THEORETICAL STUDIES

doi: 10.1111/j.1471-6712.2011.00886.x

The primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery
Sigridur Halldorsdottir PhD, MSN, BSc, RN (Professor) and Sigfridur Inga Karlsdottir Phd (cand), MSc, BSc,
RM, RN (Assistant Professor)
School of Health Sciences, University of Akureyri, Akureyri, Iceland

Scand J Caring Sci; 2011; 25; 806817 The primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery Theory is the acknowledged foundation to practise methodology, professional identity and growth of formalized knowledge. It has been noted that practice must not only be evidence-based but also theory-based. Hence, midwifery must be theory based because theories serve as a broad framework for practice and may also articulate the goals of a profession and core values. In this paper, an evolving theory on the empowerment of childbearing women is introduced, where the midwifes professionalism is central. The theory is synthesized from nine datasets and scholarly work, and then more than three hundred studies were reviewed for clarication and conrmation. According to the theory, the midwifes professionalism is constructed from ve main aspects: The professional midwife cares for the childbearing woman and her family. This caring within the professional domain is seen as the core of midwifery. The professional midwife is professionally competent. This professional competence must always have primacy for the sake of safety of woman and child. The professional midwife has professional

wisdom and knows how to apply it. Professional wisdom is a new concept used to denote the interplay of knowledge and experience. The professional midwife has interpersonal competence, is capable of empowering communication and positive partnership with the woman and her family. The professional midwife develops herself both personally and professionally, which is the prerequisite for true professionalism. This evolving theory must be regularly reconstructed in the light of current knowledge within midwifery. It is an attempt to identify and articulate the processes and components of the art and science of midwifery practice in an endeavour of continuing the disciplines development by assisting in the understanding and practice of creating further theoretical discourse, processes and products for midwifery practice. The theory has implications for midwifery education and practice. Keywords: Phenomenology, Qualitative Approaches, Survey Designs, Midwifery, Care Givers, Interpersonal Communication, Lived Experience, Professional Development, Quality of Care. Submitted 7 January 2011, Accepted 23 January 2011

Introduction
Midwives are a key profession in the care of women during the childbearing process, and research results indicate that they can have a major effect upon their well-being (1, 2) and their attitude to their newborn child (3). We take it as a given that all midwives want to be good midwives, but the question is, what factors make a midwife a good midwife? We have been researching this subject, together with other researchers, for more than a decade. The aim of this paper is

Correspondence to: Sigridur Halldorsdottir, PhD (Med. Dr.), MSN, BSc, RN, Professor and Chairman of the Faculty of Graduate Studies, School of Health Sciences, University of Akureyri, Solborg v. Nordurslod, PO Box 224, 602 Akureyri, Iceland. E-mail: sigridur@unak.is

to present an evolving theory we have constructed. Our conclusion is that a midwifes professionalism is a key factor in empowering women during the childbearing process. The fundamental aspect of the theory is that professional caring is at the core of midwifery: together with professional competence and wisdom, interpersonal competence and the midwifes personal and professional development. These aspects form a whole which is the fundamental premise of the midwifes professionalism and good midwifery care. Before introducing the method we used to construct the theory, we shall seek to place it in theoretical context, by discussing studies and theories which have previously been presented in this eld.

The midwifes professionalism

The common goal of health care and all health professions is increased health and well-being of its recipients (4).

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The primacy of the good midwife Health professionals training socializes students to behave in a certain way, and this also inuences how they think and feel about what they are doing (5). The hallmark of a profession is its ability to regulate itself. The development of a Code of Ethics is an essential activity of all professions and provides one means for the exercise of professional self-regulation. A Code of Ethics indicates the professions acceptance of the responsibility and trust with which it has been invested by society. We searched for a good denition of a profession in the literature and while there is no universally agreed denition, we have adopted the denition by the Australian Council of Professions (6) because we found that denition clear and concise. The denition is as follows: A disciplined group of individuals who adhere to high ethical standards and uphold themselves to, and are accepted by, the public as possessing special knowledge and skills in a widely recognised, organised body of learning derived from education and training at a high level, and who are prepared to exercise this knowledge and these skills in the interest of others. Inherent in this denition is the concept that the responsibility for the welfare, health and safety of the community shall take precedence over other considerations. One of the characteristics of a profession is autonomy. Through autonomy, a profession is entrusted with safeguarding the public from those who lack, for any reason, the necessary competence to work within the relevant profession. Here professionalism is paramount (7). The International Code of Ethics for Midwives presents an ideology with respect to working with the woman in childbirth. This said, the individual midwives do carry with them their own particular value system and moral standard which may be in conict with the International Code of Ethics for Midwives. Furthermore, in practice, midwives often work with physicians who have a different ideology, and the authority of physicians can make great demands on midwives balancing skills, if they are required to work according to an ideology different from their own profession. It has been claimed by the British midwives Bluff and Holloway (8) that in hospitals, there is a risk that midwives will be in the position of assistants to physicians, and not to the woman in childbirth. Such midwives, they assert, set a poor example to student midwives, because they foster a midwifery culture which is inconsistent with the stated aims of the international midwifery community, and does not meet the needs of women during the childbearing process. Independent midwives, on the contrary, set a good example in this context, they claim. Midwives see birth as a natural event, and seek to meet the needs of women during the childbearing process by helping them to be stronger and enhancing their self-condence and faith in their own abilities, while also protecting them and ensuring their safety during the birth (9).

