How Do Midwives View Their Professional Autonomy, Now and in Future?
Abstract
:1. Introduction
2. Methods
2.1. Design
2.2. Participants
2.3. Data Collection
2.4. Data Analysis
2.5. Validity, Reliability and Rigor
3. Results
3.1. Sociodemographic and Professional Characteristics of Participants
3.2. Midwives’ Views about Their Autonomy
“After working in four different hospitals in Brussels and in the Walloon region, I think that autonomy is truly dependent on the workplace …. and depends on the leading midwives and obstetricians of the team”.(item 17_participant 161)
3.3. Midwives’ Views about Their Autonomy Related to Work Content
“In the hospital I work under the supervision of the obstetrician, which limits my ability to take independent decisions. Approval from the obstetrician is always required. In primary care I work independently according to the guidelines …, I can also prescribe medication, … primary and hospital care vary day and night”.(item 1_participant 273)
3.4. Midwives’ Views about Their Autonomy Related to the Professionalism of the Midwife
“Specifically at X (Brussels hospital): no hierarchy between doctors and midwives, but complementarity +++ and teamwork”.(item 11_participant 177)
“As the advocate of physiology an active collaboration with the team of doctors in X (Brussels hospital) is pursued”.(item 9_participant 11)
“I still lack a bit of experience. This is a job we learn every day. The more experience we acquire, the more comfortable we will be in the job”.(item 8_participant 319)
3.5. Midwives’ Views about Their Autonomy in Relationship with Others
“We are often supervised by assistants who respond very medically and do not consider our experience or expertise, which often leads to frustration …”.(item 11_participant 297)
“Despite my proven competencies, I am not rewarded by the government, which is inexcusable. No extra fee for me as an accredited lactation consultant, no additional fee if you have a Master’s degree, …”.(item 9_participant 174)
“Not every woman or doctor accepts the expertise of a midwife. I think this is the most difficult thing in my profession, the daily struggle to prove that what we do is responsible, safe and qualitative care”.(item 10_participant 2)
“I often get comments like ‘Is a midwife allowed to perform a childbirth?’ ‘Isn’t that dangerous?’ or ‘I would prefer to give birth with an obstetrician anyway’ …”.(item 12_participant 9)
“When one does not know primary care, many health professionals are suspicious about my professional functioning, this is due to a lack of information and understanding of primary care”.(item 13_participant 287)
“You are not always considered as an authority in maternity care, rather as someone with an alternative, not evidence based vision”.(item 10_participant 286)
“Respect and trust are not self-evident, but are built up by good and constructive cooperation”.(item 14_participant 122)
“There is little support from the professional organization towards primary care midwives, the organization is almost exclusively governed by hospital-based midwives”.(item 15_participant 71)
“We need a professional organization such as in the United Kingdom (RCM [Royal College of Midwives]) or the Netherlands (KNOV, [Royal Dutch Organization of Midwives]), where most staff is professionally involved in policy, vision, research, ….”.(item 15_participant 174)
“There should be mandatory membership, as in France, so that they [professional association] have more means to defend and develop our profession”.(item 15_participant 129)
3.6. Midwives’ Views about Their Autonomy in the Future
“I believe that midwifery autonomy can be improved, such as midwifery led care units or midwife-led care, where we can take autonomous decisions, of course in the event of a low risk pregnancy/childbirth. However, this also requires a different view on the financing of maternity care”.(item 16_participant 22)
“For me autonomy means ‘on my own responsibility, without supervision of a doctor’, but that does not mean that there should be no good cooperation with other disciplines”.(item 9_participant 122)
“Good cooperation and agreements with other health professionals disciplines does not exclude autonomy”.(item 17_participant 122)
4. Discussion
Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- WHO. World Health, Organization. Midwives Voices, Midwives Realities. Findings from a Global Consultation on Providing Quality Midwifery Care. Available online: https://apps.who.int/iris/handle/10665/250376 (accessed on 15 July 2022).
