4.1 Design

This was a cross-sectional survey using a self-administered questionnaire. The study required midwives working in hospitals and clinics to complete an online questionnaire.

(1) The survey assessed individual health guidance and group education provided by midwives before and after the COVID-19 pandemic.

(2) The study examined the relationship between the availability and the importance of midwife support that promotes marital relationships using “wife satisfaction with husband's support.”

The STROBE checklist was completed (see File S1).

4.2 Sampling, Recruitment and Data Collection Period

The sample size was calculated using G * Power version 3. The study was calculated at a significance level of α = 0.05, an effect size of 0.30, and a power of 0.95. The sample size needed to examine the relationship between the presence and importance of midwives' support was 145 participants.

However, in a cross-sectional study to determine the actual situation of parenting guidance for fathers in obstetric facilities in Japan, the sample size was 290 midwives in obstetric facilities nationwide, and a self-administered questionnaire survey was conducted (Kamezaki and Akiyama 2021). In another cross-sectional study, 121 midwives from maternity facilities in five major cities in Japan were surveyed using a self-administered questionnaire to determine their perceptions of couple co-parenting and prenatal education (Saitou et al. 2023). The results of these two studies were rich and covered sufficient dimensions for statistical analysis. In other words, the number of samples analysed in this study was set at 300, and the recovery rate was assumed to be 30%; thus, the number of subjects studied was 890.

The following steps were taken to select facilities to cooperate with and complete the survey:

(1) The hospitals/clinics for deliveries in Japan listed on the Japanese Society of Obstetrics and Gynaecology website are divided into nine blocks. These nine blocks divided Japan into north and south, and were equalised into urban and rural areas.

(2) Overall, 80–100 hospitals/clinics were randomly selected from one block, and 890 facilities (excluding midwifery hospitals) were asked to participate in the study.

Requests for research cooperation were written by the head of the facility after explaining the purpose and methods of the study. The questionnaire was distributed to midwives who agreed to participate in the study through the head of the facility. Midwives who agreed to participate completed an online questionnaire.

The data collection period was from March to May 2022. This period was the Omicron BA.2 dominance period (March 1–June 30, 2022), which was the sixth wave of COVID-19 in Japan (National Institute of Infectious Diseases 2023).

4.3 The Subjects

The study subjects were midwives with at least 3 years of experience in a hospital or clinic. The selection criteria included midwives involved in health teaching, group education, and midwifery support to promote maternal relationships before and after the COVID-19 pandemic.

4.4 Data Collection

4.5 Method of Analysis

For all questions, missing values were excluded from the analysis. Simple tabulations were conducted on the actual situation of midwives' support for couples before and after the COVID-19 pandemic and on midwives' perceptions.

The midwifery support practices that enhance the couple's relationship were defined as “often practiced (often recommended)” and “always practiced (always recommended)” in the “midwifery practice yes” group, and “never practiced (never recommended)” and “rarely practiced (rarely recommended)” in the “no practice” group. The importance of midwifery support was defined as “rather important” and “fairly important” in the “high importance” group, and “not important” and “rather unimportant” in the “low importance” group. Fisher's exact test was used to determine the association between practice and importance of midwifery support. All analyses were performed using IBM SPSS Statistics version 28.0. The significance level was set to equal or less than 0.05.

The items in the open-ended response format were categorised based on the homogeneity of contextual semantic content. Categories were created for each of the three collaborators to ensure reliability.

4.6 Ethical Consideration

This study was approved by the Clinical Research Ethical Review Board of the Gunma PAZ University (approval number: REDACTED). Participation in the study was voluntary. The participants were informed about the purpose and methods of the study, their free will to participate, their personal information was protected, and that their data would not be used for any purposes other than the study. The questionnaires were completed via the internet by participants willing to participate in the study.

5.1 Individual Attributes of Participants

The participants' demographic characteristics are shown in Table 1. Most of the participants were in their 40s (35.2%). In terms of the duration of midwifery experience, 30.1% of participants had more than 11 years of experience and 32.4% had more than 21 years. The most common learning experiences used to support fathers and couples were journals/specialty books and midwifery/nursing education programmes.