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What competence is required of a midwife?

The term competence is often used as an umbrella concept covering knowledge, skill, attitudes and the experience required to full a certain role (7). Certain factors are often cited as requirements for a specied eld of work. Midwives associations in various countries, and the International Confederation of Midwives, have formulated professional standards for midwives. Such standards also include shared values on which the members of the profession agree. When professional standards are formulated for a profession, these are often minimum standards. Protocols for maternity care have in recent years become more common, and this is to be welcomed, because such guidelines increase evidence-based practice. The clinical guidelines from the British institution, National Institute for Health and Clinical Excellence (10) are, for example, widely used. Few such protocols, however, include nearly anything other than technical aspects of care, and they do not discuss other important factors in maternity care. This concern has been voiced by Mahran et al. (11) who carried out a survey by questionnaire among 295 midwives and obstetricians asking their views on the value of protocols. The authors conclude that the role of such protocols is to enhance the quality of the service, but they are not detailed enough to cover all aspects of the work and that there is a certain risk that the protocols restrict the freedom of professionals and reduce professional innovation (11). It has also been questioned whether emphasis on protocols entails some risk of midwives moving away from emphasis on communication and certain other factors which are important to women, according to research (12).

What are the most important aspects of midwifery services?

A midwifery service is based on meeting the needs of women during the childbearing process, on research and on critical thinking (9). Butler et al., (7) carried out a qualitative study in which they discussed the most important aspects of midwives professionalism with midwifery students, midwives and teachers of midwifery. Three principal themes emerged: that the midwife should provide safe service and has the right attitude and communication skills. In another qualitative study, by Lundgren and Dahlberg (13), midwives discussed the importance of listening properly to the woman and allowing her the opportunity to participate in decisionmaking. Midwives also mentioned the importance of establishing a relationship of trust, so that the woman can be sure that the midwife will take care of her as a person, and not as just another woman on the production line. The midwives also mentioned the importance of sensitivity to womens nonverbal communication and of being able to see the entire process of birth through with the woman, not having to leave before the birth. In a

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S. Halldorsdottir, S.I. Karlsdottir the woman is more likely to be contented with her experience, and to cope better with the postpartum period and the experiences that follow. We agree with Meleis (20) that theory development is important for all professions and scholarly disciplines. All theories are meant to reveal a certain reality within that particular profession, among other things to increase understanding and draw attention to the aspects which are of importance. We see it as vital to bring our own and others ndings together into a single theory on the empowerment of childbearing women through midwives professionalism. The purpose of our theory construction is therefore to construct a theory on the empowerment of women in the childbearing process with emphasis on the midwifes professionalism to participate in seeking an answer to the ever important question of what makes a midwife a good midwife.

phenomenological study by Byrom and Downe (14), in which they interviewed 10 midwives about the qualities of a good midwife, their conclusions had two aspects: factors relating to knowledge, skill and competence, which the researchers termed skilled competence, and on the other hand, personality factors, which they termed emotional intelligence. Nicolls and Webb (15) conducted a literature review on what makes a good midwife. They analysed 33 studies that were conducted using various methods. Research participants in the studies were about 8000 women, about 100 fathers, more that 2300 midwives and about 400 midwifery students. Eighteen of these studies were from the women as clients point of view, 13 from the midwives and midwifery students perspective and one from the perspective of midwives and other health professionals. They concluded that communication skills are the most important factor. Others factors are found in the affective domain (the midwife should be caring, warm and supportive), in the cognitive domain (the midwife must have the necessary knowledge) and in the psychomotor domain (the midwife must have the necessary skills). They add that a good midwife will take part in teaching future midwives, participate in research, treat women in childbearing as individuals, be caring and will be there for the woman. Page (16) claims that studies that have been presented in recent years and decades underline the importance of the professional midwife including support of the midwife, along with the importance of her instruction, comfort and encouragement, which can be crucial to the womans experience of pregnancy and birth.

