Narrative Inquiry into the Professional Identity-Making of Ghanaian Midwives

Abstract

Professional identity-making is a complex life-making endeavor that is shaped by both the personal and professional knowledge landscapes in which people live and work. Using narrative inquiry, four midwives who had worked in diverse contexts in Ghana were purposively selected. We highlight how midwives’ experiences across time, place, and in diverse contexts shape their professional identity-making. Three main life experiences that shape professional identity-making were discovered: 1. Childhood experiences, 2. Education experiences, and 3. Professional work experiences. Midwifery education should prepare students to attend to this complex and ongoing identity development, in order to enhance midwifery practice.

Introduction

Midwifery education and practice are means by which a layperson is transformed into a skilled and competent midwife. However, the institutional socialization processes of professional education as the only shaping force on professional identity-making are increasingly challenged. For Monrouxe, “Identity matters. Who we are, and who we are seen to be, underlies much of what we do in medical education” ^{1 (p. 41)}. In a study of medical learners’ narratives, Monrouxe ² identified eight themes in their narratives that illustrate the complexity of identity formation, emphasizing that personal and professional stories shape the identity of medical students and illustrating the importance of considering contextual, social, and temporal embeddedness of narratives. Narrative concepts of identity-making have also been explored in studies involving teachers and physicians^3,4

While research shows that midwives’ identities are shaped by how they are educated and socialized into the profession, ⁵ the shaping of midwives’ professional identities is more complex. If we focus on professional identity as only being a direct reflection of education, we limit considerations of midwives’ professional identity-making to midwifery education. Midwifery education, in both the classroom and clinical setting, is aimed at producing skilled, knowledgeable, and compassionate professionals to care for childbearing women, newborn infants, and families across the maternal cycle. ⁶ While midwifery education contributes to professional identity-making of midwives, there may be more that influences the professional identity-making of midwives.

As with all health care professionals, it is important that midwives develop a sense of themselves as professional midwives. Working with midwives to shape their professional identities is similar to the work that is necessary to develop professional identities for nurses, physicians, and others who work in health care. Clandinin and Cave ⁷ made similar observations regarding working with physicians in ways that would help them to shape their professional identities. They developed and used narrative reflective practice approaches with beginning physicians in order to understand and highlight the complexity of the experiences of physicians over time, places, and relationships in shaping their professional identities.

Understanding professional identity-making as a narrative process

My (first author) interest in midwives’ professional identity-making comes from my work as a midwifery educator. For over a decade of work as a midwife educator, I observed many young women with no interest in midwifery become competent midwives. My work, and my autobiographical narrative inquiry into my experiences within and outside midwifery education and practice, raised questions about how this shift to seeing themselves as professional midwives occurs and what experiences shape their identity-making processes. These questions moved beyond the notion of a professional identity given by certification following midwifery education and formed the basis to inquire into other ways midwives construct their professional identities.

Considering professional identity-making as occurring over time, places, and social interactions means thinking of professional identity-making as composed within the whole of one's life experience, that includes, but is not limited to, experiences in professional education. Thinking of midwives’ professional identity-making as an experiential process embodies an ontological perspective of understanding life as a series of experiences told and lived as stories. ⁸ According to Connelly and Clandinin's ⁹ narrative view of experience, human beings are story telling organisms who live stories and tell stories about their living. Being grounded in this understanding of life, narrative inquiry is both a methodology and a way of understanding experience.

Professional identity-making, part of a narrative understanding of experience, is shaped by both personal and professional knowledge landscapes in which people live. ⁴ Using a landscape metaphor to describe knowledge contexts allows for a sense of expansiveness and the possibility of being filled with diverse people, things, and events in different relationships. ¹⁰ A personal knowledge landscape comprises a person's personal knowledge contexts generated through experience over time, in different places, and through different interactions. A professional knowledge landscape comprises knowledge that is transmitted through formal education, training workshops, and protocols. ⁵ Narrative understandings, including personal and professional knowledge landscapes and stories to live by, are central to this study. Midwives’ identity-making is understood narratively with attentiveness to temporal, personal, social, and contextual factors that may shape the professional identity of midwives.

In this paper, we describe a narrative inquiry into the ways by which four midwives in Ghana experienced their professional identity-making and how their professional identities were shaped by family stories which shaped their early childhoods as well as by family stories of who they were, and were becoming, and by different professional contexts in which they worked. We show how professional identity-making is influenced by both personal and professional experiences, by early education and professional education, and how professional identity is expressed narratively through stories midwives embodied in their lived and told stories.

