of attention to a possible behavioral change, where through the midwife could positively cope and act towards all developments and innovations in midwifery practice. Drawing on the literature proactive behavior of the midwife is identified to support them to cope with the continuous developments in midwifery practice.

This current study explored the association of proactive behavior to several individual and contextual antecedents within a population of midwives. The midwives’ informed beliefs and motivation that the behavior will bring about a set of salient outcomes, is an important prerequisite of midwives’ attitude towards proactive behavior [13]. Therefore, a supplementary aim of this study is to make midwives more aware of the concept of proactive behavior and its global contribution to the women and infants quality of care [14,15].

Materials and Methods

Study design

A recent pilot study of Mestdagh et al. [6] validated a questionnaire to assess proactive behavior in midwifery students. The 75 original predefined questions, adapted to the midwiferyworking context, were translated and retranslated. An expert panel, consisting of lecturers (n = 5), researchers (n = 2) and midwives (n = 4), determined the content validity on the item level (I-CVI, 0.90- 1.00) as and well the scale-level (S-CVI, 0.89-1.00) [16]. Based on the results of the previous pilot study and the content validity check a 70-item questionnaire with a set of seven individual and three contextual antecedents related to proactive behavior was developed. The questionnaire is subdivided in four categories. The first part consists of a set of six personal and demographical questions. The second category consists of seven individual antecedents: (1) generalized compliance, (2) affective organizational commitment, (3) proactive personality, (4) change orientation, (5) control appraisal, (6) role breadth self-efficacy and (7) flexible role orientation. Third, three contextual antecedents: (1) job autonomy, (2) confidence in the possibilities of fellow students and (3) supportive supervision. Finally, two concepts, proactive idea implementation and voice speaking assessed the level of proactive behavior. The first concept; proactive idea implementation; included five components: 1) time savings, 2) working together more efficiently, 3) achieving improved results, 4) improving quality and/or 5) creating cost. The midwives in this sample were asked if and how many new ideas they had concerning these components, whether they had shared their idea(s) with anyone (their colleagues, their direct manager or others) and whether these ideas were implemented by anyone (themselves or others). The second concept of proactive behavior was voice speaking. This concept was investigated by means of two questions. In a first question, the midwife was asked to indicate if any adjustments were implemented within her working environment in response to shorten possible hospital stays after delivery. The proposed adjustments, e.g. the doubling of the starting dose of an Oxytocin®-infusion in case of a labor-induction, were extracted of two earlier focus groups, performed in December 2016 by one of the researchers of this study, with a population of midwives (n = 7 and n = 6). The midwives were then asked to describe their working method whenever one of those adjustments happened. The second question gave some recent working methods based on evidence-based guidelines in midwifery, e.g. the midwifery led care-principles. The midwife was asked to indicate the implemented methods in her working environment. Thereafter the midwives again had to describe their working method in order to implement or preserve these evidence based methods. In both cases, the possible answers fluctuated from reactive to proactive, based on the defined attributes of proactive behavior in midwifery by Mestdagh et al. [1].

The full development of this questionnaire is elaborated in the study of Mestdagh et al. [6], in summary; an overview is given in Figure 1.