1 Introduction

Education and Professional Practice of Midwives in Portugal/Spain

The professional practice of midwives requires a previous path in which motivation, effort and search for knowledge lead to the definition of a personal profile and a professional identity ^[1][2]. The teaching-learning process of midwives is developed through international guidelines, which define the standards both for undergraduate students and for the educational institutions ^[3][4][5]. Working as a midwife is a reason for pride, affirmation and manifestation of dexterity in a given territory of specific care. In some countries with fewer health resources, despite the low economic compensation, being a midwife represents a personal and professional gain in the gratification felt when taking care of and benefiting women in the pre-, intra- and post-partum periods ^[6].

Midwives' training in the countries of the Iberian Peninsula follows European guidelines, despite having a more academic focus in Portugal during theoretical curricular phase. The classroom contents and clinical experiences follow the same pattern, addressing the reproductive stages, sexuality, gynaecology and climacteric.

Introduction

Choice of a professional career is not only grounded on circumstantial reasons, but especially on image, social stereotypes and performance expectations. It is an important life stage, as it idealizes investment and devotion to a given knowledge area that will occupy a significant part of a person's life. In addition to the professional and social image, self-concept advances step by step towards the proficiency level to be achieved. Such proficiency is rooted in personal characteristics and individual competences, perhaps influenced by the values from the previous professional training, by the surrounding work culture, and also by previous experiences or models ^[7][8].

Motivation consists in persuasion and enthusiasm to achieve a given goal ^[1][9], leading to deliberate goal-directed thoughts and behaviours ^[10]. When motivation is strong, it overcomes difficulties, either predicted or not. High persistence and strong beliefs ease the decisions and direction for choosing a profession ^[11]. Among these options, the health area is frequently reported in relation to social prestige and to interest in an economically satisfactory future, but also to the altruism of wishing to assist/care for/support the “I” that exists in others, in similar beings ^[1][12][13]. The motivation to become a midwife, supported by both intrinsic and extrinsic factors, is fed on personal and emotional investment. It contributes to self-definition of the professional profile or identity ^[1][2]. Midwives' training has specific characteristics, as the learning process must follow international standards, which determine requirements for the students and for the institutions that train them ^[3][4][5]. Being a midwife is a reason for pride and provides strong professional conscience, even in remote places, despite the low wages, and despite the precarious working conditions. In addition, for midwives working in these conditions, being able to offer the best care and assistance possible to women in the pregnancy-puerperal cycle represents a personal and professional gain ^[6].

Midwives' professional role, anchored in a phase of human vulnerability, also contributes benefits to professional self-image ^[14], perhaps motivating choice of the career. Midwives are known to enjoy their profession ^[1][15], with the representative institutions conferring them due relevance in health care ^[16]. In fact, midwives are human preservation agents, providing essential care in view of the mother-child dyad vulnerability and of the uniqueness and singularity of each delivery, each childbirth, probably collaborating to perpetuation of the species. It will be in this care-related essence that the training of midwives will be grounded.

In Europe, in accordance with the principles of the Bologna Declaration, the qualifications to be achieved were identified, based on the pillars defined by Directive 2005/36/CE and by the Munich Declaration, with several training modalities taking place. In the European Community, the variations are especially related to a change in the training paradigm, in which the vocational/professional model is giving way to a graduate/student teaching model ^[17][18]. The main differences lie on the proportion of theoretical hours over practical hours ^[19][19]. A conflicting difference can be related to the academic level: undergraduate degree versus graduate or Master's degree ^[20]. Other differences are duration and access. For example: a) in the United Kingdom or Malta, midwives' training lasts three years; and b) in Croatia, access to the course is possible after finishing 8 years of study ^[21]. Although some studies point to a Master's academic level in Portugal and Spain ^[22], this is not entirely true. The professional activities also present some differences in the professional practice of midwives (Directive 2005/36/EC). In France, Sage-Femme can prescribe some drugs (haemostatics, local analgesics) and ancillary diagnostic tests (X-ray, ultrasound) ^[23]. Conversely, in Portugal and Spain, access to midwives' training requires finishing the Nursing undergraduate course (Bachelor's degree/Degree), which is not the case in other countries. This difference has even a pejorative implication, as these countries understand that there is emancipation between Nursing and Obstetrics ^[21].

