INTRODUCTION

Midwifery in the 1980s was linked to social movements and developed in close collaboration with women and families around a radical power takeover: home birth. It was not a question of going against biomedicine or presenting oneself as an alternative, but rather of going “elsewhere”.

After a period of experimentation with pilot projects in birthing centers, the Quebec government legalized the profession in 1999, integrating it as an autonomous primary care profession in the public healthcare system. This transition from a community-based practice (70s-80s) to a professional one created an identity crisis that mobilized midwives to reflect on and define the benchmarks of their specificity.^1,2 This included a philosophy and guiding principles of practice, a conception of childbirth, the importance of women and their social mission that guided their practice.

Nearly twenty years later, midwives face the challenge of continuing to integrate into a hospital and medical-centric healthcare system characterized by fragmentation, standardization of care, a focus on pathological potential, and performance-driven management. However, midwifery practice is fundamentally about continuity of relationship, normalcy and the choices women and couples make about the place of birth (home, birth center, hospital). This difference is often the source of tension and misunderstanding in interprofessional relationships, where midwives struggle to explain their specificity and assert their professional autonomy. As a result, they felt the need to revisit their identity markers in order to meet the challenges of daily practice. Moreover, most midwives practicing in the 2020s have inherited the profession’s philosophy – rich in meaning – without having participated in its elaboration.

Thus, at the request of its members, the Regroupement Les sages-femmes du Québec (RSFQ) set up a committee to examine the unique aspects of the profession, highlighting its originality and relevance.³ At the same time, a citizen’s voice from the community came forward to reaffirm the importance of having access to midwifery services based on a model that aligns with the expectations of women and families.^4,5 This committee considered the importance of collective reflection to document and understand the fundamental principles of Quebec midwifery practice in continuity with its historical roots. It became clear that this process needed to be done within the framework of a research project to better structure and deepen the reflection.

METHODS

We conducted a participatory qualitative research in order to reach as many midwives as possible, to listen to them and to elicit their reflections on their professional identity.^6,7 The methodological strategy was inspired by the cooperative inquiry approach of Heron and Reason, which is characterized by a process in which people with shared concerns and interests collaboratively develop new ways of seeing and making sense of their actions based on their own experiences and practices.^8-10

All midwives were invited to participate in person in two days of reflection on questions and scenarios. The same day was repeated twice, once in Trois-Rivières and once in Montreal, to encourage participation. Recruitment was carried out through an invitation email sent by the RSFQ to all midwives. The inclusion criteria were to be actively practicing or retired and to have worked in a birthing center or to be on maternity, sick, or study leave.

Each of these two days took the form of discussion workshops. Participants were assigned to tables of four to eight midwives from different backgrounds, depending on where they practiced and how many years of experience they had. The same topics were discussed at each table and then shared in a plenary session. Drawing on real-life experiences, participants were encouraged to identify what gave the most meaning to their practice and what inspired them in their work with women and families. In addition, they identified the core values of their profession and revisited certain concepts to deepen their understanding. Between the two days, they were invited to propose an image or symbol of what a midwife represented to them, accompanied by an explanatory text about their choice.

However, a quest for identity cannot be conducted in isolation. We therefore decided to combine perspectives with those of the clientele. Parents in different regions of Quebec were invited to share their experiences, perspectives, needs, and expectations regarding midwives in focus groups. Recruitment was carried out by the RSFQ by contacting members of parent committees, who were asked to identify one parent (woman or man) to participate in one of these groups. We ensured diverse representation based on place of residence and parental situation. Two focus groups, facilitated by an external expert, were held on the Zoom platform.

The results were analyzed separately in light of the identity criteria identified in 1999-2000 by researcher Marie-Paule Desaulniers¹ namely: the conception of childbirth, the process of giving birth, the role of midwives in this process—particularly support—and the difference between the midwifery approach and the medical approach. Attention was also given to elements that emerged from the comments and reflections of midwives and parents, in order to document and understand the specific nature of the fundamental principles of Quebec midwifery practice.

The second day with the midwives allowed for the validation and deepening of the initial analysis based on the comments collected from both midwives and clients. Various themes were discussed, including relational continuity, continuity of philosophy, differences in practices, intervention versus non-intervention, and diversification of practice.