Method
In our evaluation of the various methods for theory development, we found theory synthesis as described by Walker and Avant (18), a good method for constructing our theory considering our aim and datasets. They describe three approaches to theory building: analysis, synthesis and derivation and claim that more theory synthesis is needed to advance practice disciplines, and because midwifery is a practice discipline, we found a perfect t. In theory synthesis, the theorists combine isolated pieces of information that may even be theoretically unconnected and it entails constructing a theory from ndings of studies and scholarly writings, which may be numerous. It enables the theorists to organise and integrate a large number of ndings into a single theory. (18). The book by Walker and Avant is in Butchers (21) words pragmatic and procedural and we agree with him when he writes that no text provides a better explication of the processes of concept, statement and theory synthesis, derivation and analysis (p. 174). The present theory is based upon nine of our own datasets and scholarly works. In a published paper, only a small portion of the data of each study is presented. Therefore, in our nine datasets, there is a wealth of information that we decided to harness and create a theory from all these data. Theory construction using theory synthesis comprises three principal stages. Table 1 highlights the three stages and how each stage was carried out. In step one, we used nine of our own datasets from our published works to construct analytic frameworks (gure and tables), and in step two, we compared those frameworks to the literature (about 300 papers) for conrmation and clarication by using the relevant keywords and the constant comparative method for conformation and clarication. Many of the papers reviewed were directly or indirectly connected with The Good Midwifes Professionalism

Theories within midwifery

Theory is the acknowledged foundation to practise methodology, professional identity, and growth of formalized knowledge (17). Walker and Avant (18) have noted that practice must not only be evidence based but also theory based (p. 206). We add in line with their thought that midwifery must be theory based because theories serve as a broad framework for practice and may also articulate the goals of a profession and core values as Walker and Avant (18, pp.45) note. Not many theories have been presented in this eld, but in 1997, Dickson (9) presented a theory on the importance of caring in midwifery service. The principal aspects of the theory are that caring is the best way for women to have a positive birth experience and that communication is a crucial aspect, along with the presence of the midwife, her knowledge and understanding, and her helping the woman to retain a sense of control in the birth. Fahy and Parratt (19) have put forward a theory on birth territory: the main principle of the theory is that if midwives succeed as guardians of the women so that they are secure in their birth territory, the birth is more likely to be normal, and

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Table 1 Summary of principal stages in construction of the theory

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Stage Stage 1

Actions at each stage Key concepts and key statements from nine databases, on which the theory was based, were specied. The theory is based upon nine databases around nine research papers and scholarly works; all reporting the research and theoretical work of the authors and their colleagues (see Table 2). In these papers and theoretical works, various methodologies were used e.g. a descriptive survey (one study), phenomenology (three studies), theory construction (three scholarly works) secondary analysis (two studies). Five of these scholarly works are within the midwifery domain and four within health care, of which midwifery is a part. In the majority of the works, the main emphasis is on the experience of women as clients of midwifery and health care, around 200 women. In this rst step of the theory development, we used the above-mentioned databases to construct analytic frameworks as the basis for the theory on The Good Midwifes Professionalism The literature was reviewed to identify factors related to the key concepts or key statements and the relationship between these. At this stage, we reviewed more than 300 papers to compare the analytic framework from step one to the literature, using the constant comparative method for conrmation and clarication. A list of those papers can be obtained from the rst author. Many of the papers reviewed were directly or indirectly connected with The Good Midwifes Professionalism in regard to the woman in the childbearing process, both from women as clients point of view and the midwives/midwifery students perspective Concepts and statements about The Good Midwifes Professionalism were organized into an integrated representation of it. Having collected a fairly representative listing of relational statements pertinent to one or more key concepts, these were organized in terms of the overall pattern of relationships among variables (see Fig. 1 and Tables 37). In Fig. 1, there is an overview of the different aspects of The Good Midwifes Professionalism as it was constructed from the papers and scholarly works used as the basis for the theory development. In Tables 37, there is a further analysis of the different aspects presented in gure one. These tables are the results of theorizing in stages one and two with more than 300 papers and scholarly works

Stage 2

Stage 3

in regard to the woman in the childbearing process, both from women as clients point of view and the midwives/ midwifery students perspective. In step three, the analytic framework was presented in a gure and in ve tables. This method can be compared with painting a picture where in step one the picture is drawn and step two (the literature in this case) is used to compare the picture drawn with other similar pictures for conrmation and clarication. In step three, the picture is presented. We acknowledge, however, that only in a book where we would have unlimited space would we be able to describe this process in detail. The literature used to discuss the theory in this paper is not necessarily the literature (300 papers) used for step two in the theory development although there are some scholarly works which serve that double purpose. Walker and Avant (18) categorize theories into metatheory, grand theory, middle-range theory and practice theory; metatheory claries grand theory; grand theory guides middle-range theory; middle-range theory directs practice theory, while in reverse, practice theory tests middle-range theory; middle-range theory renes grand theory; and grand theory provides knowledge for metatheory development (21). The theory presented here is a grand theory. Grand theories within midwifery are few and one of the reasons might be more emphasis on the biomedical model rather than midwiferys own distinct body of knowledge or the emphasis found in many research funds placing less emphasis on the strengths of unique disciplinary perspectives and more emphasis on disease processes and the biomedical perspective similar to what Butcher (21) has identied in the case of nursing. Despite the current de-emphasis on grand theories, Walker

