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An evaluation of the professional status of Italian midwives

22 August, 2013

An evaluation of the professional status of Italian midwives

A critical evaluation of the professional status of Italian midwifery. Evidence Based Midwifery: September 2013


Elena Spina PhD.
 
Assistant professor in economic sociology, Department of Economics and Social Sciences, Polytechnic University of Marche Piazza Roma, 22 60121 Ancona Italy.
Email: e.spina@univpm.it


The author would like to thanks Giovanna Vicarelli, professor of economic sociology at the Polytechnic University of Marche Region, for her support and advice, and the Italian and UK midwives and medical staff interviewed for this research.

Abstract
Aim. To critically evaluate the professional status of Italian midwifery and to gain a deeper understanding of midwives’ professional autonomy.
Methods. Data were collected using a mixed method approach including participant observation, ethnographic interviews and in-depth interviews. The sample was a medium-sized maternity unit in which the practice of eight midwives was observed, followed by six in-depth interviews with obstetricians. A further eight in-depth interviews with midwives practising in hospital, community, birth centre, education and independently were also undertaken. Ethical approval and access to participants was granted from the hospital where the study was conducted.
Findings. Italian midwives appear to be working in a medically dominated system. Differences in autonomy between community and independent midwives were observed. However, the former seem to be subjected to hierarchical and functional medical dominance, while the latter appear to face a dominance that is cultural. Midwives in both settings suffer frustration and disaffection. Italian midwifery is currently a semi-profession.
Conclusion. The lack of professional autonomy, the absence of a professional identity, as well as the level of fragmentation within the professional category, seem to limit the possibility of Italian midwifery becoming an independent profession. There are many differences between the role of the midwife in Italy compared to England.


Key words: Italian midwifery, professional autonomy, medical dominance, qualitative analysis, evidence-based midwifery

Introduction
Outside the sociological field, the term ‘occupation’ is usually used as a synonymous term for ‘profession. From a sociological point of view, the two terms are distinct and usage is different. In particular, an occupation must meet certain standards and conditions in order to obtain a professional status. Even if there is not a universally accepted definition, a profession is a ‘high-status, knowledge-based occupation characterised by abstract, specialised knowledge, autonomy, authority over clients and subordinate occupational groups and a certain degree of altruism’ (Hodson and Sullivan, 2008: 258). A professional is a person who is qualified and legally entitled to pursue a profession (Hughes, 1965). While some of them are well-established professions, like medicine and law, others are regarded as semi-professions (Etzioni, 1970) due to the lack of power and autonomy and responsibility for their decision-making, as well as a lack of prestige (McBride and Schostak, 1995).

Focusing on the main results of an empirical study, this paper aims to investigate this issue. It is divided into two sections. The first is a theoretical section in which a brief history of Italian midwifery is presented in order to explain the changes in its professional status over time. The midwives’ work settings are also described in this part, as it seems useful to explore the existence of a relationship between workplaces and professional status. After describing the methodological approach used for the study, in the second part of the paper the main results of an empirical research are presented and discussed. The discussion compares the main differences between English and Italian midwives and the paper concludes that Italian midwifery is a semi-profession.

Background
Up to the medicalisation of pregnancy and birth in the 1950s and 1960s, Italian midwives had professional autonomy in their clinical practice. Working in a community setting, namely at patients’ homes, they had respect from the community they served and the population had a high level of confidence in their ability (Lanzardo, 1985). Due to the centralisation of birth into hierarchically organised hospitals, at the turn of the 1950s and 1960s, their autonomy was reduced: they moved into hospital employment where they provided care in wards and departments under medical supervision, experiencing medical dominance (Freidson, 2002a). Due to the dominant hospital setting, the medicalisation of childbirth was stressed and it started to be viewed as a medical issue by Italian women.

Working in hospitals under medical supervision, midwives ‘manifest the classic responses of an oppressed group... internalising the powerful values of medicine’ (Kirkham and Stapleton, 2000: 466). The control exercised over pregnancies and labour by gynaecologists destroyed the individual relationship established over time between women and their midwives (Page, 2003), who never had the opportunity to re-establish this personal relationship. As a result, the midwifery ‘model of care’ has progressively changed into a medical model of care. With the introduction of the Italian NHS (INHS) in 1978, which deeply changed the existing health structure, Italian midwives experienced the reduction of their autonomy and their social function changed. At the point in which over 90% of births took place in hospital, midwives partially lost their social recognition, while the  medical profession furthered its dominant position.

