*4.1. Proto-Professionals*

At the start point of the model- the top left-hand corner, the proto-professional is located. The prefix Proto is derived from Greek (*prôtos*) and means first and from pro meaning before [9]. Within the context of midwifery, this relates to the midwife as a newly registered and/or licensed practitioner. As the entry point for the profession, this quadrant allows us to explore the challenges faced by new graduates and registrants in order to help them to move along the continuum. However, it also a ffords us the opportunity to consider the relatively new attainment of a professional status for midwifery, the journey which began in the nineteenth century and despite strong medical opposition, was finally legislated for in the first decades of the twentieth century. It may be argued that the progression to a profession has led to the protection of the midwife's role in legislation but closer inspection may indicate that this may have come at the price of being less autonomous as a profession and more closely influenced by 'medical men' [11].

A midwife although signed o ff as competent and of 'good health' and character (considered to be capable of practicing safely and e ffectively [31]), they are still on a learning trajectory, will continue to develop professionally and given time and support, will continue to hone the recently acquired knowledge and skills from their education program. Many years ago, newly qualified nurses unpreparedness was described as 'a reality shock' [32] with Fenwick et al. [33] concurring with this and highlighting the importance of context and culture on the transition for new midwives and the need for strong relationships with midwifery colleagues to help them develop and grow in confidence. A structured and tailored induction and preceptorship (a period of support to help new registrants transition from student to registrant advocated by the NMC [34]) can enhance confidence as often a new registrant's experience is unstructured and insu fficient to meet their needs [35].

The ICM set a benchmark for the standardization of midwifery education with midwifery being a graduate profession in many countries [14]. It also advocates that as it is an ethical duty for all midwives to provide safe practice that continuing professional development should be compulsory for all practicing midwives [25]. For some midwives, it may be argued that, the ongoing acquisition of knowledge and skills may be solely to meet their regulators' requirements or a means of staying on the professional register. However, for many midwives (one would hope most), the continual learning is driven by a passion to provide women and babies with the optimum quality of midwifery care. This requires not only a theoretical knowledge and understanding of the evidence base and its application to practice but also the acquisition of practical skills including high level communication skills in order to care for women and babies and support women and their partner (if appropriate) in their decision-making and choices.

As with other healthcare professionals, it can be di fficult for midwives to find time to undertake these continuing professional development activities. While advocated by the ICM [25] and some countries regulators such as in the UK [36], the plethora of mandatory training for Health and Safety and other corporate priorities, coupled with sta ffing challenges, make it di fficult for midwives to be released to undertake professional development activity. Often activity is undertaken in own time, sometimes at one's own expense with a promise of time in lieu or additional payment.

## *4.2. No Midwife*

The Place Model provides the opportunity to consider the reality that 'no midwife' can present. The World Health Organization (WHO), recognize that within the right context, midwives who meet the ICM standards for education and regulation, can provide most of the fundamental care that is needed by women and their babies [13,14]. However, in many countries in the world, women do not have access to a professionally trained midwife or skilled birth attendant [37]. The State of the

World's Midwifery report [38] has highlighted that only four of the 73 middle-or low-income countries surveyed had midwives who were fully trained and skilled to provide care for women and their babies with fewer than half of these countries having legislation acknowledging midwifery as an independent profession [26]. A shortage of midwives is a worldwide phenomenon, including in high income countries where standardized and regulated midwifery education is available [39], with recruitment and more often retention of registered midwives, a key challenge maternity care providers grapple with for a multiplicity of reasons including workforce planning [40,41], work related stress [42] and bullying [43]. Failure to reach safe sta ffing levels, poor communication and professional collaboration has been shown to contribute to unsafe and substandard care [44].

In 2018, in recognition of the need for a definition of 'skilled health personnel', a joint statement was issued by the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the United Nations Children's Fund (UNICEF), the International Confederation of Midwives (ICM), the International Council of Nurses (ICN), the International Federation of Gynecology and Obstetrics (FIGO) and the International Pediatric Association (IPA) [45]. One way through which to end preventable maternal mortality is to increase the number of births attended by skilled birth attendants or health personnel. Evidence of this is already clear, as during 2012–2017, almost 80 per cent of live births worldwide were attended by skilled health personnel, an increase of 62 per cent since 2000–2005 [46] with a decrease in the maternal mortality rate of 37% since 2000. However, further progress is needed if by 2030, Sustainable Development Goal 3 (SDG 3) to reduce the global maternal mortality ratio to less than 70 per 100,000 live births is to be achieved.