and Avant (18) clearly delineate the relevance and centrality of grand theory as a source for mid-range theory and practice development. The theory is based upon nine databases, all of which deal with research by the authors and their colleagues (see Table 2). In all the empirical studies used to generate the theory, permissions were granted from the relevant Bioethics Committees. (1, 2229). The nine studies and scholarly works used for the rst stage of the theory construction are concerned inter alia with womens experience of caring and uncaring behaviour (1), and their perceptions of their situation as women in childbirth (22). Due to constraints of space, we cannot present the detail of how we worked with all these papers. However, these studies clearly revealed what was important to the women, what empowered them and what was disempowering. In the theory presented here, only the empowering aspects are portrayed the positive contributions of the professional midwife and not the lack of professionalism. In the construction of the theory, the focus was on each factor in the midwifes professionalism.

Findings
In presenting our ndings, we will start by dening the major concepts of the theory, and then describe it in general, with a gure and ve tables. We will describe each factor, i.e. what is professional caring, competence, wisdom and interpersonal competence, together with the midwifes self-knowledge and self-development, by presenting each subtheme, together with tables (see Tables 37).

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Table 2 Summary of studies and scholarly works used to develop the theory (stage I)

Authors, date Halldorsdottir and Karlsdottir, 1996a

Title Journeying through labour and delivery: perceptions of women who have given birth Empowerment or discouragement: womens experience of caring and uncaring encounters during childbirth Caring and uncaring encounters in nursing and health care developing a theory The characteristics of antenatal services from midwives, that women are satised or unsatised with: a descriptive survey Empowerment or disempowerment: a theory of interaction and its effect Womens sense of self and their experience of caring and uncaring encounters during pregnancy Nursing as professional caring: presentation of a theory of nursing Long-time memories and experiences of childbirth in a Nordic context a secondary analysis The dynamics of the nursepatient relationship: introduction of a synthesized theory from the patients perspective

Published Midwifery 12, 4861

References (22)

Halldorsdottir and Karlsdottir, 1996b

Health Care for Women International 17, 361379 ping Doctoral thesis, University of Linko ping University Medical (Linko Dissertations nr. 493) Unpublished MSc study, University of Manchester

(1)

Halldorsdottir, 1996

(23)

Karlsdottir, 1999

(24)

Halldorsdottir, 2003 Halldorsdottir and Karlsdottir, 2004

Halldorsdottir, 2006

Lundgren, Karlsdottir and Bondas, 2009

Halldorsdottir, 2008

The Icelandic Journal of Nursing 79, 1016 Presentation of research at Nordic midwives conference in Reykjavk, Mothers of light: gentle warriors from past to present The Icelandic Journal of Nursing Peer-Reviewed Scholarly Papers 1, 211 International Journal of Qualitative Studies on Health and Well-being, 4, 115128 Scandinavian Journal of Caring Sciences 22, 643652

(25) (26)

(27)

(28)

(29)

Denitions of the major concepts of the theory can be found in Table 8. All the denitions are based upon the nine datasets and scholarly works used as a basis for the theory development (see Table 2).

Description of the theory

Midwives face the complex challenge of bringing together many different factors in their work. When they are successful, the woman benets from their professionalism. The midwifes professionalism encompasses the midwifes professional wisdom (a concept entailing the intertwining of knowledge and experience), as well as the theoretical knowledge, skills and techniques required of the midwife in the womans situation. The midwife has developed personally and professionally, and succeeds in making the woman feel cared for, communicates with her in an empowering manner, and has a positive partnership with her. These ve principal factors: professional caring, competence and wisdom, empowering interaction and partnership, together with the midwifes personal and professional development combine into a whole. Figure 1

is a schematic representation of the principal factors in the midwifes professionalism, according to the theory and Table 9 delineates the various aspects of the midwifes professionalism. This many-faceted reality can be further explained, with reference to the professionalism of the good midwife providing the service, exploring each factor: 1 The good midwifes professional caring. The midwife cares for the woman and her family within the professional domain (see Table 3). This individualized caring is the heart of midwifery. 2 The good midwifes professional wisdom. The midwife has wisdom and knows how to apply it within the professional domain. Professional wisdom develops through the interplay of knowledge and experience (see Table 4). 3 The good midwifes professional competence. The midwife is competent within the professional domain (see Table 5). This competence has primacy in midwifery to ensure the safety of mother and child. 4 The good midwifes interpersonal competence. The midwife is capable of empowering communication

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Table 3 Summary of professional caring

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The good midwife cares for the woman and her family within the professional domain Genuinely cares for the woman as a client and her family Is warm, open and sensitive towards the woman e.g. perceptive of how she is feeling and provides appropriate emotional support Is understanding, sympathises with the womans suffering and shows her good will and empathy Is ethically responsible and has respect for the woman Is culturally literate, not judgemental, is conscious of and takes account of the womans cultural background Is there for the woman and able to grant the woman her undivided attention the woman nds it easy to seek her help: The midwife is present in dialogues, by listening and responding (active listening) The midwife is present in events physically and emotionally Is not afraid of a womans difcult feelings and can offer her support, e.g. in case of sorrow Is keenly interested in midwifery and recognises own responsibilities to colleagues, the profession and the wider community Has the courage to give of herself as a professional midwife and thus to be a participant in the life of the woman and her family Sets herself a high standard in wanting to provide a good service. Pursuit of excellence Has interest in and respect for women, their right to self-determination and their informed decisions based on respect for human dignity Strives to prevent harm to women in the childbirth process

5 The good midwifes personal and professional development. The midwife knows and nurtures herself, both personally and professionally (see Table 7). This personal and professional development prevents the midwifes burnout.

