Midwifery Regulation Research Articles

The Critical Social Voice of Midwifery: Midwives in Ontario

Many researchers have called community midwifery of the 1970s and 1980s a social movement. At the heart of the many goals of that movement was the desire to bring about significant social change regarding the medical and social contexts of birth. This article is an initial exploration into the critical social voice of midwifery and its current expression in Ontario, through interviewing midwives about their thoughts on the connections between midwifery, social activism and social change. The regulation and funding of midwifery in Ontario has created a new structural environment for midwifery practice and it is the phase of socio-cultural change following legislative change that is the focus of this paper. Speaking with midwives about midwifery practice and social change will help make visible the oppositional, critical work that midwives continue to do. This paper focuses on four themes identified as particular sites of the social change work of midwives in Ontario.

Birth at Home – At Home With Birth

In Canada, homebirth and midwifery seem to be inseparable. Prior to regulation, women wanting homebirths sought midwives and women wanting midwifery care often gave birth at home. Choice of birthplace, including the option of homebirth became a central tenet of regulated midwifery across the country. In this paper, the experience of homebirth is explored. Women and midwives from four provinces, both before and after midwifery regulation, spoke of their experiences of homebirth. Using hermeneutic phenomenological analysis, themes related to experiences of time, space, relationships and embodiment were identified. While some of the women's stories include comparisons of their births at homeandhospital,theobjectiveistouncoverwhatitisliketogivebirthathome notwhatisbetterorsafer or more challenging than other birthplace choices.

Community As Client: A Qualitative Descriptive Study of the Work of Midwives to Increase Access to Midwifery Care

Increasing access to midwifery care for disadvantaged groups was an explicit goal of the regulation of midwifery in Ontario. However, people of low socio-economic status (SES) remain less likely to receive midwifery care. We conducted a qualitative descriptive study to explore the work midwives do to make midwifery care accessible to people of low SES. We interviewed 13 Ontario midwives serving people of low SES, who practiced midwifery in settings ranging from a remote solo practice to a large urban practice. Participants described a broad range of ways in which they work to enhance the approachability, acceptability, availability and accommodation, affordability, and appropriateness of their services for people of low SES. We identified two distinct approaches to increasing access to care: (1) working to maximize the existing beneficial aspects of the midwifery model to whoever presents to care, and (2) stepping outside of the confines of the midwifery model, to provide what we call “community-centred care,” in which midwives are both a part of and responsive to the broader communities that they serve. The intentional, pro-active approach used by midwives providing community-centred care could be implemented more broadly to improve access to midwifery care for people of low SES. This article has been peer reviewed.

Similarities in midwifery education, regulation, and practice across Europe – a literature review

Similarities in midwifery education, regulation, and practice across Europe – a literature review

Quality Assurance in Nursing and Midwifery Education in Pakistan; Issue and Challenges