Narrative inquiry as methodology

The most commonly accepted definition of narrative inquiry is that it is a way of understanding experience. It is

a collaboration between researcher and participants over time, in a place or series of places, and in social interaction with milieus. An inquirer enters this matrix in the midst and progresses in the same spirit, concluding the inquiry still in the midst of living and telling, reliving and retelling, the stories of the experiences that made up people's lives, both individual and social, ^{11 p.20.}

Dewey's conception of experience, that is, that experience is “a changing stream that is characterized by continuous interaction of human thought with our personal, social, and material environment” , ^{12 p.39}shapes the work narrative inquirers undertake. Narrative inquiry allows us to understand professional identity as narratively constructed over time, in particular places, and within particular social contexts. The study inquired into the experiences of four midwives who had worked in diverse contexts in Ghana. ⁵ In this paper, we highlight the ways in which midwives’ experiences influence their professional identity-making. How do their experiences across time, place, and in diverse contexts shape their professional identity-making?

Methods

Guided by relational ethics, ¹³ the lead researcher purposively selected four study participants and developed a trustworthy relationship with them over a period of five months. Several face-to-face tape-recorded conversations with each participant were held at negotiated venues. The lead researcher also engaged in multiple other interactions and kept field notes on those interactions. Each tape-recorded conversation was listened to several times and transcribed verbatim. The lead researcher also documented her experiences as she worked with participants, which made visible her embodied responses of professional identity-making in relation with participants’ stories. Participants and the lead researcher co-composed narrative accounts, a kind of interim research text, through drawing on transcribed tape-recorded conversations and fieldnotes. These interim research texts of each midwife were shared with them in order to ensure their stories reflected their identity-making processes. Participants responded to interim texts by affirming their experiences. Final research texts were then constructed.

Ethical approval was obtained from University of Alberta Research Ethics Board (Pro 00066023) and from Noguchi Memorial Institute for Medical Research (ref. CPN 003/16-17). All participants were provided details of the study and signed consent forms. To ensure anonymity, participants chose pseudonyms which were used throughout the study.

Analysis and Results

After composing four narrative accounts, the four accounts were metaphorically laid side by side in order to discern resonant threads that reverberated across the accounts. One dominant narrative thread, professional identity as constructed narratively over time, and in diverse places, was identified. Participants told stories of their early experiences to show how their professional identities were, in part, shaped during childhood, and situated in early family stories, as well as shaped by the multiple professional knowledge contexts in which they were schooled and worked. In subsequent sections, we draw on the narrative account of one participant (Adjoa) to show her professional identity-making process as influenced by place, temporality, and sociality. We use the “first person voice” in order to let the conversations between Adjoa and the lead author be heard. We also discuss resonances between Adjoa's account and that of other participants.

Adjoa's account of professional identity-making

Adjoa, a midwife who owned a private maternity home, was in her early sixties. She retired from working in the public sector after over 30 years of service as a nurse/ midwife. Adjoa was invited to the study following an introduction by another study participant. Adjoa was enthusiastic about sharing her stories about becoming and being a midwife. Through informal meetings and telephone communications, Adjoa and I developed a trustworthy research relationship, which served as the basis for our subsequent face-to-face conversations.

Connecting the past to present in professional identity-making

Childhood stories of experience and professional identity-making

In our first tape-recorded conversation, I invited Adjoa to tell me about herself and how she got into midwifery. Her stories took me back to the village where she grew up as she spoke about people who shaped her early childhood and about the times and places in which she lived. The interplay of temporality, sociality, and place was evident in her stories of her childhood living. After our first conversation, we often returned to explore these stories in subsequent conversations and later, as I composed her narrative account, I saw how place, temporality, and sociality intertwined in shaping her identity as a midwife. She told of her grandmother who inculcated in her values such as respect, hard work, and truthfulness. “You cannot live with my grandmother and be lazy or disrespectful. We worked on the farm and you were expected to work hard, be it a boy or girl.” Adjoa grew up during a time when girl-child education was not a priority even for some city girls, let alone for a village girl. She did not have educated women to inspire her to pursue a career and had no thoughts about becoming a midwife or a professional of any kind. Traditionally the place of the girl child was in the home. Tending to pregnant women and helping them give birth in her village did not require formal education.