Discussion of ndings
According to the theory professional caring, competence and wisdom, interpersonal competence, and the midwifes personal and professional development together make up the midwifes professionalism. If any of the factors is lacking, the service is awed. A professional midwife, who is caring, professionally competent and has interpersonal skills and professional wisdom, is a good midwife. A good midwife is in many ways like a personal guide, who leads the woman and her family through the journey of the childbearing process and whose guidance is adapted to the needs of each woman and her family. The midwife utilises all communications to empower the woman, for instance by providing information and the appropriate knowledge, with the objective of empowering the woman. The inuence of the interaction with a good midwife is best described as empowerment. We are aware that empowerment is a term that has been open to critique. Our understanding of empowerment is that the midwife strengthens a womans condence facilitating recognition of her own strengths and capacities (see Table 8).

Table 4 Summary of professional wisdom

The good midwife is wise and knows how to apply her wisdom within the professional domain Knows how to integrate knowledge with procedure Knows what she is doing and why Knows how to create a restful place with the woman, enhance her comfort and create a peaceful environment around her Emphasizes knowing the childbearing woman Maintains condentiality Is receptive to the womans needs and conduce to her achieving her objectives Devotes herself to the art of midwifery Has the necessary knowledge of childbearing women, whether well or ill, and can take care of them in variable conditions Is professionally responsible and takes responsibility for her own clinical decisions Knows when to seek professional assistance when the care of the woman so requires Is perceptive and forward-looking and aware of environmental effects on the woman Is critical and creative in her thinking, bases her practice on evidence-based knowledge and is conscious of the importance of research ` -vis innovations Is open and critical vis-a

Womens need for professional caring

The importance of professional caring is emphasised in the theory. A desire for the good is always accompanied by the wish to create a good life for others; this is the core of caring the wish to promote the long-term happiness of others. In public service, this means that we want service adapted to each individual being served; and in the childbearing process we want to maintain the dignity of the woman giving birth. Many women want more humane, personal service during the childbearing process, with sensitivity to their needs, so that they are better prepared to cope with the processes of birth, which are both physical and mental (9, 30). According to Maher (31), we must not try to control the birthing woman, or the birthing body, but help the woman to function in harmony with the rhythm of her body; Maher is of the view that a rising incidence among Australian women of post-traumatic stress following birth, and discontent, arises from such interventions. Womens discontentment with maternity services is not conned to Australia; a Swedish study of uncaring midwives (32) revealed that of the 67 women who participated, 32 felt that the midwife had not been caring in her conduct, but on the contrary had been degrading, and that the midwife had not treated their body with respect, but undermined their human dignity.

and partnership with the woman and her family (see Table 6). For many women, this partnership is the difference between perceived caring and uncaring.

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Table 6 Summary of interpersonal competence

Table 5 Summary of professional competence

The good midwife is competent within the professional domain Creates a safe environment for mother and baby Conduces to the health of mother and baby Empowers the woman and her family Correctly assesses the condition, needs and responses of the woman Makes accurate clinical decisions Provides the appropriate care and treatment, and follows it up Educates the woman and her emotional supporters Performs tasks correctly (technical competence and skill) Is the womans advocate when appropriate Is a leader, plans and is in charge, when appropriate Makes use of information technology and gathers the latest knowledge at all times Applies evidence-based knowledge in her work Is able to work independently when necessary Has all the competence to provide a woman with appropriate care during pregnancy, birth and postpartum Recognises when the birth process ceases to be normal and knows how to respond Applies her knowledge with competence and skill Systematically keeps record of the care and treatment provided, to maintain accountability, focus and continuity of care

The midwifes professional wisdom and interpersonal competence

According to the theory, the good midwife has wisdom and knows how to apply it within the professional domain. Professional wisdom develops through interplay of knowledge and experience. Professional wisdom is needed in midwifery but seldom discussed in the literature. Part of the midwifes professional wisdom is for instance to create a peaceful environment during birth, as peace and quiet are important factors in a good birth, which has been linked to womens contentment with the experience; and it is a factor which is conducive to successful partnership between mother and child. Increasing a womans sense of security by creating a quiet environment characterized by warmth and caring should thus be one of the factors emphasised with respect to childbirth (1, 33). Interpersonal competence is emphasized in the theory, i.e. the midwife has the ability to connect with the woman and collaborate effectively with her, with the shared objective that all should go well in the process of birth. Active listening is one of the important factors in this context, along with providing information and advice which the woman understands; the midwife must be able to adapt her communications to the needs of each woman. Collaboration between the midwife and the woman is at the heart of the theory and that collaboration is based upon the midwifes caring, competence and insight. Hunter (34, 35) has studied the emotion work in midwifery. Hunter points out that this work is largely