Quality is a subjective term that means excellence and reliability of performance. Quality assurance (QA) is concerned with reviewing the performance of services after the utilization of the services. QA is the systematic process of determining whether the services meet specified requirements. The concept of QA is rooted in middle ages, and its practices became more indispensable and popular in the USA during World War II.1 It is disclosed by current research that QA develops and maintains a set of requirements for manufacturing steadfast products or services. Indeed, the QA system considerably enhances customer confidence and credibility as well as the productivity of the organization which improves work process and efficacy.2,3 In higher education, the term quality assurance is increasingly used to refer to academic standards; that is, the level of academic excellence achieved by graduates not only maintained but improved consistently. Ensuring quality in higher education is critical for production of competent graduates.4 Nursing is considered the backbone of any health system; therefore, maintaining an optimum number of competent nurses is one of the key priorities of any health system. Pakistan is facing a critical shortage of nurses for its rapidly growing population, and the country is estimated to have a shortfall of up to 1.3 million nurses as per the nurse population ratio.5 To cope with this huge shortage, Pakistan has recently allowed the opening of more nursing colleges; however, this has posed certain challenges to the system, including assuring and maintaining quality in these new schools. World Health Organization, Eastern Mediterranean region, has identified six standards for nursing and midwifery education; these include; a governance structure that encourages autonomy, an administrative structure with the responsibility to carry out the policies of the institution, a conducive teaching and learning environment, graduates of the programs must be prepared for professional practice according to standards, a sufficient number of faculty and sufficient infrastructure and teaching learning strategies.6 There is a need to ensure quality in nursing and midwifery education in Pakistan to ensure graduates possess the required competencies and can work competently at local, national, regional, and international level.7 The challenges to ensure these standards are strengthening regulatory bodies, ensuring an optimum number of faculty and infrastructure, induction of quality students, and provision of optimum clinical training facilities for students.8 QA is recognized as increasingly essential for nursing education to ensure high-quality nursing delivery to sick patients. It is established that there is little evidence to endorse the existence and implementation of a comprehensive and vigorous QA system in Pakistan. Pakistan Nursing Council (PNC), as a regulatory body of Nursing in Pakistan, is mandated to establish minimum criteria for establishing nursing, midwifery, or a public health school institute.9 PNC is the country’s key regulator of nursing and midwifery education. Along with this, with the establishment of BSN programs across the country, the health sciences universities are also one of the key stakeholders of nursing and midwifery education regulation. Likewise, the Higher Education Commission of Pakistan sets the curriculum for undergraduate nursing programs in liaison with the Pakistan Nursing Council. To ensure minimum quality, there is a need for strong coordination among key regulatory bodies. There is a need to develop a robust mechanism for ensuring minimum standards in nursing and midwifery education nationwide.

Single registered midwives contributing care for general patients: a scoping study

Background: Midwifery vacancies persist in small maternity units in Australian rural and private settings where midwives are expected to also care for general (non-maternity) patients when midwifery activity is low. Recruiting dual registered nurse/midwives over single registered midwives is preferred, as single registered midwives are seen as inflexible to assist with nursing work. Little is known about single registered midwives’ contribution to care of general patients in small maternity units. Objective: This scoping study aimed to consult single registered midwives and managers of single registered midwives to determine perspectives on single registered midwives’ contribution in small maternity units where the workload encompasses both midwifery and care of general patients, to inform further research. Study design and methods: This study used a qualitative description design. Two online focus groups were held, one containing three single registered midwives, the other three managers of single registered midwives. Similar questions were posed to each group about single registered midwives’ contribution to care in small maternity units. Data analysis was conducted collaboratively through coding and thematic categorisation processes. Results: Four major categories were found. Single registered midwives’ scope of practice concerning general patients is undefined; single registered midwives possess transferrable clinical skills applicable to general patients; practical, professional, and emotional barriers exist for single-registered midwives in small maternity units; and future research recommendations include scope of practice and workplace experiences. Discussion: Persistent midwifery vacancies are implicated in the closure of small maternity units to the detriment of childbearing families. Understanding the contribution of single registered midwives in small maternity units will inform future research and midwifery recruitment strategies to improve access to services. Conclusion: The experiences of single registered midwives working in small maternity units warrants further investigation. This scoping study contributes to the literature about single registered midwives’ experiences in small maternity units and suggests considerations for future research. Implications for research, policy and practice: Findings from this study provide information about the contribution of single registered midwives to small maternity units where there is an expectation to contribute to care of general patients in addition to midwifery. Future research into the experiences of single registered midwives working in these settings will generate information to inform recruitment strategies, potentially improving access to maternity care in small maternity units and may be used in the review of midwifery regulation and educational standards. What is already known about the topic? Midwifery vacancies persist in small maternity units in rural and regional areas where the workload comprises both midwifery and nursing practice, despite strategies to recruit dual registered nurse/midwives. Dual registrants face challenges in maintaining both nursing and midwifery professional obligations in small maternity units. There are increasing numbers of single registered midwives registering each year in Australia and educational opportunities to become a single registered midwife exist in rural settings. What this paper adds: Single registered midwives make a useful contribution to care in small maternity units, and they assist with the care of general patients. The scope of practice for single registered midwives in assisting with general patients is not defined. Recommendations for future research include scope of practice for assisting with general patients and workplace challenges faced by single registered midwives because of their midwife-only qualification.