Recent changes
When the process of the managerialisation of the INHS took place in the early 1990s, Italian midwives became involved in a process of professionalisation. Both these processes introduced some relevant changes for midwives, so as to increase their professional skills and knowledge (Spina, 2009), replacing a task-oriented logic with a responsibility-oriented view. In 1994, an academic course of study in midwifery was introduced and midwives’ professional profile was re-defined and regulated by a specific law (Ministerial Decree n. 740/1994). This recognised the role of midwives in providing maternity services, defining their set of competencies and responsibilities.

In 1999, when a new health reform started, midwives, together with other non-medical health occupations, formally lost their ‘auxiliary status’. Recognising and defining them as professions, their job description was  abolished by law (n. 42/1999) and their autonomy and responsibility were increased. One year later, a new law gave them the opportunity to hold managerial roles and, since 2006, they have been able to perform the function of team co-ordinator (l. 43/2006). The same law called for the transformation of their professional association into a royal college. A new education system was also introduced and, currently, there is an academic course of study in midwifery, even though it takes place within medical schools and is run by physicians.

However, few changes have occurred in the workplaces. A new pattern of practice was introduced for hospital midwives who have to perform different tasks, which are less manual and more bureaucratic than in the past, losing some of the traits that have identified their professional profile over centuries. This resulted both in the limitation of midwives’ competencies and in the legitimation of the medicalisation of childbirth.

Workplaces
Italian midwives can be employed in healthcare institutions, mainly within the INHS, or in the private sector as independent practitioners.

Hospital midwives provide care in wards, typically in obstetrical-gynaecological departments, or in public community centres called ‘consultori familiari’ (CF), usually working standard shifts. On one hand, the shift system favours the reconciliation of work and private life (first of all family responsibilities), on the other, it does not allow continuity of care from the beginning of labour to the end of the birth. Some midwives work in obstetrical/gynaecology  wards performing nursing functions, while others provide care during labour and birth. The lack of a job rotation system ensures neither the maintenance of skills for midwives, nor the opportunity to have a completely professional experience. This can cause both the disaffection of midwives and  fragmentation among members of the professional group.

Midwives who work in CF have to promote, protect and maintain health, with respect to the events of the sexual-reproductive sphere related to the life cycle. However, few women turn to CF when they find out they are pregnant in Italy. The majority of them turn to a gynaecologist, usually an independent gynaecologist. Therefore, midwives who work in CF usually provide care for women who do not have sufficient economic means to pay for a private service, as well as for individuals who call for a midwife’s advice and support.

Midwives who work as independent practitioners are approximately 2% of the total in Italy (Raccanelli, 2013) They may work in community settings, typically, at women’s homes, or in birth centres (there are only four in Italy). Working outside the INHS, independent midwives believe that they have to provide continuity of care for women through pregnancy, birth and during first motherhood. A pregnant woman who is supported by an independent midwife is usually actively involved in the decision-making process, therefore, a very close and supportive relationship may develop between the two women.

Method
An empirical study was conducted during the period 2005 to 2008 within a PhD programme in economic sociology. The study was divided into two phases. In the first phase, a participant observation was conducted in order to gain a deep understanding about midwifery. The ethnography was conducted over a four-month period (from July to October 2006) in a specialised maternity unit in a mid-sized city located in the centre of Italy. A team composed of eight midwives was observed.

At the end of the observation period, ethnographic interviews were carried out with midwives in order to complement and expand the project’s data collection via participant observation, with the aim of gaining deeper insights into midwives’ perceptions about their work and profession. Since gynaecologists are always involved in labour (even in case of normal confinement), six in-depth interviews were conducted with them, in order to identify their belief system regarding midwives’ work and profession.

The second phase of the research aimed to explore the point of view of those midwives who practise elsewhere, in order to grasp a different perspective. Therefore, eight in-depth interviews were carried out with privileged witnesses who have different roles within the profession (including independent midwives, midwives who play a formal role in their professional associations and midwives who teach at university). In order to evaluate how different places of birth can affect the midwives’ way of working, a birth centre run by independent midwives was also visited.