The good midwife is capable of empowering communication, connecting and developing partnership with the woman and her loved ones Has the will to work with women in the childbearing process and their families, and with colleagues, for instance in multidisciplinary teams Knows how to take the initiative in communication Knows how to reach the women in her care Knows how to connect with women in the childbearing process, based on reciprocity and mutual trust as well as develop partnership with her and her loved ones (to build bridges through communication) Takes the initiative in providing instruction to the woman and her family Knows how to provide appropriate information which the woman understands which requires certain exibility in communication, so that the midwife can meet the individual needs of each woman Knows how to communicate with women in the childbearing process in such a way that they are encouraged and are reassured that everything is going well, when that is the case Knows how to give a woman and her family bad news in a considerate manner Knows how to achieve professional intimacy with the woman in the childbearing process, so that the woman can be herself and express herself freely about the childbearing process Knows how to maintain an appropriate and comfortable distance, so that the connection/partnership with the woman remains within the professional domain Knows how to work with the woman in such a way that she maintains her sense of control during the entire childbearing process Knows how to create a collaborative network between professionals when needed

invisible, is undervalued and is largely learned in an informal manner. Work with emotions refers to handling ones own emotions and those of others. She points out that emotional support enhances the likelihood that the womans experience will be positive, while negative experience relates to fear and anxiety.

The fusion of professional competence and caring into one whole

According to the theory, the quality of midwifery service is a key aspect of the womans experience of childbirth. The quality of the support and the caring provided by the midwife is a crucial factor. As a profession, midwives are in a unique position to enhance caring in the childbearing process, but they face the complex task of fusing professional competence and caring into one whole. When they are successful, the woman benets from caring and professional competence, which comprises all the theoretical knowledge, skills and technique required in the womans situation, whether during pregnancy, birth or postpartum. We see professional caring as the core of professionalism in midwifery, and a vital aspect of the service entrusted to midwives by society. The concept of professional caring

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Table 7 Summary of the midwifes personal and professional development

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The good midwife develops herself both personally and professionally Knows how to evaluate and develop her own knowledge, competence and skill in her work Is constantly evaluating herself, for instance through professional reection Knows her own attitudes and feelings Knows her own strengths and the limits to her own ability, her weaknesses and learning needs, and can admit these to others Knows where her knowledge and competence end, and where the knowledge and competence of another profession begins Has a clear self-image, normal self-condence and a clear professional identity is professionally independent and creative Has healthy personal and professional condence Knows how to deal with stress and has developed own ways of preventing burn-out Is information literate, e.g. is alert to the constant development of knowledge, and thus pursues continuing education and lifelong learning Can work through difcult emotions and circumstances, and knows how to use the support and guidance of others when appropriate Nurtures herself as a person and as a midwife Maintains her professional competence both in knowledge and skills

experience of the birth of their rst child have fewer children, and having additional children is delayed (37). The present theory focuses on the professional competence of the midwife, and one aspect of that competence is the ability to inform the woman. As a conrmation of the importance of this aspect, OCathain et al. (38) have indicated that many women feel that they do not receive enough information during the childbearing process.

The importance of midwife woman partnership

The importance of a midwife woman partnership is emphasised in the theory. Some of the participants in our studies have emphasised that the concept relationship is not the correct concept to use for the connection or partnership between the midwife and the woman. They felt that the term relationship was more appropriate for their connections to their mates. We have therefore decided to use the concepts partnership and connection instead. This is in line with Guilliland and Pairman (39) who coined the phrase the midwife woman partnership which since then has been adopted in the ICM International Codes of Ethics (40) as well as in Codes of Ethics for many countries e.g. for midwives in Australia (41) and New Zealand (42). We share the understanding of Freeman et al., (43) that partnership is not necessarily based on equal power between the midwife and the woman. They share a common goal, but the power between them can be exercised through negotiation of the decision-making according to the relevant circumstances. Page (16) has reiterated the importance of a good relationship between the midwife and the woman. She has emphasised that if such a relationship is not established, the service will be fragmentary and unfocused. She wants to make birth more humane and warmer, and she states that it has never been so important to underline this important relationship. Lundgren (44) agrees, in her discussion. In addition, the woman must be helped to feel that she is in control of the birth, which has been specied by women as a highly important aspect of the birth (45). Some authors have also maintained that the quality of the relationship/partnership is a vital factor in the quality of midwifery service, yet these relationships/ partnerships are often undervalued, and may not even be mentioned in discussion of the most important aspects of service during the childbearing process (46). Hunter et al., (12) assert that it is the relationship between the midwife and the woman which knits together all the aspects of midwifery service. All kinds of descriptions of procedures, setting of objectives, equipment and policymaking are of limited use if the partnership/connection between the woman and the midwife is not good enough. In a study that consisted of a secondary analysis of three qualitative studies carried out in Finland, Iceland and