Then, a second level of analysis of all the data made it possible to update the specific characteristics of the profession and identify the current issues affecting it.

The research project was funded by the Social Sciences and Humanities Research Council of Canada. The research team consisted of four researchers from different disciplines: philosophy and ethics/professional identity, psychology/ professional practices, midwifery, applied human sciences, and socio-anthropology. An ethics certificate (number CER-19-253-07.08) was obtained from the Research Ethics Committee of the Université du Québec à Trois-Rivières.

RESULTS

Sixty-five midwives from all the birthing centers and midwifery services participated in the proposed activities, and fifteen parents took part in the discussion groups.

What Remains after 20 Years

At the end of this work, we can affirm that the identity markers present 20 years ago are still part of current midwifery practice. While we observed changes in language, we can say that the adoption and embodiment of most of the identity markers named at the time of the profession’s official recognition in Quebec still persist in practice. Midwives maintain a perspective of normalization, trust, contextualization and engagement in processes with the woman, seeking to discern the needs behind her requests. Their practice is relational—much more process-oriented than procedural. Because childbirth is a transformative process, midwives are attentive to passages and to birth in all its dimensions of human experience.

Midwives speak of trusting the woman to be the best person to know what is happening in her body, how she feels her baby, and to make decisions for herself and her child. They are attentive to “nurture this trust.” Moreover, it’s a “mutual trust relationship” that is “woven” throughout the course of care.

The practice is defined by the relationship with the other, from the perspective of caring, nurturing and welcoming of life. Being in relationship means first taking the time to create a person-to-person connection, which develops through continuity. Midwives themselves, when recalling experiences where they “felt like a midwife,” evoke “the strength of that follow-up we built over time.”

Midwives consistently speak of engaging in an egalitarian relationship with the woman, meaning a non-hierarchical and reciprocal dynamic. Throughout the evolving relationship—centered on the woman’s needs and knowledge—the midwife is guided by “respect for choices,” while also considering the person’s lived experience and the clinical situation. She draws on her skills and knowledge to clarify delicate or complex situations and remains ready to act “when needed.”

Midwifery is grounded in the recognition of a woman’s “capacity to give birth to her child”. It’s about acknowledging and trusting that power. Here, they speak essentially of empowerment:

Midwives view pregnancy, childbirth, and birth through the lens of normalcy; these are processes that are part of life. The midwife acts as a “guardian” of the process, protecting the “space” for its singular unfolding from a holistic perspective.

Midwives speak clearly about their professional autonomy and assert it, even though it is implicit in all professional laws in Quebec. It’s not a question of claiming status or power, but as one participant expressed so well:

What’s Different - What’s Changed

According to the participants, institutional pressures and those of medical teams have led over time to an increase in interventions both during pregnancy and childbirth. The expectation of standardized, protocol-based practice led to a reduction in professional judgment, as well as challenges an identity rooted in individualized care and professional autonomy. Additionally, the weight of medico-legal concerns and disciplinary measures has led to a more defensive practice, where trust is no longer the fundamental value guiding midwifery care. Finally, the participants reported changes in the clientele, who prefer to make as few choices as possible and to have all tests and examinations available, resulting in numerous interventions.

Relational continuity is no longer as optimal as it once was. The reality of larger teams often results in care being provided by several midwives, rather than one or two as was common at the beginning of legalization. The challenge of balancing work and personal life is frequently mentioned, as are the impacts of sick leave and maternity leave, which contribute to team mobility.

In addition, the midwives noted the paradox of a team that, on the one hand, supports the midwife’s professional autonomy but, on the other, sometimes dictates her conduct. Clearly, there are significant gaps between discourse and practice, particularly regarding continuity and autonomy, which creates ethical tensions for midwives.

Midwives also seem hesitant to speak about the sacred nature of childbirth, references to transcendence, or the spiritual dimension of birth. However, they all agree in recognizing that it is “bigger than us.”

Additionally, we noticed that while midwives speak extensively about physiological birth, they no longer use the term “natural birth,” which contrasts with the language used 20 years ago.

Similarly, the community dimension—so evident at the time of legalization—no longer seems as present. Midwives now more often refer to the family as the community-related aspect of their work.