Discussion of findings
Observation of midwifery practice in the hospital setting
The ward was composed of 13 rooms (29 beds) where women with different physical and emotional conditions were hospitalised:
• Women with diseases of the reproductive system who had undergone (or were due to undergo) surgery
• Women experiencing a high-risk pregnancy
• Women who have given birth waiting to be discharged.
This leads to a paradox that is based on two arguments. The first refers to the incongruity between the high level of specialisation of the hospital and its inadequate spaces. This suggests that pregnant women are regarded as patients, their status is medicalised and the social dimension of childbirth is neglected.

The second issue is based on the idea that the needs of the organisation and those of professionals significantly outweigh the individual interests of users.

The absence of places reserved for normal labour and birth emerges from the observation: there were no areas which were specifically devoted to low-risk pregnancies, where both labour and birth could be experienced as quite natural.

The role of the hospital midwife
Midwives who provide care in the delivery area perform a wide set of functions, including bureaucratic work. The provision of these tasks can be seen as a necessary step towards the process of professionalisation, because it implies the assumption of new responsibilities. However, it has created considerable discontent and frustration among midwives, since their attention is distracted from supportive activities towards bureaucratic work.

Hospital midwives support ‘unknown’ women during labour and birth, seeking medical advice before each takes place (even in case of natural confinement). Obstetrical and gynaecological staff are usually present during delivery, handling the situation, therefore reducing the midwives’ control over the process.

Midwives report the difficulty of creating close and supportive relationships with pregnant women, based on trust and respect. They complained that the women they meet are in the final stage of their pregnancy, thus limiting the possibility to develop a relationship of trust over time. This results in an increase of disaffection and frustration for midwives, decreasing their social visibility. Childbearing women often arrive in hospital unaware that a midwife will attend their birth, therefore, the midwife must be able to break down the women’s resistance and mistrust. This capability is not always understood and valued by physicians, or by patients who sometimes call for medical advice. Therefore, in many cases, women regard them as professionals who do not possess the necessary skills to attend the birth.

In conclusion, hospital midwives seem to have become accustomed to this way of thinking, understanding that a well-established culture cannot be uprooted by laws. Therefore, it will be necessary to wait for a generational change in medicine as well as in midwifery so that a new culture can emerge.

Three ideal types of midwives and interpersonal relationships
Even if they form a cohesive group, hospital midwives seem to have different points of view about their role, adopting a different way of working and different job behaviours. Each midwife can adopt a different professional approach, categorised into three broad types:
• Naturalistic midwives: those in this category believe in physiology, regarding childbirth as a natural process. They respect the physiology of normal birth and try to create a supportive relationship with women (Odent, 1989). They challenge the prevailing medical and medicalised views and resist any unnecessary operative interventions
• Moderately interventionist midwives: recognise that childbirth is a natural process and have a cautious perspective. Their desire to reduce women’s physical pain prevails over their need to give them emotional support
• Medicalised midwives: they play an important role in sustaining the medicalisation of labour and birth, even if they are a minority. They adopt a medical view and speed up the birthing process.

Due to their approach, medicalised midwives face fewer problems in their relationships with physicians than their colleagues, enjoying both a highly-respected position and informal protection within the hospital.

On the other hand, ‘naturalistic’ and sometimes ‘moderately interventionist’ midwives are medically dominated: they feel frustrated and disaffected with their work, because they feel subservient to medical staff. Believing in their autonomous role, they would like to handle normal confinement, therefore, the relationship with gynaecologists is usually complicated and conflict can occur at any time, even in the delivery room.

Some midwives accept and legitimate the medical point of view: they recognise that an autonomous role cannot be played within hospitals, which are seen as places for ‘cure’ and not for care. Other midwives refuse this approach, arguing that, since the majority of births take place in hospitals, they should have the chance to play an autonomous role, even within health structures.

These differences between midwives’ points of view suggest that the occupational group is internally divided and characterised by weak cohesion among members. Therefore, this can limit the possibility of achieving a process of professional mobility for midwives.

The relationships among midwives
Working relationships among midwives themselves are based on esteem and mutual respect. Differing personal opinions do not limit the development of collaborative relationships. The quality of their relationship is also due to the fact that they do not work in teams, but usually as individuals.