Conversely in high income countries, such as the UK, Australia and the US, there is an albeit small but growing number of women who choose to birth without a midwife or doctor present. Research by Jackson et al. [47] reports that women who free birth, do not view hospitals as safe places within which to birth. This view is further supported by other women who chose free birth in order to have choice, control and autonomy during birth [48] with some women relating the absence of the woman-centered care in maternity services, leaving them feeling vulnerable and unsafe [49]. It is important to note that safety relates not only to the physical sense of safety but also the emotional, psychological, and social aspects of care.

So clearly, while midwives are often recognized as skilled professionals, they are not always viewed as such and are seen to work within a system '*that can lead to a unique set of additional risks to the mother and baby'* [47] (p. 566). However, strong voices and evidence advocating midwifery led continuity of care models for most women [50,51] are leading to change. This will require not only the redesign of maternity care provision in many localities but also the education and willingness of midwives to work within continuity of care models. A continuity of care model is not a new phenomenon having been advocated for many years and one that exists in small pockets already. Indeed, it may be that midwifery is reverting back to a system of care delivery that prior to childbirth moving into the hospital setting and becoming more medicalized was the way in which care was provided.

## *4.3. Precarious Professionals*

The next quadrant of the model challenges us to consider the Precarious professional. Precarious midwives are a particularly important group. Two contrasting professional trajectories are presented in this part of the model—both can produce damaging outcomes. Firstly, those who might be deemed to be unprofessional and secondly those who do not/cannot stay in the profession for long.

There are clear standards for the minimum education requirements expected for entry to a midwifery education program, however, it is much harder to make a judgement about the values and character of a potential student midwife [23]. Given the regulatory mechanisms within midwifery, and the global standards for education and practice, it would be expected that those deemed as unprofessional would be investigated through their education providers' or employers' disciplinary system or by their regulator or both. In the UK, approximately 0.7% of midwives registered with the NMC were referred for Fitness to Practice concerns in 2017/18, accounting for 240 out of 35,830

registered midwives [52]. Referrals can be made by anyone including a service user, a member of the public, an employer or the police.

However, despite the grea<sup>t</sup> majority of women and their families, accessing the type and quality of care that they choose, in England for example, litigation in maternity care while only 10% of claims, accounted for 50% of the total value of claims [53]. Reports into failings in maternity services in the UK [54,55] have found that care provided by midwives having been subjected to scrutiny was substandard, that there was a lack of openness and honesty, were critical of midwifery supervision and of those who regulated and monitored the Trust. These failings are clearly distressing and life changing for women and their families and can impact on the confidence that women have in maternity services generally and midwives in particular. On a more positive note, a Cochrane review by Sandall et al. [50] concluded that midwife-led continuity models of care resulted in women being less likely to have interventions, with a greater chance of satisfaction with their maternity care and outcomes that were at least comparable with those of women who had accessed other models of care.

Despite clear standards for education and maternity care, globally, there is concern over the abusive and disrespectful practices perpetrated on women during childbirth [56]. A systematic review by Bohren et al. [57] identified a new typology of mistreatment of women during childbirth under seven themes: physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints. It is clear that disrespect and abuse happens not only at an individual woman and precarious professional level but also at systems' level within health care organizations, despite an increasing body of evidence being accessible at both individual professional and organizational level. Custom and practice and cultural norms are sometimes used to justify the abuse that women are being subjected to during pregnancy and childbirth. Some women reporting that they are traumatized in childbirth not only by how they are treated but also through a lack of communication, control and consent [58].Continuing professional development is vital in ensuring that midwives maintain and update the necessary knowledge and skills which underpin respectful maternity care such as interpersonal skills, values and attitudes [59].

Midwives, who, for a variety of reasons, have both short careers and limited learning opportunities can have negative outcomes not only for the profession but also for the women and families for whom they provide care. Likewise, given the investment in their professional education of both the individual midwife and the taxpayer, it is important to understand what has contributed to the precarious status of these midwives. In the UK, Ball [42] reported that the top five reasons given for leaving the profession were: being unhappy with sta ffing levels; being dissatisfied with the quality of care they were able to give to woman and babies; being overworked; feeling unsupported by their manager; and being unhappy with working conditions. A recent paper by Harvie et al. [60] identified that Australian midwives are unhappy working within a fragmented system that did not allow them to provide care for women in the way they would like, with midwives under 40 years of age being particularly vulnerable. However, in contrast in Afghanistan [61], the primary reason for leaving was lack of security due to civil unrest and conflict, family disagreement, with increased workload without paymen<sup>t</sup> coming further down in the list of contributing factors. It is clear that governments and employers need to support their employees by addressing the specific issues that impact on midwives choosing to leave the profession.

In addition, it is important to consider the selection and recruitment practices used by academic institutions. It is easy to evidence if applicants meet the academic selection criteria but making a judgement about the values, motivation and strength of character needed to be a midwife; the ability to be 'heartstrong' [62] and compassionate is less straightforward.
