Doing professionalism "differently" : negotiating midwifery autonomy in Aotearoa/New Zealand

Abstract

This thesis examines how midwives have been doing professionalism in Aotearoa/New Zealand since gaining the legal right to practise independently of doctors in 1990. It analyses midwifery autonomy as a complex and contingent outcome of a competitive political process involving key groups of actors in the health/maternity field. Unlike approaches that regard professional status simply as an outcome of an occupation’s organisational structure or political strategising, this account seeks to tease out some of the complexities involved in the relational construction of professional positioning. In the process it shows how midwifery has been able to utilise gender, profession/state and profession/consumer relations as resources in its efforts to obtain and consolidate an autonomous status vis a vis nursing and medicine. In examining the professionalising strategies of midwives, attention is paid to the role played by state actors in enhancing or diminishing the jurisdiction that a profession has over an area of work that is constituted as ‘expert’ practice. This is demonstrated in the thesis in relation to both the granting of midwifery autonomy and the subsequent introduction of fixed-fee funding for primary maternity services. These policy changes had significant implications for midwifery and medical autonomy, forms of practice and relations with clients. Discussion of how the change in funding arrangements created opportunities for midwifery to consolidate its jurisdiction over ‘normal’ childbirth highlights the significance for professions of aligning their interests with broader political and economic objectives. Analysis of how midwifery has been constituted by midwives and maternity consumers as a form of feminist professional practice based on ‘partnership’ shows how particular constructions of gender and expertise can be used as discursive resources in the struggle over autonomy. Doing professionalism according to this ‘new’ model of practice involves positioning midwives as autonomous practitioners vis a vis other health professionals but as ‘partners’ with maternity consumers. It is argued in the thesis that a distinction between ‘old’ and ‘new’ forms of professionalism should be seen as a false dichotomy. While ‘new’ professionalism may provide the basis for more equitable professional/client relations, it also supports an alternative claim to ‘expertise’ and autonomy. Professionalism should be understood as socially situated, both in practice and discursively, and as subject to interpretation and redefinition. Rather than conceptualising a shift from one model or ideal-type of professionalism (‘old’) to another (‘new’), it is argued that different forms of professionalism exist simultaneously and can be strategically utilised by professions in ongoing contestation and negotiation over professional status. How a profession uses its knowledge base as a resource in claiming jurisdiction over work that it constructs as a form of ‘expert’ practice is variable. Opportunities for doing professionalism ‘differently’ are contingent on a profession’s embeddedness in networks of relations with state actors, clients and other professions.