Nursing and midwifery education, regulation and workforce in Kenya: A scoping review.

To explore contextual literature on nursing and midwifery education, regulation and workforce in Kenya to develop an understanding of the current state and inform opportunities to strengthen the nursing and midwifery professions. Kenya has yet to achieve the minimum nursing and midwifery workforce threshold, despite the exponential increase in population and epidemiologic disease transitions. There are glaring health gaps and inequities in sub-Saharan African countries. Health systems are evolving into complex and costly utilities, increasing the demand for nurses and midwives. It is, therefore, necessary to re-examine systems that educate, deploy and retain the nursing workforce, especially given the ongoing COVID-19 pandemic and increase in non-communicable diseases. This scoping review was guided and reported following the PRISMA-ScR guidelines. Four electronic databases (PubMed, Scopus, CINAHL and Web of Science) were probed for relevant studies conducted in Kenya between 1963 and 2020. The search was supplemented using Google Scholar. Findings from selected studies were extracted and analysed thematically. Of the 238 retrieved studies, 37 were included in this review: 10 articles on nursing and midwifery education, 11 on regulation and 16 on the workforce. There have been changes in regulation and an increase in nursing and midwifery enrolment and graduates. However, maldistribution and shortage of nurses and midwives persist. Kenya's nursing and midwifery professions have undergone significant changes to meet the demand for a skilled workforce. However, the shortage of qualified and specialised nurses and midwives persists. Moreover, this shortage is exacerbated by underinvestment, outmigration and a need for more reforms to expand the nursing and midwifery workforce. Investment in nurse and midwifery education, mentorship and legislation is needed to build the capacity of the profession to provide quality health services. Several nursing and midwifery policy changes utilising a multipronged approach involving stakeholders' collaboration are suggested to address the bottlenecks from education to deployment.

Self-perceived competency of midwives in Kenya: A descriptive cross-sectional study.

Midwifery competence is demonstrated in the context of midwifery education, regulation and practice to support the quality delivery of care to women. Midwives with appropriate competencies can deliver up to 80% of maternal health services. The pre-service education programmes in Kenya offers different midwifery competencies for the various programmes, influencing expected outcomes in practice. This study aimed to assess midwives' perceived level of competence based on the International Confederation of Midwives (ICM) standards in Kenya. The study was conducted in selected public health facilities in Kenya. An observational cross-sectional design was used. A multi-stage sampling technique was used to select the counties and health facilities and random sampling to determine 576 midwives. Data were collected using a self-administered assessment tool adopted from the ICM competency domains. A total of 495 (85.9%) midwife respondents participated in this study, of which 389 (78.6%) respondents in all training categories were highly competent in the four ICM domains. The midwives' qualifications and facility level were associated with their self-perceived competence during practice. Those trained in the direct-entry midwifery programme were more competent, p = 0.016 (Kruskal wallis H = 8.432). Midwives' competence was influenced by the level of education and facility where they practice. All pre-service midwifery programme graduates must meet the essential ICM competencies and need to enhance continuous professional development (CPD) programmes and facility-based mentorship for the midwives.Contribution: To optimise midwifery-led practice in primary health care, midwifery competence should be enhanced in pre-service and in-service education for improved health outcomes.