Adjoa traced her opportunity for a career, and core values as a midwife, back to the village and her upbringing.

I come from a poor family. My parents and grandparents were all farmers. It took the free education policy of Dr Kwame Nkrumah (the first president of Ghana) for me to get the opportunity to go to school, if not I wouldn‘t have gone to school. I wouldn‘t have become a midwife. ….. thinking about this privilege keeps me humble, it makes me want to help people all the time considering that I have received help too.

Through her grandparents’ nurturing, Adjoa embodied values such as respect, humility, compassion, and readiness to help. These values shaped her attitudes toward women she cared for as a midwife. The concept of respect, fundamental to midwifery practice, was embodied in her home.

Respect for human dignity is one of the key philosophical underpinnings of the International Confederation of Midwives. ¹⁴ Ensuring that midwives provide respectful maternity care is a current issue as records of abuse and disrespect have been recorded. ¹⁵ Although there is not a clear consensus as to what actually constitutes disrespect, there is evidence to show that women value being cared for with respect and dignity. ¹⁶ Every midwife is to embody respect for human dignity, an intrinsic component of midwifery care. For Adjoa, these core values were developed through her childhood experiences and upbringing by her grandparents.

Even with the free education policy, it took determination and perseverance for Adjoa to be allowed to go to school. She had to prove to her family that she could do well in school and become somebody other than what was traditionally expected of her. That determination to always rise above the status quo, succeed, and progress in life served as impetus to pursue a career as a midwife.

I have always been a very determined person in life. So wherever I find myself, I compare myself with my former state and determine to do my best and become better. This has greatly influenced my work as a midwife.

Having won the second-best midwife award in her region at a point in her career was confirmation of her determination and hard work. Adjoa linked her success as a midwife and her award to how she was brought up. In a later conversation, Adjoa read the citation that came with the award. The words in one paragraph evoked strong emotions and reminded her of who she was nurtured to be as an individual. It was a statement of recognition for a work selflessly well done.

You have served this region for almost 34 years as a Nurse/Midwife. In all these years, you have shown loving care to all the patients who have passed through your hands. Your determination to bring comfort and love to people especially those in the deprived area have seen you leaving the city to stay with them, denying yourself of social amenities like electricity and pipe borne water. Your preparedness to serve your clients anytime be it day or night have seen increase in antenatal cases at the health center. Your leadership style and readiness to learn from others made you a role model for others to emulate.

For Adjoa, the citation summarized who she was and recognized her sacrifices for women in the rural areas who needed help. The words in the citation showed how Adjoa had touched many lives. Her experiences in the different places had shaped her stories to live by, who she is and is becoming. Listening to her stories, and writing her narrative account made visible plotlines of her identity-making processes and how her experiences in different places, within different contexts, shaped her identity.

As I read and reread transcripts and field notes, I was drawn to her stories of growing up in the village, a particular primary six teacher, her work with a particular midwife during her nursing education, her work as a midwife within different social and geographical contexts and her faith in God. Adjoa often spoke about her faith in God, about her primary school teacher, and about how the village environment shaped her life. She recalls,

At that time if you were a girl in the village, education was not part of a conscious plan for you. It was no big deal if you didn‘t want to go to school. What was important was marriage. I wanted to go to school before marriage, my primary six teacher, saw that I was very interested in education and told my parents to encourage me to go to school… Knowing that my teacher believed in me was a form of motivation. I also see it as the grace of God. I could have been like any other village girl, go into marriage early and give birth to plenty children (we both laughed) but that wasn‘t what I wanted.

Adjoa and I reflected on different people in our lives who inspired us, and who modeled behaviors of a midwife. Adjoa spoke about a midwife she worked with during her training as a nurse, who motivated her and involved her in midwifery work even as a student nurse. I spoke about my midwifery tutor who taught with such passion that I was inspired, not only to become a passionate midwife but a midwifery educator. Adjoa told of an experience, as a village girl, when she perceived midwifery as an important profession.

I saw a woman in labour when I was a young girl. There was a woman in the village who assisted the women to give birth. I don‘t know if she was a TBA [Traditional Birth Attendant]… One day I was sent to go and call her because someone in the house was in labour. I was asked to run …. the pregnant woman was moaning in pain; I just knew it was a serious thing. When I went the woman (TBA) wasn‘t home so I came back home to report. I was instructed to go and search for the woman and come with her. When eventually she came, everybody in the house became relieved. I just knew that her profession was an important one. That was the first time I considered midwifery as an important profession.