Finally, feminism was also a topic of some questioning among participants, who were seeking its meaning and especially its relevance in midwifery practice. The connections were not always clear, and there was a certain discomfort in explicitly naming this professional posture. This contrasts with Desaulniers’ study, in which feminism was self-evident for midwives.

What Has Emerged – What is New

Several elements from this research on midwives’ professional identity can be considered new compared to what was known about the profession twenty years previously. Although they still refer to writings on the philosophy of practice, their words now reflect a conception of motherhood as a transition and a unique process of transformation. This includes both respect and trust in women, as well as the mobilization of knowledge and skills in the service of welcoming life and ensuring safety. This is the “art of midwifery,” which was expressed through various images and metaphors.

Similarly, they clearly expressed a vision of their professional activity as a practice of accompaniment rather than a technical practice, although they never set these visions in opposition. It includes both respect and trust in women as well as the mobilization of knowledges and skills in the service of welcoming life and ensuring safety. This is the “art of midwifery,” which was expressed through several images and metaphors. The comparative elements are shown in the table 1.

Their words and language contrast with institutional language and discourse. Finally, in the exchanges between participants, we noticed the frequent use of terms and expressions such as “holding space” and being a “guardian” of the birthing process, which were rarely heard 20 years ago.

The shared values

The way midwives spoke about the shared values of the profession also brought something new to light regarding their professional identity. Beyond the values they named (respect, autonomy, compassion, commitment, trust), what stood out was how these values are constantly interwoven in a dynamic way, forming a meaningful tapestry that defines their profession. They also consider these values to be just as important in their personal lives as in their professional practice. Empowerment seems to run through all the conversations, and is even mentioned as being important for “all” the women including midwives. Finally, the value of wisdom was mentioned as a kind of container for all the values of the profession [see Figure 1].

What’s Being Discussed in the Midwives Community

Midwives reported a several changes and challenges in their practice. They talked about requests to diversify the single model of practice, i.e. complete maternity care (pregnancy, childbirth, postnatal). However, participants emphasized the importance of taking the time to implement any changes carefully. For them, the priority should first meet the request for natural births and out-of-hospital births, as this challenge would be a risk of losing the distinctiveness of midwifery care.

What Parents Are Saying

Parents shared what was most meaningful in their experiences of being cared for by a midwife [see Table 2]. Seven main themes emerged: the family approach, informed choices in a perspective of autonomy and empowerment, the continuity of the relationship, the relationship of trust, taking care of the person, availability and choice of birthplace. For them, it’s essential that the midwife uses a holistic approach, caring not only for the pregnancy, the baby and the mother, but also for the woman, the family and the couple. The relationship of trust nurtures a sense of being heard and welcomed as a person, with all the emotions experienced throughout the maternity journey. Parents want their decision-making abilities to be trusted. For women, the importance of relational continuity is undeniable in building confidence on their path to birth and motherhood:

The more difficult aspects of care included the lack of experience of some midwives, challenges in addressing emotional aspects, a more medicalized or directive approach, lack of continuity, and differences in approach between midwives or even midwifery teams.

Parents are also concerned about the medicalization of midwifery practice. They argue that the model as originally conceived and implemented should be preserved, because in their view: “it still corresponds to our needs.” Parents want midwives to continue to reflect on their practice and contribute to the evolution of their profession, while maintaining their core values and preserving their autonomy. These ongoing and emerging elements in the practice of Quebec midwives led the researchers to explore the contextual factors influencing midwifery in the 2020s.

DISCUSSION

The results of this research first lead us to consider how today’s midwives practice in a society that has changed significantly in 20 years. These changes also raise important reflections on identity-related issues within the midwifery community.

Midwifery in a Changing Society

Quebec society has changed a great deal since 2000 notably in terms of the authority of scientific experts (EBM), the dominance of risk ideology, the diversification of feminist movements, and the secularization of the state.¹³ These changes have had an influence on midwives’practice as a expression of their professional identity, particularly in the language they use.