Conflict between colleagues does not emerge during participant observation. The interview data demonstrated  that none of the midwives feel part of a professional community; they do not have a collective identity; they seem devoid of any sense of belonging to a group. The small size of a professional group can limit its strength, however, this explanation is not sufficiently relevant to explain why individual pride does not became a collective and systemic pride. They do not believe in the possibility of a structural change, as that is not deemed achievable because of the  lobbyist power of other health professions and, in particular, the physicians. Secondly, they do not have confidence in the organisations appointed to protect their interests.

Inter-professional relationships

Formal interaction only takes place between midwives and obstetricians. Therefore, their relationships are limited to brief interactions. The fragmentation between the professions is evident when observing the different groupings during tea breaks at the canteen, situation midwives are on one side of the room, and obstetricians on the other.
The only occasions in which they come into contact are during birth, in the delivery room, and during morning rounds. In the labour room their interaction appears to be negligible, as the midwife can usually work autonomously. The possibility of meeting in the midwives’ office is also limited because obstetricians only go there because of the physical proximity to the delivery room.

Medical staff interviews
Feeling sure that hospital midwives already play an autonomous role, all the gynaecologists interviewed claimed to be in favour of major autonomy for midwives, provided they assume all clinical responsibilities. Responsibility is the crux of the problem. Faced with increasing medical malpractice complaints and litigations, physicians tend to adopt a defensive approach, both centralising the work process and supervising the workforce. Even if some gynaecologists say that the childbearing process is a natural issue, they tend to have a very different point of view from those of the midwives, which are sometimes considered quite dangerous:
“Some midwives are obsessively devoted to natural birth and sometimes they tend to dangerously deny the problem, to minimise it. This is a dangerous perspective; it means not recognising that something can rapidly change. Some midwives are convinced that nature will take its course. Yes, of course. But nature is also bad” (Obst/Fem/Hosp/01).

Five out of six respondents said these different approaches can lead to tensions between the gynaecologist and the midwife and one stated that no discussion should take place:
“The midwife has to shut up if the gynaecologist is in the delivery room during birth… She has to do what I say considering that the responsibility is mine. If I’m not there, she can do what she wants” (Obst/Fem/Hosp/02).

Three of the six interviewees thought the gynaecologist and the midwife should solve problems by using conflict resolution, such as talking together rather than ‘declaring war’. However, three thought the final decision has to be taken by the gynaecologist. Only one interviewee felt that the presence of the gynaecologist was necessary in the delivery room. Four other doctors thought that the midwife is able to attend a physiological birth by herself. One female gynaecologist said that the presence of the doctor is unnecessary during birth, in general, but is required in a hospital:
“A pregnant woman who chooses to give birth in a hospital wants medical advice, otherwise she would give birth at home. It’s a matter of expectations” (Obst/Fem/Hosp/01).

Reflecting on medical dominance, two respondents agree that it is exerted within the hospital. One said:
“Medical dominance is exerted by physicians. This is because we deal with physiology and pathology at the same time without any distinction between them. We call it defensive medicine... this is not correct, but it has become the key word nowadays. But it’s logical. Dominance exists here because the gynaecologist takes responsibility for mistakes. Therefore, medical dominance arises from this fact. It does not come from the fact that physicians want to have the last word. They must have the last word; they go on trial otherwise. It’s a matter of wrongly shared responsibility” (Obst/Fem/Hosp/03).

Three respondents said no dominance exists. One was unaware of the literature about medical dominance, but said:
“I do not think it is present here. I think that midwives can do whatever they want until they call me for advice. When they call me, they have to do what I say. However, independently from their responsibilities, the gynaecologist is not on an equal footing with the midwife. Each profession has its own role to play. It is like in the army. The captain is above the soldiers and the general is above the captain. There is a hierarchy. There must be a hierarchy. If I have a problem here that I can’t solve, I have to call the health director. Even he may not be able to solve it, but I can’t avoid calling him because he is responsible for the organisation” (Obst/Mal/Hosp/02).

Interviews demonstrated that both the medical approach and medical behaviour can limit the acquisition of professional autonomy for midwives, reducing their possibility to perform their functions and ultimately impacting on professionalisation.