Adjoa's interest in midwifery was influenced by the Traditional Birth Attendant in her village, Though not educated as a midwife, the role of the Traditional Birth Attendant in assisting women to give birth was significant enough to make a lasting impression on Adjoa and influence her choice of career.

In a later conversation, Adjoa revisited her childhood experiences, saying how they shaped how she relates, even now, with her clients. She told stories of how she worked in several rural communities and villages without looking down on the women but attended to them with respect, care, and compassion. Adjoa was convinced that her ability to respectfully relate with people of all manner of backgrounds has its roots in her upbringing in the village and her subsequent exposure to different work settings.

As for me I cannot look down or disrespect a person in any way. It is something that some midwifes don‘t know. I think that if you have not lived in the village like some of us who grew up in the village you will not understand the life there and you may not be successful working there unless you are prepared to learn.

Through Adjoa's experience of relating with people from different socio-cultural and economic backgrounds, she learned to build trusting relationships with clients and families over many years.

You have to understand the rural life to appreciate their behaviour and meet their needs. Unfortunately, there is nothing in our training as midwives that prepare us for that. I was brought up with farming so wherever I go I want to implement that too. I always had a farm. It makes them see that I identify with them. So when the people see that I have interest in what they do they open up.

Resonances across adjoa's, other participants’, and my childhood experiences

Although Adjoa, the other three participants, and I had different experiences, there were resonances across our experiences of developing a professional identity as a midwife. For example, Happy, another participant, also shared stories of her childhood experiences. Coming from a strong religious background, Happy was nurtured to be respectful, humble and caring. Unlike Adjoa, Happy described her decision to become a midwife as a calling. Her stories to live by, her identity, are grounded in her belief that she is ultimately accountable to a superior power (God) who sets the values and standards for her conduct. Happy's identity as a midwife was shaped by her personal philosophy of who a midwife should be and her life experiences within and outside the midwifery professional knowledge landscape. Beginning her nursing career at a mission hospital, Happy transitioned into midwifery already embodying values of humility, care, self-sacrifice, compassion, dedication, and respect for human life and dignity. These were the principles by which she was nurtured both at home and at the mission hospital where she was introduced into the health care profession.

All four participants had similar but unique accounts of how interacting with different people at places under different circumstances, as well as their experiences within and outside midwifery landscapes shaped their identities as midwives in profound ways.

Professional education stories of experience and professional identity-making

After middle school, Adjoa, who wanted to be a nurse, gained admission into one of the few nursing schools in the country at that time. She entered nursing training at the time when the Qualified Registered Nursing program was being phased out. In her school, she was among the first six students admitted to the Enrolled Nursing Programme. Adjoa described how she developed interest in nursing and midwifery.

I have always admired nurses. I admired how when someone is sick they take time to take care of the person and how the sick is cared for even at home. Especially how children are cared for with love and compassion I found it admirable. I had the impression that nurses were caring. I decided to be a nurse.

Her nursing education was a combination of concurrent working and schooling. Working alongside her professional schooling gave her the opportunity to get involved with some midwifery activities. This was her first actual encounter with midwifery practice, other than what she knew of the work of the Traditional Birth Attendant in her home village. Adjoa recalls that because there was a shortage of nurses and midwives, student nurses were required to be actively involved in acute patient care and sometimes provided maternity services under supervision. She described how she was given the opportunity to assist in the care of women in labor as a student nurse.

We used to go for night duty at the labour ward as student nurses, I developed interest to do midwifery. We went to the labour ward and attended to pregnant women. There was one midwife working there who took special interest in me. Usually when she gets cases from the sub-district she would have to go into the communities. She was elderly so sometimes she will give the delivery bag to one of us (students) and ask you to go with the ambulance.

On some occasions Adjoa was sent by the midwife to bring women in labor to the hospital. She was expected to carry a delivery bag in readiness to assist the woman to give birth if the need arose before they got to the hospital. On one occasion, she had to conduct the delivery alone and that experience was significant in shaping her confidence for, and her interest in, midwifery. When she arrived at a client's house to take her to the hospital, the baby was at the point of being born. Adjoa was forced to conduct the delivery based on what she had seen the midwife do at the labor ward.