- Prosen, M. A systematic integrative literature review of the factors influencing the professionalization of midwifery in the last decade (2009–2019). Midwifery 2022, 106, 103246. [Google Scholar] [CrossRef] [PubMed]
- Halldorsdottir, S.; Karlsdottir, S. The primacy of the good midwife in midwifery services: An evolving theory of professionalism in midwifery. Scand. J. Caring Sci. 2011, 25, 806–817. [Google Scholar] [CrossRef] [PubMed]
- Gözükara, İ.; Çolakoğlu, N. The Mediating Effect of Work Family Conflict on the Relationship between Job Autonomy and Job Satisfaction. Procedia-Soc. Behav. Sci. 2016, 229, 253–266. [Google Scholar] [CrossRef] [Green Version]
- Iliopoulou, K.K.; While, A.E. Professional autonomy and job satisfaction: Survey of critical care nurses in mainland Greece. J Adv. Nurs. 2010, 66, 2520–2531. [Google Scholar] [CrossRef] [PubMed]
- Labrague, L.J.; McEnroe-Petitte, D.M.; Tsaras, K. Predictors and outcomes of nurse professional autonomy: A cross-sectional study. Int. J. Nurs. Pr. 2019, 25, e12711. [Google Scholar] [CrossRef] [Green Version]
- Bondarchuk, O.; Pinchuk, N. Professional autonomy of scientific and pedagogical workers as an indicator of their subjective well-being. Bull. Postgrad. Education. Soc. Behav. Sci. Ser. 2020, 13, 54–70. [Google Scholar] [CrossRef]
- Towler, J.; Bramall, J. Midwives in History and Society; Taylor & Francis: Abingdon, UK, 2023. [Google Scholar]
- Mivšek, P.A.; Hundley, V.; van Teijlingen, E.; Pahor, M.; Hlebec, V. Slovenian midwifery professionalization: Perception of midwives and related health professions. Eur. J. Midwifery 2021, 5, 1–10. [Google Scholar] [CrossRef]
- Healy, S.; Humphreys, E.; Kennedy, C. A qualitative exploration of how midwives’ and obstetricians’ perception of risk affects care practices for low-risk women and normal birth. Women Birth 2017, 30, 367–375. [Google Scholar] [CrossRef]
- Baird, K. Exploring autonomy in education: Preparing student midwives. Br. J. Midwifery 2007, 15, 400–405. [Google Scholar] [CrossRef]
- Weltens, M.; de Nooijer, J.; Nieuwenhuijze, M.J. Influencing factors in midwives’ decision-making during childbirth: A qualitative study in the Netherlands. Women Birth 2019, 32, e197–e203. [Google Scholar] [CrossRef]
- Everly, M. Facilitators and barriers of independent decisions by midwives during labor and birth. J. Midwifery Women’s Health 2012, 57, 49–54. [Google Scholar] [CrossRef]
- Vermeulen, J.; Luyben, A.; Buyl, R.; Debonnet, S.; Castiaux, G.; Niset, A.; Muyldermans, J.; Fleming, V.; Fobelets, M. The state of professionalisation of midwifery in Belgium: A discussion paper. Women Birth 2020, 34, 7–13. [Google Scholar] [CrossRef]
- Clemons, J.H.; Gilkison, A.; Mharapara, T.L.; Dixon, L.; McAra-Couper, J. Midwifery Job Autonomy in New Zealand: I do it all the time. Women Birth: J. Aust. Coll. Midwives 2021, 34, 30–37. [Google Scholar] [CrossRef]
- Yoshida, Y.; Sandall, J. Occupational burnout and work factors in community and hospital midwives: A survey analysis. Midwifery 2013, 29, 921–926. [Google Scholar] [CrossRef]
- Mestdagh, E.; Timmermans, O.; Fontein-Kuipers, Y.; Van Rompaey, B. Proactive behaviour in midwifery practice: A qualitative overview based on midwives’ perspectives. Sex. Reprod. Healthc. Off. J. Swed. Assoc. Midwives 2019, 20, 87–92. [Google Scholar] [CrossRef]