A historical narrative of the development of midwifery education in Indonesia

AimTo describe the history of midwifery education, present the current education programmes and explore the ways that have been undertaken to advance the midwifery profession in Indonesia. MethodsHistorical and contemporary government documents were reviewed. FindingsThe history of midwifery education in Indonesia shows a complex picture during and since colonisation with government, education institutes and association proposing different ways in which midwives were to be educated. Advocacy from the midwifery profession in Indonesia meant increasingly it is midwives who are determining how midwifery education is provided. Recent initiatives have resulted in a diploma, advanced diploma, bachelor’s degree, and a master’s degree in midwifery. The work of the midwifery profession advocating for midwifery education culminated in the Midwifery Act 2019. These changes in this Act will ensure that midwifery education meets the needs of women and their families but also lead to competent midwives who have the knowledge and skills to provide midwifery services at all levels of health provision. The history of midwifery in Indonesia illustrates the importance of the ICM pillars of association, regulation, and education. ConclusionThe history of midwifery education in Indonesia shows that for too long midwifery education was decided, determined and even regulated by authorities and disciplines other than midwifery. However, when the midwifery association and regulation inform and regulate midwifery education then there is an opportunity to provide care that will make a difference in outcomes for women and their families. The historical analysis of the story of Indonesia midwifery gives insight into what is required for quality education.

From the community handywomen to frontline heroes: Charting a century of Irish nursing and midwifery regulation

Abstract This paper argues that professional regulatory frameworks are shaped by sociocultural factors and prevailing ideologies that stem from society’s interactions with and expectations of the regulated professions. Taking a century of Irish nursing and midwifery regulation as a case reflection, the paper highlights five regulatory pivot points to provide a historical narrative of how adopting a sociocultural perspective can enlighten our understanding of the current regulatory form. A form that in early twenty-first-century Ireland resulted in the establishment of a professionally contentious, non-professional (lay) majority on the regulatory board for these frontline professions. The paper concludes by suggesting that when viewed through a sociocultural lens, regulatory change is to be expected. As prevailing ideologies change, power, influence and cultures alter to support and reinforce the new ideology. Professional regulation thereby becomes reflective of society’s views on professionalism and professional identity, drawing on society’s historical experiences of the professions.

Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations

IntroductionMidwifery associations are organisations that represent midwives and the profession of midwifery. They support midwives to reduce maternal and newborn mortality and morbidity by promoting the overall integration of midwifery...

The Regulation of Professional Midwifery in the United States

The World Health Organization (WHO) designated 2020 as the International Year of the Nurse and the Midwife. Part of the WHO campaign focuses on the fact that nurses and midwives comprise more than half of the shortfall in the global health workforce. In the United States, maternity care is critical because half of rural counties have no access to maternity providers and because the rate of maternal morbidity and mortality continues to climb, surpassing rates of countries with similar incomes. Midwives have a proven record for quality, safety, cost-savings, and high patient satisfaction, yet they attend only 10.2% of births in the United States. In many countries with better maternal mortality and morbidity outcomes, midwives attend 50% to 70% of births. This article reviews the history of professional midwifery in the United States, including the development of the certified midwife credential, outlines current challenges in regulation of the profession, and summarizes widely accepted recommendations to improve access to high quality maternal and child health through support of the midwifery workforce. It is intended to assist state boards of nursing in understanding how they might expand their authority to include the licensing and regulation of certified midwives.

Medication access and midwifery integration: An example of community midwifery advocacy for access in Washington State, USA.

Medication access and midwifery integration: An example of community midwifery advocacy for access in Washington State, USA.

The state of professionalisation of midwifery in Belgium: A discussion paper

AimTo describe the state of the professionalisation of midwifery in Belgium, and to formulate recommendations for advancing the midwifery profession. MethodsA descriptive overview of maternity care in Belgium and the professionalisation of midwifery through an analysis of relevant policy and academic texts, underpinned by Greenwood’s sociological criteria for a profession: (1) own body of knowledge, (2) recognised authority, (3) broader community sanctions, (4) own code of ethics and (5) professional culture sustained by formal professional associations. From these insights, recommendations for advancing the midwifery profession in Belgium are formulated. FindingsCurrent strengths of the professionalisation of midwifery in Belgium included unified midwifery education programmes, progress in midwifery research and overarching national documents for guiding midwifery education, practice and regulation. In contrast however challenges, such as the limited recognition of midwives’ roles by its clientele, limitations of midwives’ competencies and autonomy, lacking development of advanced roles in maternity care practice and a lack of unity of the organisation and its members, were also identified. Based on these, recommendations are made to strengthen Belgian midwifery. ConclusionsRecommendations for advancing the midwifery profession in Belgium includes in particular increasing public awareness of midwives’ roles and competencies, implementing the full scope of midwifery practice and monitoring and advancing this practice. Thus, professional autonomy over both midwifery practice and working conditions should be enhanced. United midwifery organisations, together with women’s groups, other maternity care professionals and policy-makers as equal partners are key to bring about changes in the Belgian maternity care landscape.

