Essential Competencies - 2018 UPDATE for Midwifery Practice Final version published January 2019 - International Confederation of Midwives
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Essential
Competencies
for Midwifery Practice
2018 UPDATE
Final version published January 2019
1Contents
2 INTRODUCTION
3 THE REVIEW PROCESS
3 APPROACH TO THE COMPETENCIES
4 COMPETENCY FRAMEWORK
5 FRAMEWORK STRUCTURE
6 EXPLANATION OF COMPETENCY COMPONENTS
7 LANGUAGE Introduction
7 ADVANCED, OPTIONAL, The International Confederation of Midwives (ICM) Essential Competencies
CONTEXT-SPECIFIC INDICATORS, AND for Midwifery Practice outline the minimum set of knowledge, skills and profes-
COMPETENCIES sional behaviours required by an individual to use the designation of midwife
as defined by ICM1 when entering midwifery practice. The competencies are
8 GENERAL COMPETENCIES presented in a framework of four categories that sets out those competen-
cies considered to be essential and that “represent those that should be an
13 PRE-PREGNANCY AND ANTENATAL expected outcome of midwifery pre-service education”2.These competency
statements are “linked to authoritative clinical practice guidance documents
17 CARE DURING LABOUR AND BIRTH used by the World Health Organization” 3,4,5,6,7,8,9 and ICM’s Core documents
and Position Statements.10
19 ONGOING CARE OF WOMEN AND NEWBORNS
Guidance documents undergo revision based on ever-evolving research. ICM’s
22 ENDNOTES essential competency statements are also evaluated and amended as the rel-
evant evidence concerning sexual, reproductive, maternal and newborn health
care and midwifery practices emerges. The competencies presented in this
document have been updated through such a review process.
2The Review Process The updated competencies (2018) were disseminated in mid-October 2018
and ICM received extensive positive feedback from members and partners.
ICM’s ‘Essential Competencies for Basic Midwifery Practice’ were first devel- ICM also received feedback from a small number of respondents that the la-
oped in 2002 and updated in 2010 and 2013. Between 2014 – 2017 the com- bour and birth icon should show the woman in a more upright birthing position
petencies were reviewed through a research study led by a team from the and that the midwife’s autonomy and role in managing emergencies should be
University of British Columbia (UBC) 11 and supported by a core working group more strongly emphasised. Consequently, minor amendments were made and
of midwifery educators12 and a taskforce of stakeholders.13 The research pro- the updated document (dated January 2019) was disseminated.
cess included a literature review, thematic analysis of policy and other doc-
uments related to midwifery competencies, a modified Delphi approach in-
volving three rounds of an online survey and development of a conceptual Approach to the Competencies
framework for presentation of the competencies. The three-round Delphi sur-
vey was conducted online in French, English and Spanish with an inclusive The updated competencies are organised into a framework of four inter-relat-
sample of invited participants drawn from ICM Member Associations (across ed categories; general competencies that apply to all aspects of a midwife’s
all ICM regions and language groups and from low, middle and high-income practice, and competencies that are specific to care during pre-pregnancy,
countries), midwifery educators, midwifery regulators, ICM Standing Commit- antenatal, labour, birth and the postnatal period.
tees, the ICM Board and stakeholders.14
The updated competencies are written as holistic statements that reflect the
The ICM Board received the final draft report and updated competencies, ICM’s Philosophy and Model of Midwifery Care in addition to the ICM Definition
including a proposed new competency framework, from the research team in and Scope of Practice of a Midwife.18 As such the competencies promote:
April 2017. Council Members asked that the final format of the competencies
enhance simplicity, accessibility, usability and measurability of the competen- • the autonomy of midwives to practise within the full scope of midwifery prac-
cies by multiple audiences including those for whom English is a second lan- tice and in all settings
guage. The incoming Board (2017 – 2020) established a sub-committee to • the role of the midwife to support physiology and promote normal birth
provide oversight to the process of finalising the updated competencies. Two • the role of the midwife to uphold human rights and informed consent and
consultants, a learning designer15 and a midwife educational expert,16 were decision making for women
contracted to revise the format of the draft framework (2017) and the draft • the role of the midwife to promote evidence-based practice, including reduc-
competencies with the aim of increasing the simplicity, accessibility, usability ing unnecessary interventions
and measurability by multiple audiences. Changes were to be based on the • the role of the midwife to assess, diagnose, act, intervene, consult and refer
2017 draft competencies and were to retain their integrative approach. The as necessary, including providing emergency interventions.
