INTRODUCTION

Over time all occupations strive to become professions as they are associated with high moral status, being respected, have the expertise, and social prestige¹. While traditional professions represent the classical patriarchal values of power and self-sufficiency, ‘new’ professions are based on democratic professionalism², promoting equality and partnership in the expert–patient relationship, reflective practice, and inter-professional collaboration. Instead of distance, the ‘new’ professionalism values cooperation where control is exchanged for support; knowledge is part of the therapeutic partnership³. The profession strives for cooperation with other independent professional groups, respecting each other, to achieve the best possible outcomes for patients⁴. In addition, the profession works in partnership with patients to ensure that care is appropriate and patient-centered.

The professionalization of an occupational group needs continuous political engagement⁵. No profession operates in isolation but instead is connected with others in the system of occupations. Relationships with similar professions play an important role in the professionalization of an occupational group⁶. Nursing and midwifery have achieved certain characteristics of a profession⁷. Pahor³ claims that the subordination of nursing and midwifery by medicine reflects the patriarchal subordination of women. At the same time, Witz⁸ suggests that it is the nature of the work (caring vs curing) that perpetuates this. Some claim that midwives will never achieve the professional status of medicine because they are within the same occupational hierarchy as medicine. It would require medicine to lose its status for midwifery (and other health occupations) to gain a more powerful position. Until then, midwifery is argued to be a para- or semi-profession^9,10. In developing as a profession, medicine also defined the professional activity of midwives (defining normal and pathological) and taking over control of birth¹¹. The final winning strategy was to shift the place of birth from home to the hospital¹², resulting in most midwives working in an environment of medical dominance. Childbirth became medicalised¹³, as obstetricians claimed that pregnancy and birth could only be defined as uncomplicated only in retrospect¹⁴. The medical model treats birth as a potentially pathological process^15,16.

In Slovenia, nurses have achieved certain elements of professionalization (self-regulation, autonomous education within universities and independent associations)¹⁷. Nursing started to develop a unique body of knowledge and its theories during the 1950s¹⁸, however, in some parts of Europe, including Slovenia, nurses remained under the supervision of medicine. The public often perceives them as doctors’ assistants, and their knowledge is regarded as simplified medical knowledge³. There are also tensions within the professional group; not all members want nursing to professionalize. Since they are not unified as a group, it is easier for medicine to subordinate them¹⁹. Our study focused on the opinion of nurses regarding the professionalism of midwives since, in Slovenia, their fields of work are not clearly defined. Historically^1,20, nurses and obstetricians are competitors with midwives in pre-and post-natal care.

Today Slovenian midwives hold a similar position in the healthcare system to nurses, despite the fact these professions developed differently. Slovenian midwives, as in other parts of Europe, remained relatively autonomous until the 18th century²¹ when the rise of the medical profession began and reproductive health systems were established²². The battle between midwives and obstetricians is not only for control over birth. It is a battle over authoritative knowledge²³, i.e. the authenticity of esoteric knowledge²⁴ regarding pregnancy, birth and postpartum. ‘Ownership’ of childbirth, on the symbolic level, is connected with the jurisdiction and distribution of power²⁵. By defining their scope of practice (pathology), obstetricians also demarcated that of midwifery (physiology)²⁶. Although many women now give birth with a midwife in many countries, it is obstetricians that lead on guidelines and practices in hospitals²⁷. As a result, women have also seen midwives as subordinate to obstetricians¹⁵. Since the maternity hospital is the territory of medicine, midwives became obstetric nurses - they adapted their titles, uniforms, role and even behaviour²⁸. Nurses/midwives are authorized to do certain tasks due to the excessive workload of obstetricians, while obstetricians kept the cognitive jurisdiction (intellectual subordination)⁶. Midwives’ subordination is not only evident in their relationship with medicine but also nursing. In the new millennium, the academic cadre of midwifery teachers has grown stronger (achieving academic titles and taking over core midwifery subjects in the curriculum); however, these developments have not been long enough to establish midwifery’s research and theoretical basis. Few studies on the professionalization of midwifery have been conducted in Eastern Europe^29,30, where midwifery developed differently from other high-income countries with more autonomous midwifery practice²⁷.

Mivšek et al.¹ had previously analyzed how midwives see their professional status, which is closely connected with the perception and recognition of related professional groups. We compared midwives’ views of Slovenian midwifery professionalization with clinical colleagues (nurses and obstetricians) who work with them. The research question was: ‘How do nurses and obstetricians perceive Slovenian midwives, particularly regarding midwives’ professional status?’.

METHODS

RESULTS

Altogether 152 midwives (50.7%) responded. Nurses returned 335 questionnaires (48.8% response rate) and 29.1% of obstetricians responded (n=121). After excluding probationers and retirees and considering nurses and midwives professional self-identification, the final analysis contained 127 midwives, 350 nurses and 101 obstetricians (Table 1).