5.2 Midwives Practice for Couples in Hospitals and Clinics Before and After the COVID-19 Pandemic

Regarding the impact of the COVID-19 pandemic, approximately 65.7% of individual health guidance was not particularly different from that before COVID-19; however, in group education, the most common impact of the COVID-19 pandemic caused a change of approximately 72.7% to web/video and approximately 45.4% reduction in scale (Table 2).

The situations in which midwives provided direct support to couples before the COVID-19 pandemic are presented in Table 3. In most of the situations where midwives provided direct support to couples, midwives did not actively provide support to all couples: “couples accompanied by their husbands” during pregnancy checkups, “couples who requested it” during mothers' and parents' classes and delivery with the husband, “couples who needed it” during postpartum checkups, and “no support for couples” during the 1-month postpartum checkups.

Before COVID-19, the reasons that made it difficult for midwives to provide support to couples were as follows (multiple responses): first, “Husbands do not have the opportunity to come to the hospital for checkups and guidance,” 168 (74.3%); second, “Time adjustment is difficult,” 128 (56.6%); and third, “Shortage of manpower,” 79 (35.0%).

The changes and alternatives to midwifery practices for couples and husbands due to the COVID-19 pandemic are shown in Table 4. More than 80% of the respondents indicated that the COVID-19 pandemic affected their support for couples during pregnancy checkups, mother and parent classes, and delivery with their husbands. In addition, approximately 40% of the patients were affected during the postpartum health guidance and during the first month of postpartum checkups. Due to the impact of COVID-19, husbands are no longer allowed to participate in the hospital, and the system has been changed to “health guidance communicated from wives to husbands,” “husbands participate only for high-risk pregnancy,” “changed to web/video,” and “husbands participate in phone/video calls.”

As shown in Table 5, free-response statements were categorised in terms of how midwives could support couples after the COVID-19 pandemic. The results fell into seven categories: “Small-group classes for couples with infection control measures,” “Online or web-based classes for couples,” “Indirect support for husbands/couples through videos and booklets,” “Individualized couple interviews with emphasis on support for husbands,” “support for postpartum couples in collaboration with the community,” “Support for couples to increase intimacy during pregnancy and to help them visualize postpartum childcare,” and “Seeking effective support for couples within the limitations of COVID-19.”

5.3 Midwives' Perceptions of Support for Couples

Table 6 shows the results of the six responses regarding midwives' perceptions of couples' support. Items, such as “I consider the husband as an object of support” and “I want to further enhance support for the couple (husband),” together with “Agree,” and “Somewhat agree,” were high at approximately 80%. However, items, such as “I understand the needs of the couple well” and “I understand how to support the couple well,” together with “Disagree” and “Somewhat disagree,” accounted for approximately 30% of the responses.

5.4 Relationship Between Midwifery Practices and Importance to Marital Relationship During Pregnancy

Utilising the assessment scale “Wife's satisfaction with husband's support,” we examined the relationship between midwifery practices and importance to the couple's relationship (Table 7). The high and low importance of midwifery support was significantly associated with whether midwifery practice was provided (p < 0.01). That is, [listening to the wife's concerns] for “physical and emotional support,” [Help with household chores as much as possible] for “sharing household chores and childcare,” and [discuss baby items and the environment with the couples] for “Prepare for childcare and discuss with the couple,” midwives with midwifery practices to encourage the couple's relationship were perceived as highly important. However, even among midwives without midwifery practice, such as [going out with his wife to take care of her health] and [talking to his wife about what kind of father he wanted to be] were perceived as highly important (p < 0.01).