- Nedvědová, D.; Dušová, B.; Jarošová, D. Job satisfaction of midwives: A literature review. Cent. Eur. J. Nurs. Midwifery 2017, 8, 650–656. [Google Scholar] [CrossRef] [Green Version]
- Pollard, K. Searching for autonomy. Midwifery 2003, 19, 113–124. [Google Scholar] [CrossRef]
- Healy, S.; Humphreys, E.; Kennedy, C. Midwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review. Women Birth 2016, 29, 107–116. [Google Scholar] [CrossRef] [PubMed]
- Herron, A. Autonomy and Midwifery. Doctoral Dissertation, Middlesex University, London, UK, 2009. [Google Scholar]
- Behruzi, R.; Klam, S.; Dehertog, M.; Jimenez, V.; Hatem, M. Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: A case study. BMC Pregnancy Childbirth 2017, 17, 1–14. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Sandall, J.; Soltani, H.; Gates, S.; Shennan, A.; Devane, D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst. Rev. 2016. [Google Scholar] [CrossRef] [Green Version]
- Vermeulen, J.; Buyl, R.; Luyben, A.; Fleming, V.; Fobelets, M. Defining midwifery autonomy in Belgium: Consensus of a modified Delphi study. J. Adv. Nurs. 2022, 78, 2849–2860. [Google Scholar] [CrossRef] [PubMed]
- Sharma, A.; Minh Duc, N.T.; Luu Lam Thang, T.; Nam, N.H.; Ng, S.J.; Abbas, K.S.; Huy, N.T.; Marušić, A.; Paul, C.L.; Kwok, J.; et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J. Gen. Intern. Med. 2021, 36, 3179–3187. [Google Scholar] [CrossRef] [PubMed]
- PlanKad Vroedvrouwen 2019. Cel Planning van het Aanbod van de Gezondheidszorgberoepen, Dienst Gezondheidszorgberoepen en Beroepsuitoefening, Directoraat-generaal Gezondheidszorg, FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu. Available online: https://overlegorganen.gezondheid.belgie.be/sites/default/files/documents/vroedvrouwen_op_de_arbeidsmarkt_2019.pdf (accessed on 15 July 2022).
- Lefèvre, M.B.N.; Camberlin, C.; Devriese, S.; Pincé, H.; de Meester, C.; Fricheteau, B.; Van de Voorde, C. Organisation of maternity services in Belgium. Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE). 2019. KCE Reports 323. D/2019/10.273/68. Available online: https://kce.fgov.be/sites/default/files/atoms/files/KCE_323_Maternity_services_Belgium_Report_0.pdf (accessed on 15 July 2022).
- Polit, D.; Beck, C. Essentials of Nursing Research: Appraising Evidence for Nursing Practice; Lippincott Williams & Wilkins: Philadelphia, PA, USA, 2009. [Google Scholar]
- Edmondson, M.; Walker, S. Working in caseload midwifery care: The experience of midwives working in a birth centre in North Queensland. Women Birth 2014, 27, 31–36. [Google Scholar] [CrossRef] [PubMed]
- Perdok, H.; Cronie, D.; van der Speld, C.; van Dillen, J.; de Jonge, A.; Rijnders, M.; de Graaf, I.; Schellevis, F.; Verhoeven, C. Experienced job autonomy among maternity care professionals in The Netherlands. Midwifery 2017, 54, 67–72. [Google Scholar] [CrossRef] [Green Version]
- Thompson, C.; Prottas, D. Relationships among organizational family support, job autonomy, perceived control, and employee well-being. J. Occup. Health Psychol. 2006, 11, 100–118. [Google Scholar] [CrossRef]
- Papoutsis, D.; Labiris, G.; Niakas, D. Midwives’ job satisfaction and its main determinants: A survey of midwifery practice in Greece. Br. J. Midwifery 2014, 22, 480–486. [Google Scholar] [CrossRef]