consultants redesigned the framework, and reworded and reorganised the
competencies, drawing on ICM’s core documents17 and position statements The competencies are integrated statements and not a list of tasks. Examples
to ensure alignment. A team from Laerdal Global Health designed the visual are illustrative and not an exhaustive list.
representation of the competencies and the final version was completed in
April and accepted by the Board in May 2018. Midwife educators are expected to structure curricula and design learning ac-
tivities that will enable midwifery students to learn the knowledge and develop
the skills and behaviours that are integrated within each competency.
3Competency Framework
The competencies are organised into four inter-related categories as outlined below
1. GENERAL COMPETENCIES 2. COMPETENCIES 3. COMPETENCIES 4. COMPETENCIES
SPECIFIC TO PRE- SPECIFIC TO CARE SPECIFIC TO THE
Competencies in this category are about the midwife’s PREGNANCY AND DURING LABOUR ONGOING CARE
autonomy and accountabilities as a health professional, ANTENATAL CARE AND BIRTH OF WOMEN AND
the relationships with women and other care providers NEWBORNS
and care activities that apply to all aspects of midwifery Competencies in this Competencies in
practice. All General Competencies are intended to category are about this category are Competencies in this
be used during any aspect of midwifery care whereas health assessment of about assessment category address
competencies in categories 2, 3, and 4 are each specific the woman and fetus, and care of women the continuing health
to a part of the reproductive process and must be viewed promotion of health and during labour that assessment of mother
as subsets of the General Competencies, not stand-alone well-being, detection of facilitates physiological and infant, health
subsets. Educational and/or training providers should complications during processes and a safe education, support for
ensure that the General competencies are interwoven pregnancy and care birth, the immediate breast feeding, detection
in any curriculum. Assessment of the competencies in of women with an care of the newborn of complications, and
categories 2, 3, and 4 must include assessment of the unintended pregnancy. infant, and detection provision of family
competencies in category 1. and management planning services.
of complications in
mother
or infant.
4Framework Structure
The diagram below provides a visual representation of the framework structure.
GENERAL
COMPETENCIES
PRE-PREGNANCY CARE DURING
AND ANTENATAL LABOUR AND
CARE BIRTH
ONGOING CARE
OF WOMEN AND
NEWBORNS
5Explanation of Competency Components
This graphic outlines the components of the competency framework.
CATEGORY
CATEGORY # # Competency title COMPETENCY
CATEGORY
TITLE
KNOWLEDGE
DESCRIPTORS INDICATORS
Category descriptors outline the Each competency is accompanied
SKILLS & BEHAVIOURS
primary focus of each category. by a list of indicators that outline
The high-level description acts as the necessary knowledge, skills
a linking mechanism between the and behaviours required to achieve
category and the competencies the performance measure of
clearly showing the relationship the competency. In formulating
between the higher order groupings indicators, skills and behaviours are
(i.e. categories) and the more grouped together since they are
detailed information concerning the observable components of a
the actual competencies (i.e the competency. Indicators for attitudes
competency description and its were not stipulated since attitudes are
associated components/indicators). not easily observable or measurable.
6CATEGORY #
COMPETENCIES
# Competency title
Language
TITLE The competencies and indicators were evaluated for clarity of language,
KNOWLEDGE
measurability, and ease of translation. Concrete verbs were used to facili-
tate the measurement of the competency and/or indicator. All competencies
and indicators are written to:
• Show alignment between the competency and indicators;
• Contain verbs appropriate for the level required and that are measurable;
• Use consistent language that is clear and free of jargon; and
SKILLS & BEHAVIOURS • Provide sufficient detail for comprehension.
