**2. Background**

Documentary evidence of the role of Midwives can be found in early history and in a number of places in the bible with textbooks and training for midwifery being traced back to 17th century. Donnison [11] and Borsay and Hunter [12] provide useful accounts of the checkered history of the professionalization of midwifery, not least its' evolution from a 'female mystery' and wisdom [11] (p. 11) to one which has often become dominated by a male view of the world and the perceived need to control childbirth. The International Confederation of Midwives set global standards for midwifery practice, education and regulation [12–14]. These standards are reflected in midwifery education, practice and regulatory frameworks that are found in many countries. However, to enable global autonomous midwifery practice, it is expected that these standards provide not only a basis for the review of existing regulatory frameworks but also the impetus, guidance and direction to countries where regulatory frameworks for midwifery are limited or absent.

The International Confederation of Midwives (ICM) define a midwife as:

*'a person who has successfully completed a midwifery education programme that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and*/*or legally licensed to practice midwifery and use the title 'midwife'; and who demonstrates competency in the practice of midwifery.* [1]

Across the world, country specific legal and professional structures are in place. While legislation is largely viewed as supportive of the profession, fear of litigation has been shown to have a negative impact on how midwives practice [15,16] with regulation and a blame culture and 'the fear factor of risk' [17] and litigation [18,19] inserting a very real fear factor within the realm of professional autonomy and judgement.In the United Kingdom (UK), for example, Midwifery is a protected legal function making it a criminal o ffence for anyone other than a registered midwife or medical practitioner, (except while in training or in an emergency) to attend a woman in childbirth [20]. All women have the right to access the care of a midwife free at the point of delivery and theoretically, taking account of their medical, childbirth histories and preferences can choose to deliver at home, in a birth center (Midwifery Unit) or in an Obstetric Hospital. There are also a number of independent midwifery care providers; some requiring payment, and some not as they are part of commissioned maternity care provision. However, there is evidence that some midwives, particularly those caring for and supporting women making unconventional birth choices are practicing in fear of litigation [21].

Midwives in the UK, as in many other countries, are a graduate profession and as such are regulated by the Nursing and Midwifery Council (NMC) which is turn is overseen by the Professional Standards Authority for Health and Social Care. At the point of registration, midwives are expected to have the necessary '*behaviors, knowledge and skills required to provide safe, e*ff*ective, person-centered care and services'* [22] (p. 7). Underpinning these behaviors, knowledge and skills is professionalism, defined by the NMC as being

*'* ... *characterized by the autonomous evidence-based decision making by members of an occupation who share the same values and education* ... *'* [22] (p. 6)

A midwife's professionalism is demonstrated through being accountable, a leader, an advocate and being competent [23]. While it is postulated that Midwives are autonomous practitioners, it is clear that they work within a strict country specific legal, regulatory, professional and moral code of practice [24], are expected to follow best practice evidence based guidelines such as those of the National Institute for Health and Care Excellence (NICE) and work within their employer guidelines and policies. While most often the lead professional for women with a straightforward pregnancy, when necessary, close collaboration with obstetric colleagues in particular and other multidisciplinary colleagues, in partnership with women and their families is required to achieve optimal outcomes. Continuing professional development is not only an aspiration for midwives but in many countries a regulatory requirement in order to remain as a registered midwife and to continue to practice [24,25].

Midwives might also be seen to have a relatively strong global identity which is in part due to a network of midwifery associations across the world providing a sense of unity and support among midwives but also fostering strong relationships with policy makers and other health care professionals [25], potentially influencing health care policy and resource allocation. However, Castro Lopes et al. [26] highlight that being a predominantly female profession, gender issues and public opinion in some countries may negatively impact on midwives associations' relationships with those in authority and leadership, restricting their inclusion in key negotiations and discussions. Midwives have a long history of challenging on gender issues, not least in professional discussions where medicalized terminology such as diagnosis of pregnancy, symptoms of pregnancy and the notion of a pregnan<sup>t</sup> woman's return to the normal state after birth [27], were often used by a predominantly male medical profession, until relatively recent times.

So, how can this Place model be applied within the context of midwifery to examine the status and professional learning of midwives?

## **3. Origins and Components of the Place Model**

The origins of the model and how it evolved are explained in depth in Clarke [2], but in essence, in its original version, the model uses two perceptions of 'place' as the lens through which to examine the place of a teacher; (1) '*the humanistic geography tradition as a process-the career long professional learning journey*' and (2) '*place, in the sociological sense of teacher status'* [2] (p. 69). The combination of status and professional learning were recognized as key strengths of teacher education, and it was considered that this would be a useful lens through which to view midwives and explore their status and professional learning.

The subheading of the model is an important starting point for understanding the structure and application of the model within the context of midwifery. Replacing the original 'Who is teaching me today?' with' who is my midwife today? immediately puts the woman at front and center and places the midwife 'with woman'; the literal meaning of midwife.

The Place © model itself resembles a graph. The horizontal axis is a continuum: a cumulative, career-long, professional learning journey for the midwife (not a time-scale). It draws on Hoyle's [28] appraisal of professionality- where 'restricted' focuses on the individual's practice and autonomy and the 'extended' on wider society, multidisciplinary collegiality and career long learning and development towards being and becoming Clarke's (2019) [29] trustworthy experts. The vertical axis focuses on the status of the midwife, based on public perceptions of the esteem in which midwives are held, ranging from low to high. Clearly, midwives have less agency in relation to this but by seeking to control their learning trajectories they may seek to influence this key dimension of professionalism. As Figure 1 illustrates, the intersection of these axes a ffords the creation of four quadrants: proto-professionals, precarious professionals, professionalized and professional. A fifth element of the model sits outside the axes, where the answer to the question 'Who is my midwife today?' is 'no-one'; the reality for some women globally, particularly in low and middle income countries.

**Figure 1.** The Place Model.

## **4. The Place Model within the Context of Midwifery**

Examples from midwifery will now be used to convert the Model to a 'living graph' (Leat, 1998) [30] in which we might consider how the Place Model can be used to '*map both career-long professional learning trajectories and to inform comparisons at individual and systemic levels'* [2] (p. 73) in a similar way to how it was used to explore teacher professionalism and status [2]. The starting point is the axis of the model, starting with the top left corner, the 'proto-professionals' before going o ff-axis to the 'no midwife' component and then moving anticlockwise around the three remaining in-axis quadrants of the model, ending at the 'professionals' quadrant.

It is possible to 'populate' each of the five sections of the model's metaphorical landscape as a Living Graph (Leat, 1998) [30] using illustrative examples drawn from the profession of midwifery to bring the model to life and raise key questions about the profession.