- Smith, J. The culture of midwifery and autonomy. Br. J. Midwifery 2014, 22, 675–676. [Google Scholar] [CrossRef]
- Zolkefli, Z.; Mumin, K.; Idris, D. Autonomy and its impact on midwifery practice. Br. J. Midwifery 2020, 28, 120–129. [Google Scholar] [CrossRef]
- Cronie, D.; Perdok, H.; Verhoeven, C.; Jans, S.; Hermus, M.; de Vries, R.; Rijnders, M. Are midwives in the Netherlands satisfied with their jobs? A systematic examination of satisfaction levels among hospital and primary-care midwives in the Netherlands. BMC Health Serv. Res. 2019, 19, 832. [Google Scholar] [CrossRef]
- Gemperle, M.; Grylka-Baeschlin, S.; Klamroth-Marganska, V.; Ballmer, T.; Gantschnig, B.; Pehlke-Milde, J. Midwives’ perception of advantages of health care at a distance during the COVID-19 pandemic in Switzerland. Midwifery 2022, 105, 103201. [Google Scholar] [CrossRef]
- Wilson, D.; Errasti-Ibarrondo, B.; Low, G.; O’Reilly, P.; Murphy, F.; Fahy, A.; Murphy, J. Identifying contemporary early retirement factors and strategies to encourage and enable longer working lives: A scoping review. Int. J. Older People Nurs. 2020, 15, e12313. [Google Scholar] [CrossRef] [PubMed]
- Warmelink, J.; Wiegers, T.; de Cock, T.; Klomp, T.; Hutton, E. Collaboration of midwives in primary care midwifery practices with other maternity care providers. Midwifery 2017, 55, 45–52. [Google Scholar] [CrossRef] [Green Version]
- Eggermont, M. De juridisering van de beroepsuitoefening van de Belgische vroedvrouw vanaf de 19de eeuw: Een saltatoire evolutie [The juridization of the profession of Belgian midwife from the 19th century on: A saltatory evolution]. 2018. Available online: https://www.jstatsoft.org/article/view/v048i02 (accessed on 15 July 2022).
- Vermeulen, J.; Swinnen, E.; D’haenens, F.; Buyl, R.; Beeckman, K. Women’s preferences and knowledge about the legal competences of midwives in Brussels, Belgium. A descriptive observational study. Midwifery 2016, 40, 177–186. [Google Scholar] [CrossRef]
- Larsson, M.; Aldegarmann, U.; Aarts, C. Professional role and identity in a changing society: Three paradoxes in Swedish midwives’ experiences. Midwifery 2009, 25, 373–381. [Google Scholar] [CrossRef] [PubMed]
- McEvoy, P.; Richards, D. A critical realist rationale for using a combination of quantitative and qualitative methods. J. Res. Nurs. 2006, 11, 66–78. [Google Scholar] [CrossRef]
- Lugtig, P.; Luiten, A. Do shorter Stated Survey Length and Inclusion of a QR Code in an Invitation Letter Lead to Better Response Rates? Survey Methods: Insights from the Field. Available online: https://surveyinsights.org/?p=14216 (accessed on 15 July 2022).
- Rosseel, Y. Lavaan: An R package for structural equation modeling and more. Version 0.5–12 (BETA). J. Stat. Softw. 2012, 48, 1–36. [Google Scholar] [CrossRef] [Green Version]
- Bentler, P.M. EQS Structural Equations Program Manual. BMDP Statistical Software; Inc BentlerEQS: Los Angeles, CA, USA, 1989. [Google Scholar]
- Cook, W.L. A structural equation model of dyadic relationships within the family system. J. Consult. Clin. Psychol. 1994, 62, 500–509. [Google Scholar] [CrossRef] [PubMed]
- Kenny, D.A. Measuring Model Fit. 2015. Available online: http://davidakenny.net/cm/fit.htm (accessed on 15 July 2022).
