Claude AI summary of The impact of Twinning up North: A qualitative exploration among Icelandic and Dutch midwives
rick davies
Journal: Women and Birth, 39 (2026) 102125 https://www.sciencedirect.com/science/article/abs/pii/S1871519225002598
1. Why MSC Was Used
The authors used MSC to evaluate the personal and professional impact of a three-year cross-cultural midwifery collaboration (Iceland and Netherlands, 2018–2020). The stated rationale was that MSC's open-ended, participant-centred approach could capture experiential depth that standard evaluation instruments would miss — specifically, the "more than just the average experience," including unexpected or individual-level effects. The method was also chosen because it invites respondents to go deep and personal rather than producing generalised or aggregated accounts.
This is a legitimate and well-grounded rationale, consistent with the Guide's description of MSC as particularly suited to capturing impact that is diverse in form and difficult to predict in advance. The authors also noted that this is believed to be the first application of MSC to a twinning project, adding a context-novelty justification. Notably, the paper is authored by people with direct insider knowledge of both the twinning field and MSC — the fourth author is explicitly described as having more MSC experience than the others, and was brought in partly for that reason.
2. How It Was Used
The implementation had two sequential phases:
Phase 1 — Written story collection. An online survey was sent to all 25 participants approximately one year after the project ended (August 2021). Each participant was asked two open-ended questions — one about the most significant change in midwifery in their country since the project, and one about the most significant change in their own work as a midwife. The questions referenced MSC by name and defined "significant change" as "the most important change." Stories were requested to be at least 200 words.
Phase 2 — Focus groups. The written responses were analysed and used to develop a semi-structured questioning route. Two focus groups were then held face-to-face (20 of 25 participants), each lasting approximately 60 minutes, with mixed national composition. These were transcribed verbatim, returned to participants for accuracy checks, and analysed using a hybrid deductive/inductive thematic approach with Dedoose software.
What was not present, assessed against the Guide:
The Guide identifies three steps as fundamental: story collection (Step 4), selection of the most significant stories by stakeholders (Step 5), and feedback to participants on what was selected and why (Step 6). This implementation includes Step 4 in a recognisable form. However, Steps 5 and 6 are effectively absent. The selection and synthesis of stories was performed by the research team through thematic analysis — a researcher-led process, not a participatory stakeholder selection process. The focus groups partially compensate, in that they involved participants in exploring and validating themes, but this is not the same as the structured, transparent selection process the Guide specifies. There is no indication that feedback was provided to participants on which stories were considered most significant and why.
The two questions are structured around a personal/professional distinction, which functions loosely as two domains. However, unlike the Guide's conception of domains — which can be predefined or emergent, but are ordinarily used as explicit categories within which stories are collected and then compared — these are better understood as topical prompts that shaped what participants wrote about, rather than classification categories used in a selection process.
The temporal gap of approximately one year between project end and data collection was a deliberate choice, intended to reduce "afterglow" effects and allow genuine reflection. The Guide does not prescribe a specific timing for evaluation-oriented story collection and acknowledges that different reporting frequencies serve different purposes. The one-year gap has face validity for post-programme evaluation, though the Guide does note (citing Ghana) that stories can feel stale when there is a long delay between event and review.
3. Challenges and How They Were Addressed
Researcher proximity. Three of four authors were directly involved in the Twinning up North project — one as project manager. This creates an obvious risk of confirmation bias in story collection and analysis. The authors addressed this explicitly: the fourth author, who had more MSC experience and was not a project team member, was included specifically to challenge assumptions and facilitate critical self-reflection. This was built into the research team meeting structure as a standing agenda item. This is a sensible and transparent mitigation strategy, though it does not eliminate the underlying risk.
Confidentiality in a small community. Participants were informed that full confidentiality was not achievable given the small size of the Icelandic midwifery community. This was acknowledged honestly. Quotes were anonymised by number rather than name, and nationality was not attached to quotes. This represents a reasonable but incomplete resolution of a genuine structural challenge.
COVID-19 and life events as confounding factors. The project ran from 2018 to 2020, overlapping with the pandemic and with various personal life events among participants. The authors explicitly acknowledged that these may have independently influenced the changes participants reported. They did not attempt to control for this, but the focus group discussions provided some space to explore the relationship between twinning-specific and other factors.
Potential bias toward success stories. The authors acknowledge this as a limitation — MSC is known to elicit positive accounts more readily than negative ones, and participants who did not join the focus groups (6 of 26 who started the project) may have had more critical perspectives. One participant who completed the project but felt disappointed about the leadership development component did contribute this view through the written questionnaire and focus group, which adds some balance.