entails a combination of inner feelings and actions, leading to the midwife carrying out some action for the woman which she perceives as caring. We have chosen to use the term professional caring, to underline that caring in midwifery must include professional competence; without this, one can hardly speak of caring from the perspective of women during the childbearing process. Hence, we see professional caring as a broader concept than caring per se, as from our viewpoint professional caring is a part of professionalism, closely related to the knowledge, competence and wisdom midwives gain through their education and experience. We also see professional caring as closely related to the connection/partnership which must be formed between the midwife and the woman. Professional caring means in addition to truly care for the woman, her child and her family and to want the best for them. Waldenstro m (36) has maintained that the attitudes of midwives and their ideology are probably the most important factor in womens contentment with the service they provide more important than continuity of service and many other factors. Research results also indicate that women who feel supported during birth need less pain relief and less intervention, and give birth to children who are in better condition than otherwise. In addition, after the birth, women who have received support during birth feel better, and feel more positive towards themselves, the birth and their children (3). Women who have a negative

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S. Halldorsdottir, S.I. Karlsdottir

Table 8 Denition of the major concepts of the theory

Concept Midwifery

Denition An autonomous scholarly discipline, with its own objectives and specialized service, which is provided through the midwifes professional caring, competence and wisdom, her interpersonal skills and her partnership with the woman in childbirth, together with her own personal and professional development. The midwifes professionalism enhances the well-being of the woman during the childbirth process, and the childbearing woman is empowered. When professionalism is lacking, this has a discouraging and even disempowering effect upon the woman A woman in the childbearing process is a person who is part of a family and of a community. In the context of the childbearing process, the woman is a vulnerable individual who needs the help of a professionally competent midwife, who has the qualities of professional caring and wisdom, as well as interpersonal skills. A woman in the childbirth process is a person under a strain, who has an especially great need for professional caring, and is more sensitive than usual to uncaring Health has many dimensions, including the physical, mental, emotional, social and communal. The health of a woman during the childbearing process can improve or deteriorate in various ways, both through the womans own actions and those of others, e.g. the midwife. In short, the health of a woman during the childbirth process consists of the womans subjective sense of a strength that enables her to achieve her most important objectives concerning her long-term happiness and welfare The context or environment of a woman during the childbirth process is of two kinds: the internal context, comprising the womans needs, expectations, her prior experiences and her sense of herself and the external context, comprising factors outside the woman herself, but affecting her, such as her partner and her family The subjective sense of a woman of being empowered through an encounter with a professional midwife. The basis for the midwifes professionalism is the midwifes professional competence and wisdom, professional caring and interpersonal competence as well as the midwifes personal and professional development. Empowerment decreases the womans vulnerability, increases her well-being, gives her a stronger voice in her situation, gives her a stronger sense of control in the childbearing process and enables her to empower herself and cope better with the situation which the childbearing process entails

The childbearing woman

Womens health during the childbirth process

The context of the childbearing woman

Empowerment of the childbearing woman

The midwife's professional caring

The midwife's professional competence

The professionalism of the good midwife

The midwife's professional wisdom

The midwife's interpersonal competence

The midwife's development

Figure 1 Overview of the professionalism of the good midwife

Sweden, comprising 29 dialogues with women about their memories and experiences of birth, interaction with the midwife was the principal theme (28). These authors

found that the relationship the women felt with the midwife and the atmosphere created by the midwife were keys to their positive experience of birth. During pregnancy, women often experience doubt of their ability to carry and give birth to a baby, due to fear of the actual birth. One of the roles of the midwife is to help women deal with their fear and enhance their selfcondence during pregnancy through interpersonal competence. Fear of birth also appears to play a part in womens experience of pain during birth, and hence it is important to help women deal with their fear (47). According to the theory, successful connection and partnership between the woman and the midwife allow the woman to express her fear and apprehensions without embarrassment. This partnership is therefore the foundation for working with the fear and mitigating it before the birth. In the study mentioned earlier by Lundgren et al. (28), women across three countries indicated that the women felt that they would always remember the good midwife. A good midwifes contribution includes empowering the women, so that the woman feels that she is strong and full of condence. It emerged in all the studies that the women are full of gratitude for having had a good, caring midwife,

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Table 9 The main aspects of the midwifes professionalism

815

Emphasis on the Midwife Who the midwife is What the midwife knows and understands What the midwife does How the midwife connects to other people How the midwife tends to her own self

What is the Basis? The Midwifes Mode of Being Knowledge and experience Action Intercommunication Inner work

Grounded in The Heart The Mind Interconnection between heart, mind and hands Heart to heart, mind to mind hands to body Evolution

Main aspect of the theory Caring Wisdom Competence Communication and connection Self-knowledge and self-development

whom they trusted and connected with, and who guided them so well through the birth however difcult it was.

midwifery is one of the main reasons that midwives leave the profession (49).