- Kline, R.B. Principles and Practice of Structural Equation Modeling, 3rd ed.; Guilford Press: New York, NY, USA, 2011. [Google Scholar]
n (%) 312 (100) | ||
---|---|---|
Gender | Female | 309 (99.0) |
Male | 3 (1.0) | |
Age (years) | 20–30 | 74 (23.7) |
31–40 | 96 (30.8) | |
41–50 | 65 (20.8) | |
>50 | 77 (24.6) | |
Professional experience as a midwife (years) | <5 | 71 (22.7) |
5–10 | 60 (19.2) | |
11–20 | 81 (26.0) | |
21–30 | 47 (15.1) | |
>30 | 53 (17.0) | |
Professional setting 1 | Hospital-based care | 185 (59.3) |
Primary care | 66 (21.2) | |
Both hospital-based and primary care | 28 (9.0) | |
Education and/or research | 55 (17.3) | |
Other | 32 (10.3) | |
Professional activities in hospital-based care 2 | Postnatal ward | 148 (47.4) |
Labor ward | 153 (49.0) | |
Antenatal consultation | 61 (19.6) | |
Ultrasound | 7 (2.2) | |
Reproductive medicine | 2 (0.6) | |
Gynecology | 13 (4.2) | |
Neonatology | 62 (19.9) | |
Other | 36 (11.5) | |
Region | Brussels Capital | 95 (30.4) |
Flanders | 156 (49.9) | |
Walloon | 61 (19.7) |
How Do You Generally Rate Your Autonomy as a Midwife? | To What Extent Do You Think That a Midwife Should Be Able to Work Autonomously in Belgium? | ||
---|---|---|---|
n (%) 1 | n (%) 1 | ||
Age (years) | 20–30 | 59 (79.7) | 72 (97.3) |
31–40 | 80 (83.3) | 95 (99.0) | |
41–50 | 58 (89.2) | 64 (98.5) | |
>50 | 65 (84.4) | 73 (94.8) | |
Professional experience as a midwife (years) | <5 | 54 (76.1) | 70 (98.6) |
5–10 | 50 (83.3) | 59 (98.3) | |
11–20 | 72 (90.0) | 79 (97.5) | |
21–30 | 43 (83.7) | 46 (97.9) | |
>30 | 43 (81.1) | 50 (94.3) | |
Professional setting | Hospital-based care | 151 (81.6) | 180 (97.3) |
Primary care | 63 (95.5) | 66 (100) | |
Both hospital-based and primary care | 24 (85.7) | 26 (92.9) | |
Other | 72 (83.7) | 84 (97.7) | |
Region | Brussels Capital | 88 (92.6) | 91 (95.8) |
Flanders | 126 (81.8) | 152 (98.7) | |
Walloon | 46 (73.0) | 59 (96.7) |
Dimension: Work Content | Work Content Score (5–20) | ||||
---|---|---|---|---|---|
Mean | Standard Deviation | N | p-Value | ||
Age (years) | 20–30 | 15.28 | 2.71 | 74 | 0.58 |
31–40 | 15.71 | 2.60 | 96 | ||
41–50 | 15.97 | 2.46 | 65 | ||
>50 | 15.47 | 2.25 | 77 | ||
Professional experience as a midwife (years) | <5 | 14.89 | 2.87 | 71 | 0.07 |
5–10 | 15.88 | 2.42 | 60 | ||
11–20 | 15.99 | 2.47 | 81 | ||
21–30 | 15.51 | 2.23 | 47 | ||
>30 | 15.75 | 2.32 | 53 | ||
Professional setting | Hospital-based care | 15.18 | 2.45 | 182 | <0.01 * |
Primary care | 17.31 | 2.06 | 64 | ||
Both hospital-based and primary care | 15.41 | 2.87 | 29 | ||
Other | 14.89 | 2.01 | 37 | ||
Region | Flanders | 15.56 | 2.50 | 156 | <0.01 * |
Brussels Capital | 16.27 | 2.22 | 95 | ||
Walloon | 14.69 | 2.71 | 61 | ||
Dimension: professionalism of the midwife | Professionalism of the midwife score (5–20) | ||||
Mean | Standard Deviation | N | p-value | ||
Age (years) | 20–30 | 15.93 | 2.34 | 74 | 0.16 |
31–40 | 16.43 | 2.27 | 96 | ||
41–50 | 16.86 | 2.14 | 65 | ||
>50 | 16.69 | 2.17 | 77 | ||