Advanced, optional,
context-specific indicators,
and competencies
Competencies and indicators previously designated as advanced/optional/con-
text specific are not included as a separate category in the framework for essen-
tial competencies. Such statements are conceptually inconsistent with defining
the competencies that are expected of all midwives. ICM will consider if it is
necessary to develop, in the future, competencies that extend/expand beyond
those deemed as essential.
7CATEGORY 1 1.a Assume responsibility for own 1.b Assume responsibility for
GENERAL decisions and actions as an autonomous
practitioner
self-care and self-development
as a midwife
COMPETENCIES
KNOWLEDGE KNOWLEDGE
• Principles of accountability and • Strategies for managing personal safety
transparency particularly within the facility or community
• Principles and concepts of autonomy setting
Competencies in this category
• Principles of self-assessment and reflective
are about the midwife’s autonomy practice SKILLS & BEHAVIOURS
and accountabilities as a health • Personal beliefs and their influence on • Display skills in management of self in
professional, the relationships with practice relation to time management, uncertainty,
women and other care providers, • Knowledge of evidence-based practices change and coping with stress
and care activities that apply to all • Assume responsibility for personal safety in
aspects of midwifery practice. General SKILLS & BEHAVIOURS various practice settings
Competencies apply across each of • Demonstrate behaviour that upholds the • Maintain up-to-date skills and knowledge
categories 2, 3 and 4. public trust in the profession concerning protocols, guidelines and safe
• Participate in self-evaluation, peer review practice
and other quality improvement activities • Remain current in practice by participating
• Balance the responsibility of the midwife to in continuing professional education
provide best care with the autonomy of the (for example, participating in learning
woman to make her own decisions opportunities that apply evidence to practice
• Explain the midwife’s role in providing care to improve care such as mortality reviews or
that is based on relevant law, ethics, and policy reviews.)
evidence • Identify and address limitations in personal
skill, knowledge, or experience
• Promote the profession of midwifery,
including participation in professional
organizations at the local and national level
8 Category 1: General Competencies1.e Uphold fundamental human rights
1.c Appropriately delegate aspects of
1.d Use research to inform practice of individuals when providing midwifery
care and provide supervision
care
KNOWLEDGE KNOWLEDGE KNOWLEDGE
• Policies and regulation related to delegation • Principles of research and evidence-based • Laws and/or codes that protect human rights
• Supportive strategies to supervise others practice • Sexual, reproductive health rights of women
• Role of midwives as preceptors, mentors, • Epidemiologic concepts relevant to maternal and girls
supervisors, and role models and infant health • Development of gender identity and sexual
• Global recommendations for practice and orientation
SKILLS & BEHAVIOURS their evidence base (e.g. World Health • Principles of ethics and Human Rights
• Provide supervision to ensure that practice Organisation guidelines) within midwifery practice
is aligned with evidence-based clinical
practice guidelines SKILLS & BEHAVIOURS SKILLS & BEHAVIOURS
• Support the profession’s growth through • Discuss research findings with women and • Provide information to women about their
participation in midwifery education in colleagues sexual and reproductive health rights
the roles of clinical preceptor, mentor, • Support research in midwifery by • Inform women about the scope of
and role model participating in the conduct of research midwifery practice and women’s rights and
responsibilities
• Provide information and support to
individuals in complex situations where there
are competing ethical principles and rights
• Practice in accordance with philosophy
and code of ethics of the ICM and national
standards for health professionals
• Provide gender sensitive care
9 Category 1: General Competencies1.f Adhere to jurisdictional laws, 1.h Demonstrate effective interpersonal communication
1.g Facilitate women to make
regulatory requirements, and codes with women and families, health care teams, and
individual choices about care
of conduct for midwifery practice community groups
KNOWLEDGE KNOWLEDGE KNOWLEDGE
• The laws and regulations of the • Cultural norms and practices • Role and responsibilities of midwives and other maternal –
jurisdiction regarding midwifery surrounding sexuality, sexual infant health providers
• National/state/local community practices, marriage, the childbearing • Principles of effective communication
standards of midwifery practice continuum, and parenting • Principles of effectively working in health care teams