I saw that the woman was not ready to get into the car and had sat down pushing, … I was shaking but was composed and very careful. I just did what I saw the midwife do. I had been with her on several occasions. She really involved me a lot in her work. So I cut the cord, delivered the placenta, and took the baby and mother to the hospital. I felt proud of myself. When I got back the midwife started calling me ‘my midwife’. I was happy. All these increased my interest in midwifery right from the time I went into nursing.

As we talked about Adjoa's childhood and upbringing through to her nursing education, I saw the different layers of experiences, exposure, opportunity, determination, faith, hard work, and mentorship as part of her identity-making processes. I was drawn to further inquire into my own childhood experiences and upbringing and could now connect the pieces of my past to my present and even envisage a future as a midwife. In a state of reflection during our conversation, Adjoa noted, “In fact, as I think about it now, my childhood and upbringing had made the midwifery work interesting for me. I don‘t see working hard as a burden.” She was beginning to connect her past to who she was as a midwife.

Resonances across adjoa's, other participants’, and my education experiences

Adjoa, through the narration of her experiences, described the processes that shaped her stories of professional identity-making. It was evident how her childhood experiences, through to midwifery education, and many years of working within midwifery knowledge landscapes were interwoven with her professional identity-making. Reflecting across the experiences of the four participants showed how midwifery education can transform a layperson into a competent professional. Martha, another participant, recounted how she initially did not want to become a midwife because she could not stand the sight of blood. While life circumstances forced her into nursing and midwifery, the training and socialization she received as part of her education contributed significantly to her present identity as a midwife. Anna, another participant who worked as a nurse, was moved by the obvious maternal health needs of women and the absence of a midwife in a village where she worked many years ago. Her experience shaped her decision to study midwifery. They all told stories of particular tutors and midwife clinicians who inspired them or positively modeled the profession to them. The lead author had similar stories of how her professional identity-making process was directly and indirectly influenced by education, and by the individuals who were involved in teaching and learning.

Professional work stories of experience and professional identity-making

Following Adjoa's successful nursing education, she worked as a nurse in two distinctively different health facilities: one was a small clinic and the second was a referral center. Although she did not get the opportunity to work at the maternity unit in both facilities, her interest in midwifery did not decrease. She hoped that one day she would become a midwife and care for mothers and babies.

After a few years of working, Adjoa received a transfer letter to work in a small village for six months. Though skeptical about the unexpected transfer, she accepted the offer, not knowing that it was going to be a life-changing experience for her and would significantly shape her future. It was a new clinic built between two districts in the Western Region.

This small coastal village became a place to launch Adjoa into her career as a midwife, a move that significantly shaped her identity. Adjoa spoke about her work in the small village. Although she was a nurse, the community members assumed that everyone who worked at the clinic could attend to every health issue including childbirth. With no other clinic nearby to refer women in labor, Adjoa assumed the role of midwife. Without formal midwifery training, she relied on her personal practical knowledge^5,17 gained from working with a midwife as a student nurse and from life experiences where she supported pregnant women who came to her. She recalled her student experiences of carrying the delivery bag to clients’ homes and assisting in delivery as part of her professional identity-making process. At the village clinic she ran clinics for pregnant women and conducted deliveries.

I wasn‘t a midwife then but I was working as a midwife. I did deliveries and other midwifery things. I knew I had to do midwifery. It was from there that I went to do midwifery. I remembered everything I did when I was assisting the midwife as a nursing student. The only thing is that every pregnancy and birth is different but I didn‘t know that then but somehow I always figured out what to do.

Adjoa's identity-making was also shaped by the social environment in which she lived as well as by her relationships with women as well as with members of the entire community. Getting to know and understand people was significant in her stories of becoming and working as a midwife.

I had to learn the Nzema language. When they came to the clinic they spoke Nzema. If you don‘t speak, you continue to be a stranger to them so I had to learn. I did some farming too. It is something I love to do. Even here you can see I have a small garden. I think in the village it makes the people feel you are part of them.