Within the group of nurses and midwives, females prevailed (98%), obstetricians were more gender equal (57.4% females); obstetricians were older, reflecting their length of employment. All obstetricians had completed postgraduate education (compared to only 1.6% of midwives and 2.1% of nurses) while almost half of midwives and nurses had finished only secondary school. In Slovenia, midwifery education was on a secondary school level till 1982; in 1996 a BSc midwifery program within the University of Ljubljana started; in between there was no midwifery education.

With regard to management, 18% of nurses and 15% of midwives held managerial posts (leading a team/department), compared to 51% of obstetricians. Approximately half of the hospital midwives worked in delivery rooms; most nurses in maternity hospitals worked on the postpartum wards, while obstetricians worked in several locations. In the community centers, nurses collaborated with midwives within community healthcare and obstetricians within gynaecological dispensaries.

DISCUSSION

The overall estimation of Slovenian midwifery professionalism by all three groups was quite positive; however, different occupations placed different values on the various elements of professionalization.

Slovenian midwifery is most poorly evaluated in the attribute of professional knowledge. Professional knowledge should be specific, having undergone rationalization and evaluation by the profession to ‘master the way of knowing’ and support the qualities, skills and behaviors needed for practice. However, in the case of Slovenian midwives, midwifery knowledge is not considered the sole property of midwives. This is probably because nurses perform postpartum care, and obstetricians do antenatal examinations. Another important criterion is that the development of professional knowledge requires a certain academic level of education, and this has been a challenge for Slovenian midwives¹. Half of the obstetricians and nurses did not see the need for midwives to have degreelevel education. It is obvious that they still considered midwifery to be more of a vocation since more than 50% of participants thought that practical skills were more important for midwives than theoretical knowledge. The literature indicates that professionalism is marked with highly specialized theoretical knowledge, while skills are connected to craft¹². However, in our study, the midwives were not a homogenous group. They did not share the value of academic knowledge - the difference in participant educational level was obvious; the opinion of graduate midwives differed in comparison to the opinion of midwives with secondary school education¹. The large number of midwives educated at the secondary level could explain the anti-academic stream¹⁹ revealed in our study.

The feeling of belonging to a profession is very important for professionalism. This study identified that Slovenian midwives are not a cohesive group. The majority did not see themselves as a specific professional group, and half of them noted that all midwives should be nurses first. Some midwives even responded to the study as nurses, probably because they did not identify themselves as midwives. After consideration, we included them in the professional group they selected. The presentation of midwives as specialized nurses might arise also from the status that midwifery has in Eastern Europe²⁷. Many midwives in our survey occupied posts of nurses and their status in health institutions was very similar to that of nursing. Professional roles are not clearly defined²⁰; nurses and midwives are often considered the same profession. Even though autonomy reached average 3.0 on the four-point Likert scale, other results reflect a strongly hierarchical structure within the nursingmidwifery-medicine triangle.

The various reasons for weak professional identification include education since the majority of midwives were educated by nurses and obstetricians (there were no midwifery teachers before 2005); the midwifery scope of practice has not been clearly defined and overlaps with nursing. Midwifery positions are not recognized in all institutions and midwives are often employed in nursing positions.

Obstetricians and nurses also did not perceive midwifery practice as unique and even categorized them as obstetric nurses. Midwifery education is now reasonably autonomous²⁷, however, its practical component is still a weakness. This is because students cannot acquire the required knowledge and skills in clinical settings since other professionals perform tasks that are typically undertaken by midwives elsewhere (antenatal examinations are taught by obstetricians, postpartum visits by nurses). Some claim midwifery knowledge is not specific enough to be an entity on its own²⁶ and define it as a less demanding obstetrics approach³⁵. Since very few in our survey would have been trained solely as midwives (after 2008) and not as a subspeciality of nursing, the professional socialization of midwives who perceive themselves as midwives and not obstetric nurses will only have influenced a small number of midwifery graduates.

Slovenian midwives have the right to perform five (out of ten) examinations in healthy pregnant women by law but are rarely employed in antenatal care, even if EU directives clearly state that management of normal pregnancies is midwives’ competency. Since midwifery education in Slovenia was abolished in the 1980s, there was a lack of midwives and consequently, they are poorly represented in pre- and post-partum care¹. Most midwives are employed in maternity hospitals; in some, they can practise relatively independently in physiological births, however, the responsibility for the outcomes of labor still rests with obstetricians. Therefore, all midwifery practice must be in concordance with the medical profession⁶. This might be a reason why obstetricians did not recognize midwives as competent autonomous professionals for normal pregnancy, birth and postpartum³⁶ and they estimated that midwives did not want more professional responsibilities. At the same time, obstetricians often seek their advice and claim to professionally respect midwives. The reason for their underestimation of midwifery competencies could be that they are still formally responsible for the birth outcomes. Nurses estimated that midwives are autonomous to a larger extent than midwives themselves. This might be why they would like to identify with them and thought midwives should be nurses first.