Professional experience as a midwife (years) | <5 | 15.23 | 2.14 | 71 | <0.01 * |
5–10 | 16.63 | 2.46 | 60 | ||
11–20 | 16.94 | 1.95 | 81 | ||
21–30 | 16.89 | 2.16 | 47 | ||
>30 | 16.83 | 2.13 | 53 | ||
Professional setting | Hospital-based care | 16.24 | 2.16 | 182 | <0.01 * |
Primary care | 17.23 | 2.66 | 64 | ||
Both hospital-based and primary care | 16.79 | 1.80 | 29 | ||
Other | 15.97 | 1.92 | 37 | ||
Region | Flanders | 16.50 | 2.29 | 156 | 0.03 * |
Brussels Capital | 16.85 | 2.13 | 95 | ||
Walloon | 15.77 | 2.20 | 61 |
I Am Not Supervised by Doctors or Other Health Professionals n (%) 1 | I Am Recognized by Society n (%) 1 | I Am Professionally Recognized n (%) 1 | Other Health Professionals in Maternity Care Respect the Role of the Midwife n (%) 1 | A Legitimately Established Professional Association of Midwives Defines the Rules Governing the Exercise of Their Profession. This in Consultation with the Competent Authorities n (%) 1 | ||
---|---|---|---|---|---|---|
Age (years) | 20–30 | 29 (39.2) | 40 (54.1) | 49 (66.2) | 55 (74.3) | 58 (78.4) |
31–40 | 44 (45.8) | 56 (58.3) | 58 (60.4) | 76 (79.2) | 65 (67.7) | |
41–50 | 33 (50.7) | 40 (61.5) | 44 (67.7) | 50 (76.9) | 49 (75.4) | |
>50 | 35 (45.5) | 54 (70.1) | 58 (75.3) | 58 (75.3) | 51 (66.2) | |
Professional experience as a midwife (years) | <5 | 26 (37.7) | 39 (56.5) | 44 (62.0) | 54 (76.1) | 53 (74.6) |
5–10 | 30 (50.0) | 30 (50.0) | 41 (68.3) | 46 (66.7) | 45 (75.0) | |
11–20 | 38 (46.9) | 47 (58.0) | 49 (60.5) | 64 (79.0) | 49 (60.5) | |
21–30 | 22 (46.8) | 38 (80.9) | 38/ (80.9) | 36 (76.6) | 31 (66.0) | |
>30 | 25 (47.2) | 36 (67.9) | 37 (69.8) | 39 (73.6) | 36 (67.9) | |
Professional setting | Hospital-based care | 58 (31.8) | 116 (63.7) | 125 (68.6) | 151 (82.9) | 133 (73.0) |
Primary care | 254 (84.4) | 32 (50.0) | 37 (57.8) | 35 (54.7) | 42 (65.6) | |
Both hospital-based and primary care | 12 (41.4) | 18 (62.0) | 21 (72.4) | 23 (79.3) | 20 (68.9) | |
Other | 141 (45.2) | 24 (64.9) | 26 (70.3) | 30 (81.1) | 28 (75.8) | |
Region | Brussels Capital | 41 (44.2) | 57 (60.0) | 64 (67.3) | 82 (86.3) | 65 (68.4) |
Flanders | 69 (44.2) | 109 (69.8) | 127 (81.4) | 117 (75) | 109 (69.9) | |
Walloon | 30 (49.2) | 24 (39.4) | 18 (29.5) | 40 (65.6) | 49 (80.3) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Vermeulen, J.; Fobelets, M.; Fleming, V.; Luyben, A.; Stas, L.; Buyl, R. How Do Midwives View Their Professional Autonomy, Now and in Future? Healthcare 2023, 11, 1800. https://doi.org/10.3390/healthcare11121800
Vermeulen J, Fobelets M, Fleming V, Luyben A, Stas L, Buyl R. How Do Midwives View Their Professional Autonomy, Now and in Future? Healthcare. 2023; 11(12):1800. https://doi.org/10.3390/healthcare11121800
Chicago/Turabian StyleVermeulen, Joeri, Maaike Fobelets, Valerie Fleming, Ans Luyben, Lara Stas, and Ronald Buyl. 2023. "How Do Midwives View Their Professional Autonomy, Now and in Future?" Healthcare 11, no. 12: 1800. https://doi.org/10.3390/healthcare11121800