This sense of belonging and security became important to ensure that the community patronized the clinic. It also deepened Adjoa's understanding of the importance of relationship in midwifery. Ultimately building positive relationships with clients and families became part of who Adjoa became as a midwife. Learning to speak the Nzema language allowed her to become part of the community and not to be perceived as a stranger. As part of increasing her acceptance by the community, Adjoa kept a farm and occasionally hired locals to work on the farm. Her farm being part of her out-of-work activity kept her occupied and helped her to enjoy her stay better. Working with a narrative concept of identity-making makes visible often silent ways that professional identities are shaped. Some of these seemingly unrelated events that facilitate the work of the midwife can easily go unrecognized.

Adjoa's success in working in that particular community and in others she told me about were not solely due to her ability to take care of pregnant women and conduct deliveries. It seems that her ability to relate to the community in familiar ways and be innovative was what ensured her success. These experiences shaped her identity as a midwife.

Resonances across adjoa's, other participants’, and my professional work experiences

Participants showed how drawing on their personal practical knowledge as well as their technical knowledge took leadership and collaborative initiatives to enhance their work. Martha narrated how she took the initiative to collaborate with an entire community in order to gain their trust and get mothers to seek professional care. Martha spoke of how her ability to socialize and collaborate with community members as well as to reach out to other colleagues when she needed help facilitated her work in the villages. She stressed the importance of humility and relationship building in midwifery. This too resonated with the first author's experiences. Martha understood that relationship building, alongside personal practical knowledge, was key to a successful midwifery practice.

I needed the community to collaborate with me so I thought of how best to do that. Personally, I am a very sociable person. I easily get along with people. And I am always ready to help anybody who comes to me for help. I was very interested in doing the work well. I also needed to get clients to attend the clinic. I could be there for over one month with no deliveries. I wanted that to change so I had to do that to win them.

Discussion

Making meaning from the narrative accounts

Professional identity-making processes as described by the four midwives in this study is characterized by various life experiences occurring over time, at different places, and as a result of different social interactions. The midwives highlighted their childhood experiences as the starting point for their stories to live by, their identities, as midwives.

Looking across all four narrative accounts and my own stories of professional identity-making, it becomes evident that midwives’ professional identity-making, although unique to each individual, have resonances across their uniqueness. Our findings show how midwives have constructed their identities and how their identities have shaped their practices. Additionally, we show how their contexts have shaped their identities. One way for midwives to think about who they are and are becoming in their profession is through the stories they tell about their experiences from different knowledge landscapes.

Midwifery education and practice have changed and keep evolving over time as do social, cultural, and familial narratives in which midwifes’ lives are composed. These dynamic personal and professional knowledge landscapes have significant parts to play in shaping professional identity-making. Adjoa's past experience of living and growing up in the village helped her to adjust quickly and work in rural communities for years and shaped her professional identity. Martha's educational experience, her ability to socialize, collaborate, and lead influenced her identity as a midwife. Happy's belief that midwifery is a calling and that she was accountable to a superior power influenced who she became as a midwife. In similar ways Anna's life experiences including her own childbirth experience are plotlines in thinking about her professional identity.

Shifting the educational professional knowledge landscapes

As the participants’ stories of their experiences show, different life experiences come into play in professional identity-making including education, upbringing, and work contexts. Attention needs to be paid to the individual midwives who are sent to particular places to provide care. Midwifery curricula, though standardized in Ghana, must provide opportunity for students to experience the different knowledge landscapes of midwifery practice.

Midwives who are transferred or posted to places where they do not have prior experience must be supported. One way to work with them is to help them construct or reconstruct their professional identities in order to help them find ways to take up the new opportunities in these unfamiliar places. It is also important to psychologically prepare or empower midwives, especially newly qualified ones, before they are sent out to unfamiliar places, places that are completely different from those of their childhood experiences and their experiences in midwifery education. Equipping them to inquire into their identities, their stories to live by, in order to know who they are as midwives, to know what values and beliefs they hold, and to know what experiences have shaped their beliefs, values, and attitudes offer ways to begin to work with midwives around their professional identity-making. Ensuring that there are reflective narrative writing opportunities in the planned curriculum is another way to do this work.

In this study, the most significant aspect of their identity-making process was how they all reconstructed their professional identities through the stories they told about their experiences. There are three dimensions of importance about the professional identity-making processes of midwives: importance of professional identity-making professionalism; importance of how identities can shape care relationships and influence care; and the importance of how professional identities can enhance midwives’ ability to take their place in multidisciplinary health systems as effective collaborators and leaders.