The independent midwives’ perspective
The independent midwives interviewed have chosen to practise in the private sector, in order to avoid both the limitations and the excess of bureaucracy that characterise the public sector, mainly hospitals, where some of them have worked in the past. Practising in their own offices or at patients’ homes, they seem to prefer the instability and the insecurity of the private labour market to the stability granted by the public sector.

The choice to work in the private sector usually stems from the wish to perform an activity that is seen as ‘different’, giving them the opportunity to develop a complete set of skills, which are required to handle different situations as well as criticism. Their move to the private sector is not justified by economic reasons, nor by a lack of confidence in the INHS. Many of them, in fact, express deep regret at the lack of public services offering pregnant women an alternative to hospital and not giving professionals the opportunity to work according to the epistemological principles of their own disciplines.

Independent midwives strongly believe in women’s power and have a natural and physiological perspective towards pregnancy and childbirth; they feel sure that, in low-risk pregnancies, women are competent to have a safe birth. They refuse any unnecessary operative interventions, believing that natural confinement is essential for the creation of a good mother-child relationship.

Therefore, their work is based on the respect of women’s needs, wishes and expectations. They consider the childbearing process as one of the most special experiences in a woman’s life; therefore, they let “the woman’s body speak”, as an interviewee says, giving them both physical and emotional support. If any problem occurs, they promptly ask for medical advice. Women who decide to be attended by independent midwives usually have a similar point of view regarding pregnancy and childbirth, so they are ready to take the risk. Independent midwives are usually less worried than their hospital colleagues about complaints or legal actions taken by patients.

The main difference that emerges between independent and INHS midwives is related to cultural approach.
“We see birth as a social event [...] because a learning process during birth can take place as well as a change in the primary relationship (between the mother and her baby) which is reflected outwardly in terms of trust in the world” (Ind/Mid/Fem/01).

“Birth should be seen as the cornerstone of a society, as the beginning of life, the imprinting for future social, family and emotional relationships” (Ind/Mid/Fem/02).

“There’s a lack of respect for birth, for women, for children and for people. It is an issue that goes beyond the professional behaviour. This is the cultural meaning usually attributed to giving birth to a child: quickly, healthily, no matter how the child comes out and then back home” (Ind/Mid/Fem/03).

As the interviews show, independent midwives do not follow established routines; some procedures do exist, but they are loosely organised, not universally applied by midwives because they are the results of an empirical process.

A very different way of thinking about their profession exists between independent midwives and those who work in hospitals. As Kirkham and Stapleton (2000: 469) observe: ‘The difference in trust and in sources of support may be because these midwives have opted out of the NHS and its culture of midwifery, or it may be that their very different models of midwifery practice increased both the need and the opportunity to develop appropriate support networks.’

The difference is so great that two professional profiles can be imagined. An interviewee said of hospital colleagues:
“I see them as another profession. We have two very different points of view... They see us as crazy people; they think we take on too much responsibility”
(Ind/Mid/Fem/02).

The gap between them is evident both on the theoretical and the practical level:
“Only if a midwife does what the doctors want, is she recognised as a good midwife. Therefore, also those who do not agree with the medical opinion, usually have to adapt to it in order to obtain recognition and consideration” (Ind/Mid/Fem/04).

This reveals the cultural subordination that midwifery as a group are experiencing.

The possibility that independent midwives have to practise outside the INHS gives them more discretion, but does not grant complete autonomy. This is culturally threatened by the inability to challenge the dominant medical models. The process of obtaining content by physicians is not attributable solely to the medical profession. If, on one side, it has usurped maternity care from the jurisdiction of midwifery, on the other, midwives have not been able to challenge this process for several reasons. Midwifery is dominated by females and many would say that this determines the profession’s status as semi-profession (Witz, 1992). Gender can limit female perspectives of development, especially if one takes into account the male connotation of the medical profession, which continues to hold a strong power.

Another issue, linked to the midwifery profession’s gender composition, concerns the patriarchal culture of Italy. This culture could have influenced the structuring of social and professional roles. In particular, it is said that this culture has strongly affected the development of social institutions, reproducing logics and work patterns devised for men only, even within increasingly ‘feminised’ places, such as hospitals.

Midwives found it difficult to capture the true essence of social change. In order to professionalise themselves, for example, they have always tried to conform to other professions (mainly physicians), instead of focusing on their own peculiarities. Seeking emancipation through a process of imitation, rather than through the strengthening of their capabilities, means that midwifery values could be rejected and work contents modified.