The importance of professionalism and ideology within midwifery

Each profession must come to a collective conclusion about what professionalism means within the relevant discipline, and also what is unprofessional, what is good practice and what is not. Hunter and Segrott (48) are sceptical that clinical guidelines and protocols are not necessarily always useful, because they feel that these fail to address various aspects of the midwifes work. We are of the same opinion, and in view of the theory, more emphasis should be placed upon midwives professional caring and wisdom, interpersonal competence and personal and professional development than is the case under the present criteria. Hunter (34) has stressed the with woman ideology. Her ndings are that if midwives are allowed to work in accord with this ideology, they experience greater job satisfaction. If not, the work is emotionally difcult for them. She refers to studies which indicate that the work of the midwife involves considerable stress, that it is an emotionally demanding job and that there is much that affects the midwife personally. However, Hunters study (34) indicates that it is not working with the women which is emotionally draining for midwives, but having to work with people who have a different ideology. When midwives can work within the ideology of midwifery, the work and their ideals are in harmony, and then they nd their work emotionally rewarding. If midwives are unable to work according to their own ideology, this leads to various negative emotions such as irritation, anxiety and anger, which are emotionally wearing. Hunter (34) points out that midwives sometimes face a choice between allying themselves with the institution where they work, or with the women they are working with. According to her research, such a dilemma has a very demoralising effect upon midwives. Not being able to work in accord with the fundamental principles of

Further development of this theory

Theory provides a more complete picture for practice than factual knowledge alone and theories formulate, identify, and articulate the science and practice of every discipline (21). Midwifery scholars need to identify and articulate the processes and components of the art and science of midwifery practice. This theory is an attempt to do that in an endeavour of continuing the disciplines development by assisting in the understanding and practice of creating further theoretical discourse, processes and products for midwifery practice, similar to what Kagan (17) has described. All theories are reconstructed in the light of new data in that area and through theory testing, concept revision, statement revision and theory revision. The theory presented here is therefore seen as always being in the process of emerging as is our world view. According to Walker and Avant (18), the next steps in the phases of our theory development are Theory testing Concept revision, statement revision and theory revision, and Further theory testing We encourage our colleagues in and out of Scandinavia to critique the theory and use it to generate research questions and take part in testing the theory as well as concept, statement and theory revision.

Conclusions
Professions base their education upon specic objectives of its discipline. Midwifery is such a profession. The objective is to prepare prospective midwives for work in a modern society, within a scholarly discipline, which is also a practice discipline in constant evolution. In our view, theories and models regarding professionalism in midwifery should always include professional caring and

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S. Halldorsdottir, S.I. Karlsdottir erence to the unique midwife-woman partnership, which the woman in the childbearing process needs (5355). Professional standards in midwifery must be constantly reviewed, and must be in accord with the latest available knowledge within the profession, and especially studies of womens good and bad experiences of midwifery service. It makes sense to conclude that this is the best way to ensure that midwifery service is in accord with the wishes and needs of women in the childbearing process. It is important that midwives should seize the unique experience they have with women in the childbearing process to empower them as much as possible. It is also important that they be aware of the powerful inuence they can have on the lives of the women and their families. The theory is intended to pinpoint all the empowering factors which must be present, to make a midwife a good midwife.

wisdom, interpersonal competence and personal and professional development, in addition to the professional competence required to provide a safe service, and hence special attention should be paid to these factors in curriculum planning. Emphasis should be placed upon evaluating the attitudes, interpersonal competence and self-care of student midwives, and not only their cognitive and practical competences. Teachers of midwifery can use this theory as a framework for evaluating competence. Student midwives can use the theory to gain a better understanding of what is required of a professional midwife and the personal qualities they need to nurture to be good midwives. The theory could also be used to design evaluation forms for assessing student midwives from year to year and on graduation. We are in agreement with Barclay (50), who has urged midwives to consider their work and its effect upon health care: how midwives can shape health care as it applies to women in the childbearing process, and how the service provided to woman in society can be improved. We consider that as a profession, midwives can have great inuence on enhancing and humanizing the experience of women during their maternity care. Medical obstetric care must be reviewed, to ascertain what has happened to natural birth (9, 51). Mutual respect must also be achieved between midwives and obstetricians (52), and it is necessary to consider the ethical basis of midwifery, especially with ref-

Acknowledgements
Foremost we thank all the women who participated in our studies and gave their time and shared their experiences. We also acknowledge the nancial support of the University of Akureyri Research Fund and the Icelandic Midwifery Association Research Fund. Finally, we thank our colleagues at the University of Akureyri, School of Health Sciences.

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