Story collection question design. The first question asked about "the most significant change in midwifery in your country" — a collective, systemic question that goes beyond individual experience and sits at an unusual level of abstraction for MSC. The Guide's standard question asks about observed change in a community or program, not a national professional context. This is a contextual adaptation, and arguably appropriate given the project's explicit focus on systemic midwifery leadership, but it introduces ambiguity about whether the reported changes were attributable to the twinning project or to other forces.
4. What Benefits the Use of MSC Delivered
The approach yielded rich, participant-centred accounts of impact that surfaced five coherent themes of personal and professional growth, centred on leadership development and professional identity. The method's emphasis on the participant's own perspective aligned well with the project's ethos of empowerment and peer learning — both values that also underpin the twinning methodology. The depth and specificity of the stories was sufficient to construct a grounded theoretical account (the "virtuous cycle of growth") that a questionnaire-based evaluation would not have generated.
The two-phase design — written stories followed by focus groups — produced genuine methodological complementarity. The written phase captured individual, reflective accounts under conditions of privacy; the focus groups allowed collective exploration and triangulation. This combination is an innovation relative to the Guide's standard approach, and a productive one in this context. The Guide does describe focus groups as one legitimate way of conducting the selection step (Step 5), though that is not precisely how they were used here.
The decision to collect stories approximately one year after the project's end appears to have allowed participants to distinguish lasting change from immediate enthusiasm. Several participants used temporal language suggesting considered reflection, which gives the findings more evaluative weight than immediate post-project responses might have.
5. Lessons for Future Users of MSC
On the question of what constitutes MSC. The abstract describes the approach as using "the Most Significant Change methodology"; the Significance Statement describes it as "a qualitative approach inspired by the Most Significant Change technique." The latter is the more accurate characterisation. The absence of a participatory selection process and structured feedback means this is a partial or adapted application of MSC, not a full implementation. Future authors should be explicit about which elements they have used and which they have omitted — both as a matter of methodological honesty and to allow readers to assess the contribution accurately.
On the omission of participatory selection. The Guide's rationale for the hierarchical selection process is not merely procedural — it is substantive. When participants and stakeholders debate which stories are most significant and document their reasons, they generate data about values, priorities, and organisational direction that the stories themselves do not contain. Replacing this with researcher-led thematic analysis produces a different kind of knowledge: more systematised and analytically coherent, but less participatory and less generative of organisational learning. Future users of MSC in small-group programme evaluation contexts might consider whether a modified selection process — for example, asking all participants to read each other's stories and identify the most significant, with documented reasoning — could be practically incorporated.
On the absence of feedback. No feedback mechanism is described. Given that the project had already ended when stories were collected, feedback to participants on which stories were selected and why would have limited utility for future programme management. However, sharing the thematic findings back to participants (the accuracy check did not appear to include any feedback on analytical conclusions) would at minimum have honoured the participatory spirit of the method. Future evaluations using MSC at end-of-programme should consider whether and how to close this loop even in a post-hoc context.
On post-programme versus ongoing MSC. The Guide positions MSC primarily as an ongoing monitoring tool, used throughout a programme cycle. This application uses it retrospectively, as a single evaluation exercise. This is a legitimate adaptation — the Guide acknowledges MSC's contribution to evaluation as well as monitoring — but it forfeits the method's capacity to support iterative learning and programme adjustment in real time. In a twinning project with a defined endpoint, the window for such adjustment has already closed by the time stories are collected. Future twinning programmes might consider using MSC earlier in the project cycle to enable mid-course learning.
On researcher proximity and reflexivity management. The use of an independent fourth author with methodological expertise and distance from the programme is a model worth generalising. In small-team applied research where researchers and evaluators are often deeply embedded in the programmes they study, building in a methodological 'outside eye' is a structural safeguard worth recommending explicitly.
On the "inspired by" adaptation model. This paper illustrates an increasingly common pattern in the MSC literature: partial adoption with honest acknowledgement of adaptation. The adaptation is responsive and contextually justified. Viewed through the Guide as a living document rather than a fixed prescription, this represents MSC evolving into a smaller-scale, end-of-programme qualitative evaluation tool for professional development contexts — a use case the 2005 Guide did not explicitly anticipate. Whether the core participatory and feedback elements can be preserved in such contexts, or must be abandoned for practical reasons, is a question the broader MSC community would benefit from examining explicitly.