Implications

Professional identity, described as the cornerstone of professionalism ¹⁸ calls us to position professional identity-making as important to midwifery education and as a profession. Professional identity in midwifery; however, has not received much attention in the literature as compared to other disciplines. For example, research into teacher professional identity has been carried out over decades.^4,11 Midwife professional identity-making is one area that needs research attention.

Much research in midwifery focusses on pushing forward the agenda of safe motherhood by ensuring that every birth is attended to by a skilled birth attendant. Several initiatives have been rolled out in Ghana and other parts of the world to advance this agenda. Prosser et al ¹⁹ identified gaps in midwifery practice that led to measures to increase the number of midwives by increasing access to training and equipping them with the necessary knowledge and skills to operate at a highly professional level. All these initiatives were put in place to ensure quality care and to reduce maternal morbidity and mortality. The successful implementation of all these initiatives requires some level of professionalism from the midwives. It is vital to pay attention to ways by which developing professional identities can be enhanced among midwives. A study that looked at developing professional identities in medicine, noted that having a strong professional identity helps one to consider personal values and how they relate to what the profession requires, as well as the expectations of clients and other professionals. ¹⁷ Improving the skills of midwives and equipping them with technical knowledge is very necessary and important in ensuring professional standards are upheld, but guiding midwives to develop strong professional identities is equally necessary to augment a successful professional practice.

Midwives’ professional identities, who they are and what they stand for within professional spaces, influence how they relate with their clients and how care is provided. Adjoa and the other participants showed how their individual identities, constructed from different life experiences, helped them to effectively use the knowledge and skills acquired through education and training into living out caring relationships with their clients. The stories they live by suggest that a personal understanding of ones’ professional identity as a midwife shapes how care is provided. In other words, the relational aspect of midwifery practice could be linked to the professional identities that midwives consciously or unconsciously have of themselves. Constructing professional identities will enable midwives to consider their own values, beliefs and attitudes and how it influences who they are expected to be and how they are expected to act as midwives. Becoming conscious of their own beliefs and values also helps midwives to work with women with an understanding that women come into the midwifery space with their own identities and philosophy of childbirth and motherhood. As midwives come to understand that identity is constructed narratively, they may become more conscious that women bring to the childbirth process all the experience that shapes how they perceive themselves as mothers. This understanding is significant for the relationships midwives build with their clients, and shape how they care.

Considering that relationships in midwifery practice could be with the woman, her family or even an entire community, ⁵ the perceived identity of midwives (individual or group) by the public is also important. The public (mother, family and community) relate with midwives based on the perceived identity they (public) have of midwives. A systematic review conducted by Bohren et al ²⁰ on the mistreatment of women during childbirth in health facilities, have revealed that such mistreatment can happen between the women and their providers, including midwives. Several initiatives have been proposed to change these narratives. From this research, professional identity-making can be considered as a possible starting point for midwives to conceptualize relationships. The better the midwife understands herself and what she represents, the better she may understand her clients.

Furthermore, developing strong, positive professional identities has been found to encourage the development of confidence, enhance collaborative leadership skills, and promote team work. ²¹ Currently nurses and midwives globally are being challenged to aspire for leadership positions. The 2020 year of the nurse and midwife agenda, dubbed the Nightingale Challenge, seeks to inspire the next generation of young nurses and midwives into leadership positions. This challenge follows the International Council of Nurses’ realization that although nurses and midwives are expected to take up bigger roles in the multidisciplinary health care system, they are often held back for reasons such as inadequate training in leadership skills. The aim is to inspire confidence and personal development. Developing a vibrant professional identity is of great importance to achieving this aim.

Recommendations

Education

Although there are many benefits associated with developing strong, positive professional identities, not much is known about ways in which midwives are guided to practically construct their professional identity. It is recommended that midwifery educators should explore and consciously provide opportunities for students to reflectively construct their professional identity by paying attention to the different life experiences that shape who they are, and are becoming, as midwives.

Research

Research regarding ways by which student midwives can be guided to develop their professional identity is needed. It is also important to explore and document how the professional identity of midwives influence the care they provide.

Conclusion

Professional identity-making is a complex life-making endeavor that is shaped by personal and professional knowledge landscapes.^9,22 It was evident in the experiences of the midwives who participated in this study that they composed their identities over time, in particular places, and within particular social and individual contexts. It is critical for educators and decision makers to attend to this complex and ongoing identity development, in order to support and enhance midwifery practice and education.