*4.4. The-de-Professionalized*

Moving around the model to the next quadrant, the focus is on the de-professionalized. For midwives who are educated to the global standards set by the ICM [14], it would be expected

that they would be professional at the point of registration and for that positive professional learning trajectory to continue throughout their professional working life [25]. This is often a far from straight forward trajectory and there are a range of circumstances which may lead to deprofessionalization, even for the most experienced midwives—some deprofessionalization is a product of intrinsic factors such as personal disposition, some is produced by a range of external factors.

De-professionalized midwives may be experienced midwives who for some reason are disillusioned and who are sometimes also discouraging and unsupportive to student midwives and new registrants. They are the midwives that the students least want as their practice mentors or new registrants don't want as their preceptors as they have little or no interest in teaching them or helping them to gain the experience, they need to develop their midwifery skills and competencies [35]. Reasons for deprofessionalization, may arise from the demands placed on midwives from the emotional and physical aspects of being a midwife. Some midwives can retire in mid to late 50s but as most midwives are women and may have worked part-time; they may have limited pensions so that it is not always possible for midwives to stop working when they would like to or when the job becomes too physically or emotionally demanding. A recent study commissioned by the Royal College of midwives highlighted that many midwives

*felt exhausted by their day-to-day work, emotionally and physically drained, dreaded the thought of another day's work and seriously wondered how much longer they could carry on.* Hunter (2018) (p. 15) [63]

In addition, as mentioned previously, midwives practice within an increasing litigious environment and are fearful of making a mistake or missing something that may cause harm to a mother or baby [16,17,64]. Examples of externally driven deprofessionalization include overseas midwives who on travelling to UK are not assessed as competent by NMC Competence Centers or are assessed as not reaching the required competency standard in the English language. They may feel deprofessionalized and may actually be unable to join the profession in their new country of residence, at least temporarily until or if they meet the standards. However, given the shortages of midwives globally and the drive in many countries to recruit midwives from other countries, maternity care providers often offer additional support to these potential new registrants in order to assist with their transition. From the perspective of the healthcare provider, this may mean that overseas midwives are more closely supported during their initial months of experience, until they have proved themselves as safe practitioners. Despite the importance of and the increasing number of overseas midwives being employed across the world, Ohr et al. [65] are one of a few papers who report on the learning from the development and operationalization of a program to enhance the transition of overseas qualified nurses and midwives (OQNMs) to Australia. The program included cultural acclimatization and tailored support from leaders across the organization.

Crucially, some midwives within the deprofessionalized quadrant present a risk to the profession, organization and more importantly to the women and babies in their care. It is therefore vital that midwives that are identified as deprofessionalized, perhaps through their employers' appraisals system, are supported to identify how this can be addressed, most often through individualized continuous professional development which can be tailored to meet their needs or being supported to upskill in a particular aspect of midwifery care.

## *4.5. The Professionals*

The final quadrant examines the high status, highly professional midwife in the light of regulation, guidance and professional expectations for continuous professional development, including research-based practice and critical reflection on practice. The professional midwives continue to grow, enjoy the pursuit of learning, retaining and learning new skills and knowledge in order to meet the needs of the women and families they care for.

The day-to-day role model portrayed by the most professional midwives (Clarke's most *trustworthy experts*) is, perhaps, both unrecognized and poorly rewarded. It is useful however, for student midwives to consider who their midwife role models are and to plan their own learning trajectories towards careers which are built on the trustworthy expertise, which is needed in the profession, even whilst avoiding the more dystopian corners of the Place Model.

The grea<sup>t</sup> majority of women who access maternity services are satisfied with their care and outcomes. Renfrew et al.'s [4] evidence informed framework for maternal and newborn care has identified, as many as 56 outcomes for mothers and babies that could be improved by care that is within the scope of a midwives practice. It is clear therefore that where the professional midwife or 'skilled health personnel' provides care for women and their families that they have improved outcomes. Conversely, poor care may lead not only to death but also to morbidity that has long lasting negative impacts on the physical and psychosocial health and well-being of the woman and her family [66] leading to potential intergenerational health inequalities. Professional midwives don't only need to meet the core competencies [25] identified by ICM but also to have the ability to be continually adapt to the ever changing landscape of midwifery care; discerning about the evidence base and increasingly adept at the appropriate use of technology to support their practice [67,68].

In many countries, professional midwives are graduates, with increasing numbers of midwives achieving master's degree level education and being awarded a PhD or Professional Doctorate. However, having achieved these academic qualifications, there is limited structures to support them to continue in clinical practice while fully utilizing these higher-level skills for the good of their profession, women and their families. Often, the PhD midwives return to a similar role to the one they left in practice or move to a university setting, becoming subsumed into an academic life that is focused on research outcomes such as securing funding and peer reviewed publications. However, there are examples of structures that have been put in place to support clinical academic researchers to flourish in the recognition that '*A rich and diverse health research environment helps patients and invigorates the workplace'* [69] (p. 4). No one approach or model fits all and it is incumbent on the midwifery profession to find ways in which to provide the necessary infrastructure and support to help midwives within all types of roles and levels of expertise to thrive in order that women and their families can in turn be provided with optimum care.