Looking at the question of professional representation, a stronger sense of belonging can be seen among independent midwives; a strong desire to identify with shared values. The interviewees complained not only about the lack of dissemination of certain principles and values (those of midwifery), and the subsequent failure of the sedimentation of a culture, but also about the fact that there is no agreement regarding the recognition and the validity of these values, even among members of the same professional category.

The interviews allow the observation of strong intra-professional fragmentation, bringing to light a completely different way of interpreting the profession between hospital midwives and independent practitioners.

Professionalisation
Both in Italy and England, midwives have to be registered with the professional body in order to practise. Italian midwives have to be registered with the Provincial College of Midwives,  which is a professional organisation representing the professional group and keeping the professional register. English midwives have to be registered with the NMC, whereas the RCM is both the trade union and the professional organisation run by midwives for midwives that aims to promote and advance the profession. Even if registration with the latter organisation is not compulsory, the RCM represents the majority of practising midwives. Beyond organisational differences, it is important to point out the different model of professionalism prevailing.

In the Italian model, the State limits self-regulation of professions and the structural weakness of professional associations tends to consolidate over time. This weakness appears to be due to the prevailing market and economic logic, as well as the effect of bureaucratic ‘dirigisme’ (Giannini, 2003). This leads to questions about the usefulness of professional associations, which can be seen as corporative bodies unable to limit political action and market pressures. These forces, by contrast, tend to alter the values and ideals of service to the community that professions serve, which attempt to comply with the logic of ‘dirigisme’ and mass consumption, without being able to restore the prior dynamics and structure, as Freidson suggests (2002a; 2002b).

The Italian model appears to be characterised by professional associations, which acquire the configuration of ‘clans’: groups that use a model of governance, based on a blend of familistic logic and well-established lobbies (Vicarelli, 2005). Looking at the midwifery profession, it can be observed that there is low participation in the activities of the association in Italy: midwives seem to distrust their professional organisation, which is considered as a self-referring subject, unable to lobby on its own.

By contrast, the Anglo-Saxon model of professionalism is based on the power of the professional associations that are able to regulate and control the market. The robustness of this model of professionalism, that considers professional associations as a heritage to be protected, is to be found in the secular roots of royal institutes in the social context. These organisations guarantee the competencies of their members by requiring some obligations of them.

Professional groups operate with relative freedom on the market and are able to obtain monopoly on their activities, thanks to the legitimation of the State. This allows them to maintain a high degree of professional autonomy as well as to exercise forms of control on working conditions (Vicarelli, 2005). This is proven by the strong adherence to representative bodies, mainly due to their ability to provide services and benefits in order to protect and enhance the profession. The RCM enjoys the consensus of its members, keeping control over maternity policies. According to this view, UK midwifery can be considered a powerful subject, that is able to influence health governance and the maternity services, when compared to Italian midwifery. The consolidation of these different models of professionalism over time has not only affected the dynamics of intra- and inter-professional interaction, but also the organisational structure and supply system of maternity services.

Conclusion
Should Italian midwifery be considered a profession? It is difficult to answer this question. National history, as well as social, cultural and institutional dynamics, seem to suggest a negative answer. The lack of professional autonomy, the absence of a professional identity, as well as the level of fragmentation within the professional category, seem to limit the possibility of becoming a profession in the true meaning of the word (Carr-Saunders and Wilson, 1933). The process of midwives’ social mobility (Sarfatti Larson, 1977) is limited by the fact that they are still too divided in their perceptions of professional and organisational identity; they do not have a professional perspective nor a strategic view. Furthermore, the spread of a medicalised mindset among users, as well as increasing medical dominance, can affect their chance to play an autonomous role. They are not yet able to challenge medical power-holders.

What should Italian midwives do to increase their status?
Italian midwives should find, within their own professional consciousness, the motivations to counteract. They should put their professional project into practice in order to mark their boundaries, excluding physicians from their occupational field (Odent, 2008). They should then socialise their model of care as the correct alternative to the medicalised one, strengthening their characteristics, rather than trying to resemble physicians. Until then, they are probably destined to remain a semi-profession (Etzioni, 1970).


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