Midwifery education, regulation and association in the Democratic Republic of Congo (DRC) – current state and challenges

ABSTRACT Background: In the Democratic Republic of Congo (DRC), maternal and neonatal health outcomes are poor and delivering healthcare services of sufficient quality is a challenge as there are only 0.6 midwives, physicians, or nurses for every 1,000 inhabitants. Objective: To explore the current state of the midwifery profession in the DRC and to suggest suitable strategies for increasing the quality and quantity of a highly competent midwifery health workforce in the DRC. Methods: Data were collected at a workshop with 17 key persons using three questionnaires developed by the International Confederation of Midwives, and three focus group discussions. The analysis was focusing on quantitative and qualitative content. Results: In DRC the midwife profession is not legislated. A midwifery association is well established, but due to a lack of resources does not function optimally. Two midwifery education programmes exist: a three-year direct-entry programme resulting in a diploma in midwifery, and a 12-month postgraduate programme for nurses resulting in a certificate in midwifery. Neither of the programmes leads to a bachelor’s or master’s degree. At the institutions offering the midwifery programmes (n = 16), the educators’ academic qualifications are lower than required and there is a lack of teaching and training equipment for meeting the education needs. Conclusions: The Sustainable Development Goal on health, and specifically the health of mother and newborn, will be difficult to meet in the DRC. We therefore suggest that (i) the midwifery education programmes be improved to meet international standards; (ii) these programmes be designed in a way that allows for an academic degree at either the bachelor’s or master’s level; (iii) the competence level of the midwifery educators be increased; and, most crucially, (iv) a regulatory structure be formed that legislates and regulates the midwifery profession and its autonomous practice.

Midwifery Students’ Confidence in New-Born Care at Completion of Training in Selected Midwifery Schools in Zambia. A Multicentric Study: A Case of Zambia

Background: Quality education is one of the important factors in empowering midwives to provide quality health care services to mothers and newborns irrespective of their practice settings. Due to lack of standardization of the duration, content, and structure of midwifery education and different pathways to midwifery across the world, midwives may lack the confidence to deliver quality health care services in the main domain of the ICM competences. Aim: To assess the confidence of final year midwifery students in the domain of new-born care based on the ICM midwifery competencies. Methods: The first phase consisted of a quick situation analysis of midwifery education and regulation in Zambia, followed by a cross-sectional survey through a self-administered questionnaire to assess the confidence of final year midwifery students. Results: Most (51.9%) of the respondents were aged between 18 and 28 years, and majority of them were placed in Levels 1, 2 and 3 Hospitals and also clinics for their clinical practice, with between one hundred to ten thousand annual births, followed by 16.9% who were placed in Level 3 hospitals only. Most students (38.3%) reported receiving classroom instruction by both Lecture and Demonstration. Few students (22.7%) responded that they were not satisfied with their clinical supervision, while 77.3% were satisfied. There was significant association between confidence to perform skills independently and having enough time to practice on models in the labs (p value = 0.024), confidence when practiced for the first time on mothers (p value = 0.007) and satisfaction with supervision during clinical practice (p value = 0.000). Binary logistic regression of characteristics associated with confidence to perform new-born skills independently revealed significant association between satisfaction with clinical supervision and confidence to perform skills independently, 95% CI [1.83, 15.37]. Conclusion: Midwifery students need quality training both theoretically and practically in order for them to gain confidence in newborn care upon completion of their training. They need adequate time to practice on models in the skills laboratory, and need adequate clinical supervision for them to gain confidence in performing new born skills independently.