The weight of experts,^14,15 such as the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the proliferation of screening programs recommanded, have shaped practice towards information and decision-making process around prenatal tests even before a relationship is established between the woman and the midwife. Several elements contributed to the reduction of the importance of professional judgment and the increasing number of midwives interventions over time: the integration into an interventionist obstetrical system, the prominence given to clinical guidelines, the institutional pressure to “apply” recommendations, follow protocols and work in a standardized way. Additionally, the managerial logic of the healthcare system,¹⁶ focused on performance, pushes midwives toward controlling actions and time, leaving less room for relational continuity.¹⁷ This challenges an identity rooted in individualized, person-centered care.

Then, in a context of rising technology and risk intolerance,^18,19 it becomes increasingly difficult for midwives to uphold her different perspective based on trust, normality and assumed uncertainty. Discussions around informed choice now require constant reference to risk, and a certain vision of risk fuels fear. This creates a contradiction with the trust-based approach that defines the profession.

A practitioner must be able to exercise his or her professional posture, and we have seen that midwives have a different relationship to risk than that constructed by medical model. They must find a language that reflects their conception of risk and their relationship to uncertainty. How can they communicate information for decision-making while remaining focused on the essentials: pregnancy and childbirth are transformative health events that carry profound meaning for women and families? Conversations with woman should not only reflect this, but should also leave room for the woman’s perception of risk and the expression of her values. How can midwives develop decision-making tools that are relevant to women, without “directing” their choices?

Moreover, fear of legal action and disciplinary measures also leads to defensive practice, further widening the gap between midwives’ discourse and their actual practice. Finally, participants also reported changes in the clientele, who sometimes prefer to make as few choices as possible and to have all tests and examinations available.

The weight of experts and the omnipresence of risk require midwives to be strong as practitioners, and to have confidence in their profession as well as in birth processes and in women themselves. This difference in paradigm should not be seen as a burden, but rather as a necessary stance to uphold a welcoming approach to life in its broadest sense.

Reflections on Identity Issues

Finally, social transformations and those in the healthcare network have brought to light issues of identity, notably language and coherence for the Quebec midwifery profession. A number of themes for reflection were proposed to the midwifery community in the form of questions, for discussion and appropriation. Firstly, how can we bring into the public arena a midwifery language that allows us to talk about our professional world in our own words, without borrowing a language that doesn’t suit us? This includes their conception of birth, their relationship to risk and uncertainty, and their understanding of midwifery intervention, including the importance of non-intervention. Secondly, how can midwives remain consistent with the identity principles that define the uniqueness of their profession while continuing to integrate and evolve within the healthcare system? Thirdly, how can we discern, become aware of and adopt strategies for preserving professional autonomy in situations of interprofessional collaboration in the context of a dominant medical culture?

Finally, it is also essential to examine current practice gaps, the challenges of diversifying the model of care, and how to transmit and protect the fundamental element of relational continuity.

The community of practice is important, but the bodies that support the profession must be called upon to answer these questions, whether it’s the one that works in the public interest (OSFQ), the one that works in the interest of its members (RSFQ) or the one that trains future professionals (UQTR).

CONCLUSIONS

Midwifery in Quebec has evolved over the years, transitioning from a community-based model to a recognized professional practice within the healthcare system. Core elements of its professional identity remain strong: trust, relationship, empowerment, the primacy of normalcy, and autonomy. However, relational continuity appears more difficult to maintain, even though it is clearly affirmed. Other elements that were once obvious—such as the sacred nature of birth, the feminist stance, and the community perspective—are now less explicitly expressed. The sacredness is still acknowledged in the sentiment that birth is “bigger than us,” and the community dimension is now more closely tied to the importance of family.

Language has also changed. Midwives now speak of “physiological childbirth”, borrowing from institutional vocabulary. However, they use expressions that go far beyond this to express their vision and role as midwives at the moment of birth, such as “holding space” and being “guardian” of the birthing process. Developing a language that is truly their own, to affirm their identity and uniqueness, is one of the challenges highlighted by this study.

Midwives face the challenge of a relational practice that accompanies women and families in their unique experience of giving birth in a maternity care universe oriented by the hospital and a medical vision of health. Ultimately, it is about finding ways to navigate this reality while preserving their professional stance and social mission.

We believe that the challenges and questions raised by this research could also resonate with midwives elsewhere in Canada and around the world, as they reflect on their practice and professional identity.