The autonomy of midwifery has a large impact on interprofessional relations. Good cooperation is possible only among independent professional groups that respect each other and are in equal positions⁴. Obstetricians in the study appreciated midwives but did not consider them to be equal. Midwives felt threatened by both related professional groups, which is not good for interprofessional collaboration³⁷. Boundaries of subordinated professions are even more often challenged than those of dominant ones¹⁰.

Midwives in maternity hospitals are often subordinated by medicine³⁸ and/or nursing²⁸. Some midwives therefore assimilated and accept the medicalized practices³⁹. In our study, some did not even feel competent in managing normal pregnancies and deliveries. This indoctrination shows a decline of professional midwifery identity that is crucial for the formation and maintenance of inter-professional boundaries⁴⁰. Also, other studies report autonomy to be the weak characteristic of midwifery professionalism⁴¹. The lack of autonomy perceived by midwives can affect their attitude towards patients, although they are aware of the need to practise women-centered care. Three-quarters of midwives agreed with the statement that their ability to fulfil women’s wishes is curtailed because of the lack of independence. Only empowered professionals can empower patients²⁶.

A professional should collaborate with and be assertive toward other professional groups³⁷. However, midwives in our study feel jeopardized by nursing and medicine. In Slovenian midwives, we can question their ability to be assertive and advocate for women. Three-quarters of midwives claimed that women’s satisfaction is their priority. However, the other occupations, especially obstetricians, agree less with this. They are also the most restrained in the agreement that midwives’ practise informed decision. Some Slovenian midwifery practices in maternity hospitals are still not evidence-based, and informed decisions could sometimes be in contrast with institutional doctrine, which represents an ethical dilemma to midwives.

The relationship between midwifery and obstetrics is controversial⁷; maternity care in complicated cases needs medical intervention; therefore, it depends on obstetrics but midwifery fights domination by obstetrics over its own field of physiological childbirth⁴². The situation does not enable midwifery jurisdiction over its practice⁴³. Gabe et al.⁴⁴ claim that since medicine has the authority to define pathological (and so also the normal), it also sets boundaries for midwifery. Subordinate position of midwives could affect also how women see them. It could be a reason for midwives’ perception of their low value in society. They think the public appreciates more other health professionals. However, their perception is different to the views of the other two professional groups.

Individual members of the profession create the picture of a profession in public, but above all, this image is created by the professional association that advocates for the professional interests in relation to the state¹⁰. The association promotes the profession in public³² and with this raises the reputation of its members in society⁶. It can be, therefore, problematic that the competitive group is representing midwives. Slovenian midwives and nurses have a joint national association, however, with many more nurses, midwives form a small minority, which is reflected when making the political decisions where the conflict of interest exists (postpartum or prenatal care, for example). The consulting body of the Ministry of Health is for nursing only.

It might be the feeling of poor social recognition or ambiguous obstetricians’ attitude regarding the professional abilities of midwives and unsolved agreement regarding the competencies and field of work with nursing, why midwives think their association does not represent them well. In contrast, obstetricians and nurses feel that midwifery professional association links members well.

The association should control the activities of professionals since they are specialized and nonmembers cannot evaluate them⁴⁵. In Slovenia, this seems problematic as midwifery practice is being evaluated by other professional groups, as claimed by almost half of the participants of each of the three groups. Midwives and nurses also largely agreed upon the statement that ‘in case of professional mistakes, midwives are not protected’. Obstetricians see it very differently. Half of them thought that ‘midwives do not take the necessary responsibility in the case of professional mistakes’; as formally responsible for the birth outcomes (also normal ones), they might feel unjustifiably exposed. Autonomy is closely connected with responsibilities²⁸. However, not all Slovenian midwives are willing to accept more of them.

We must not forget the element that was perceived as the strongest of all six characters of professionalism by all three groups of participants - ethics. Also, by other studies, ethics was identified as a strong factor of midwifery professionalism⁴⁶.

CONCLUSIONS

Slovenian midwifery was marginalized with the abolition of midwifery education and the resulting lack of midwives in the past. This could be a reason for the weak traditional characteristics of ‘old’ professionalism. However, elements of ‘new’ professionalism offer new opportunities for midwifery, especially the concept of working in partnership with women. With public trust in midwifery work and with more active engagement of the professional association, the image of midwifery could be promoted in the media, and midwifery could be more visible at the governmental level. As a result, midwives’ professional status among fellow professionals and the wider society would also change. Future studies should evaluate women's views of midwifery in Slovenia.