6.1 Midwifery Practice for Couples in Maternity Hospitals and Clinics Before and After COVID-19

In a previous study by Willson et al. (Wilson et al. 2022), which identified the experiences of women who conceived and delivered during the COVID-19 pandemic, the authors reported that women received prenatal care in multiple ways, including face-to-face, telephone, home visits, and video calls, and that only one-third of the women received prenatal education, most of which was conducted in person or by video calls. It has also been reported that independent midwives working primarily in primary care adapted their midwifery practice during the COVID-19 pandemic (Baumann et al. 2021) and that midwives also engaged in new forms of care services, such as infection control online (Iwao et al. 2023). Similar to previous studies, in response to the impact of COVID-19, midwives in Japan have changed to a flexible system that allows midwives to respond to situations where practice with husbands and couples is limited, such as non-personal support through online or video calls, and separate support for couples in situations involving important explanations, such as high-risk pregnant women.

However, even before the COVID-19 pandemic, midwifery care for couples was mainly passive midwifery care for pregnancy, childbirth, and postpartum, with “couples accompanied by their husbands,” “couples who wish to,” and “couples who deem it necessary.” In other words, even before the COVID-19 pandemic, midwifery care for couples in Japan was provided only to husbands who were active in their wives' pregnancy and childcare, and not all couples were offered ongoing midwifery care. The reason for this, as in the study by Kamesaki et al. (Kamezaki and Akiyama 2021), is that even before the COVID-19 pandemic, there were few opportunities for midwives to provide direct support to husbands and couples, and midwives experienced difficulty in coordinating their time and lack of manpower, making it difficult to provide direct and continuous midwifery care to couples. In other words, midwives' support for couples who were not active in Japanese maternity hospitals before COVID-19 was further limited after COVID-19. This has made it difficult for expectant women and their partners to receive ongoing midwifery care and information, which in turn has made it difficult for couples to develop intimacy and increased their anxiety about parenthood (Suwalska et al. 2021; Yonezawa et al. 2022). The results of the open-ended question about how midwives can support couples after completing the COVID-19 pandemic indicated that direct support, such as allowing midwives to attend classes in a safe environment, and indirect support, such as making information easily accessible through videos and the web, showed that both types of support were important. In addition, there is a need for midwives to provide individualised and ongoing support to couples.

6.2 Midwifery Practices for Encouraging Couples' Relationships During Pregnancy

There are three aspects of husbands' support that wives find satisfactory: “Wife's physical and mental support,” “sharing housework and childcare,” and “preparation for parenthood and couple discussion” (Nakajima and Tokiwa 2013). Furthermore, these are also the three important aspects of midwives' support for enhancing the relationship between couples during pregnancy. As shown in the results of 5.4, [listening to the wife's concerns] for “physical and emotional support,” [Help with household chores as much as possible] for “sharing household chores and childcare,” and [discuss baby items and the environment with the couples] for “Prepare for childcare and discuss with the couple,” midwives with midwifery practices to encourage the couple's relationship were perceived as highly important. This study found an association between the midwives' practices and the importance of promoting marital relationships during pregnancy. In other words, midwives considered and practiced the importance of support in enhancing relationships between couples during the COVID-19 pandemic.

Most participants were 40 years old or older, and approximately 60% had more than 11 years of midwifery experience. This finding indicates that the midwives who participated in this study were career-oriented. Although midwives were keenly aware of the need for more support for marital relationships, even the most clinically experienced midwives did not fully understand couples' needs or specific ways to relate to them. Additionally, learning about specific midwifery support for couples from pregnancy onward was mainly based on individual midwives obtaining information from training and journals, which was insufficient for midwifery practice. If midwives can continue to support couples to have a good relationship during pregnancy, the friction between the couple and postpartum depression can be avoided, and postpartum crises can be prevented (Nakajima 2022). In Japan, where the problems of nuclear families and declining birthrates are becoming more serious, it is important for midwives to help couples increase intimacy and support them in becoming parents. These findings suggest the need for educational programmes for midwives to increase intimacy and support couples in becoming parents.

6.3 Limitations

The limitations of this study include the fact that the sample size was insufficient to determine the current status of midwives in Japan as a whole, as the collection rate was below 30% owing to the influence of COVID-19 and internet-based collection, and that career midwives with more than 11 years of midwifery experience accounted for 60% of the sample. Future studies are needed to increase the sample size and accumulate data on midwives in maternity hospitals other than hospitals and clinics.