2 Midwives' Education in Portugal and Spain

Midwives' Education in Portugal. A total of 18 years are required to enrol and attend the training course that enables working as a midwife. In sequence: a) 12 years of mandatory schooling ^[24]; b) four years to obtain the Bachelor's degree in Nursing; and c) two years of effective clinical practice as a nurse. The last criterion is a requirement of Ordem dos Enfermeiros (OE) for the candidates working in Portugal. The interested candidate applies on their own initiative to one of the Higher Education Institutions (HEIs) that provide such training. In the selection process, the curriculum is evaluated and scored. Students can be admitted or rejected according to the number of vacancies annually announced by the academic institution. Successful completion of the two-year training program grants the student an academic Master’s degree, that is, the 2^nd cycle academic qualification.

Midwives' Education in Spain. Training in the area is designated as Obstetrics-Gynaecology Nursing (Midwife), and the candidate can access after a 16-year training path: a) 12 years of basic education; and b) four years of “undergraduate” in Nursing ^[24]. The candidate, a Nursing graduate, sits for a state exam, which is announced annually by each autonomous community, for admission to the specialization. The state exam calendar is published in the Official State Bulletin (Boletim Oficial del Estado, BOE). After 2003 (Law No. 44/2003 of November 21^st), each Midwife Teaching Unit from each autonomous region defines the number of vacancies for the Obstetrics-Gynaecology Nursing specialization. Therefore, each hospital that is accredited to receive students (Midwife Teaching Unit) annually defines the number of vacancies if it understands that there is a training need ^[25]. It is not possible to apply directly to the Teaching Unit, as is the case with the applications for Master’s degrees in Universities.

The training model is called “Resident Intern Nurse” (Enfermero Interno Residente, EIR), and admission is through a written contract with the Teaching Unit (Royal Decree 1,146/2006). Annual signature of the contract requires a previous medical examination as a proof that the student is healthy. In this document, the mentor that will monitor the student's progression is designated. The student earns a salary, which is the base salary and is not allowed to work and study at the same time.

Table 1 presents a summary of the training topics in Portugal and Spain^*.

*Adapted from ^[26].

3 Midwives' Professional Practice in Portugal and Spain

The essential purpose of the rules and principles of the midwives' professional practice, classically called Legis Artis, is human life and its perpetuation. The changes in the human body, particularly in the pelvic structure, imposed by the shift from brachiation to bipedalism ^[27][28], led to the phenomenon called “obligate midwifery”. It is on these human adaptations, overcoming the obstetrical dilemma ^[29] between the mobile foetus and constrains of the pelvis, that midwives provide care to women.

In Portugal, the professional practice of midwives is regulated by Ordem dos Enfermeiros (OE). This public law organization (Law No. 156/2015 of September 16^th) is governed in the same way as all professional associations in the country (Law No. 2/2013 of January 10^th). It is an autonomous and independent body responsible for regulating the profession, not to be mistaken for a union organization. Preserving people's rights, good assistance and guarantee of the human interests are functions of OE. OE also has an authority role in the knowledge area and defines the professional competencies to be attained during training. Once academic training is finished, the processes of the individuals with a Master's degree in Maternal and Obstetric Health are submitted to OE, for the necessary accreditation as a Nurse Specialized in Maternal and Obstetric Health (Enfermeiro Especialista em Saúde Materna e Obstétrica, EESMO) and, thus, to be allowed to work in the country (Article 2, No. 2).

In Spain, the profession of Midwife is regulated by competences that comply with the European law. Midwives are autonomous professionals that work in the primary and differentiated care scopes. The coverage area includes reproductive health, sexuality and climacteric. In addition to the clinical area, the normative also recognizes the following as performance fields: management, teaching and research. There is acknowledged investment in research and publication, namely in subject matters that deal with its care-related autonomy ^[30] or in continual improvements in care, as is the case of the evidence-based practice ^[31]. Completion of the EIR is a way to access the PhD course.

Table 2 presents some topics regarding the professional practice in Portugal and Spain.

Table 2 Topics regarding the professional practice in Portugal and Spain.

*Adapted from ^[26].

In summary, although with the same European directive as a starting point, the EESMO and Midwife training courses follow different paths ^[32]. In Portugal, training is more academic in the first phase, in the theoretical field, with academic disciplines that last two semesters in 1^st year. In both countries, the clinical experiences follow the same pattern in the practical fields. Regarding this matter, internships are supervised and take place in the context of care for the reproductive cycle, sexuality, and pre- and post-reproductive gynaecology, as well as in the pre-conception and climacteric phases.