Failure or progress?: The current state of the professionalisation of midwifery in Europe.

INTRODUCTIONThroughout Europe midwives called for increasing professionalisation of midwifery during the 1980s and 1990s. While the Bologna Declaration, in 1999, supported this development in education and research, it remains unclear how other fields, such as practice, have fared so far. This study therefore aimed to explore the current state of professionalisation of midwifery in Europe.METHODSAn exploratory inquiry was conducted with an on-line semi-structured questionnaire. Its content was based on the Greenwood sociological criteria for a profession. Descriptive statistics and thematic content analysis were used to analyse the data. Participants were national delegates from member countries to the European Midwives Association.RESULTSDelegates from 29 European countries took part. In most countries, progress towards professionalisation of midwifery has been made through the move of education into higher education, coupled with opportunities for postgraduate education and research. Lack of progress was noted, in particular in regard to midwifery practice, regulation, and leadership in health care provision and education. Most countries had a code of ethics for midwives as well as a midwifery association. Based on organisational collaborations with other disciplines, the sustainability of a distinct professional culture was unclear. An increased focus on future development of midwifery practice was proposed.CONCLUSIONSProgress in midwifery education and research has taken place. However, midwives’ current roles in practice as well as leadership and their influence on healthcare culture and politics are matters of concern. Future efforts for advancing professionalisation in Europe should focus on the challenges in these areas.

Julia ChinyereOparah and Alicia D.Bonaparte (Eds.), Birthing justice: Black women, pregnancy, and childbirth. New York, NY: Routledge, 2016, 234 pp., ISBN: 978‐1‐61205‐837‐5

Julia ChinyereOparah and Alicia D.Bonaparte (Eds.), Birthing justice: Black women, pregnancy, and childbirth. New York, NY: Routledge, 2016, 234 pp., ISBN: 978‐1‐61205‐837‐5

The Midwifery Services Framework: Lessons learned from the initial stages of implementation in six countries

In 2015, the International Confederation of Midwives (ICM) launched the Midwifery Services Framework (MSF): an evidence-based tool to guide countries through the process of improving their sexual, reproductive, maternal and newborn health services through strengthening and developing the midwifery workforce. The MSF is aligned with key global architecture for sexual, reproductive, maternal and newborn health and human resources for health. This third in a series of three papers describes the experience of starting to implement the MSF in the first six countries that requested ICM support to adopt the tool, and the lessons learned during these early stages of implementation. The early adopting countries selected a variety of priority work areas, but nearly all highlighted the importance of improving the attractiveness of midwifery as a career so as to improve attraction and retention, and several saw the need for improvements to midwifery regulation, pre-service education, availability and/or accessibility of midwives. Key lessons from the early stages of implementation include the need to ensure a broad range of stakeholder involvement from the outset and the need for an in-country lead organisation to maintain the momentum of implementation even when there are changes in political leadership, security concerns or other barriers to progress.

United States Model Midwifery Legislation and Regulation: Development of a Consensus Document.

Midwifery is defined and regulated across all 50 United States. However, states' regulations vary markedly, creating confusion for policy makers and consumers, and can limit services to women. In 2011, the International Confederation of Midwives released Global Standards for Midwifery Education, Regulation, and Association, providing guidance for international midwifery for the first time. US organizations representing midwifery education, regulation, and professional associations (US MERA) agreed to work together on common goals. The purpose of this modified Delphi study, conducted by US MERA, was to develop a consensus document on principles of model US midwifery legislation and regulation. Expert panelists (N = 51) across maternal and child health care professions and consumer groups participated over several iterative rounds. The final document establishes guiding principles for US midwifery regulation, including regulatory authority, education, qualifications, regulation, registration and licensure, standards of practice and conduct, complaints, and third-party payment for services. As more US states recognize and license midwives of all credentials and in every practice setting, we can envision a time when equity, informed choice, safety, and seamless access to quality midwifery care will be the right of every birthing family.