• Ethical principles • Principles of empowerment • Cultural practices and beliefs related to childbearing and
• ICM and other midwifery • Methods of conveying health reproductive health
philosophies, values, codes of ethics information to individuals, groups, • Principles of communication in crisis situations, e.g. grief
communities and loss, emergencies
SKILLS & BEHAVIOURS
• Practise according to legal SKILLS & BEHAVIOURS SKILLS & BEHAVIOURS
requirements and ethical principles • Advocate for and support women • Listen to others in an unbiased and empathetic manner
• Meet requirements for maintenance to be the central decision makers in • Respect one others’ point of view
of midwifery registration their care • Promote the expression of diverse opinions and
• Protect confidentiality of oral • Assist women to identify their perspectives
information and written records needs, knowledge, skills, feelings, • Use the preferred language of the woman or an interpreter
about care of women and infants and preferences throughout the to maximise communication
• Maintain records of care in the course of care • Establish ethical and culturally-appropriate boundaries
manner required by the health • Provide information and anticipatory between professional and non-professional relationships
authority guidance about sexual and • Demonstrate cultural sensitivity to women, families, and
• Comply with all local reporting reproductive health to assist communities
regulations for birth and death women’s decision making • Demonstrate sensitivity and empathy for bereaved women
registration • Collaborate with women in and family members
• Recognize violations of laws, developing a comprehensive plan of • Facilitate teamwork and inter-professional care with other
regulations, and ethical codes and care that respects her preferences care providers (including students) and community groups/
take appropriate action and decisions agencies
• Report and document incidents and • Establish and maintain collaborative relationships with
adverse outcomes as required while individuals, agencies, institutions that are part of referral
providing care networks
• Convey information accurately and clearly and respond to
the needs of individuals
10 Category 1: General Competencies1.i Facilitate normal birth processes in 1.j Assess the health status, screen for 1.k Prevent and treat common health
institutional and community settings, health risks, and promote general health problems related to reproduction and
including women’s homes and well-being of women and infants early life
KNOWLEDGE KNOWLEDGE KNOWLEDGE
• Normal biologic, psychologic, social, and • Health needs of women related to • Common health problems related to
cultural aspects of reproduction and early life reproduction sexuality and reproduction
• Practices that facilitate and those that • Health conditions that pose risks during • Common health problems and deviations
interfere with normal processes reproduction from normal of newborn infants
• Policies and protocols about care of women • Health needs of infants and common risks • Treatment of common health problems
in institutional and community settings • Strategies to prevent and control
• Availability of resources in various settings SKILLS & BEHAVIOURS the acquisition and transmission of
• Community views about and utilization of • Conduct a comprehensive assessment of environmental and communicable diseases
health care facilities and place(s) of birth sexual and reproductive health needs
• Assess risk factors and at-risk behaviour SKILLS & BEHAVIOURS
SKILLS & BEHAVIOURS • Order, perform, and interpret laboratory and/ • Maintain/promote safe and hygienic
• Promote policies and a work culture that or imaging screening tests conditions for women and infants
values normal birth processes • Exhibit critical thinking and clinical • Use universal precautions consistently
• Utilize human and clinical care resources to reasoning informed by evidence when • Provide options to women for coping with
provide personalized care for women and promoting health and well being and treating common health problems
their infants • Provide health information and advice • Use technology and interventions
• Provide continuity of care by midwives tailored to individual circumstances of appropriately to promote health and prevent
known to woman women and their families secondary complications
• Collaborate with women to develop and • Recognize when consultation or referral
implement a plan of care is indicated for managing identified health
problems, including consultation with other
midwives
• Include woman in decision-making about
referral to other providers and services
11 Category 1: General Competencies1.l Recognize abnormalities and
1.m Care for women who experience
complications and institute appropriate
physical and sexual violence and abuse
treatment and referral.
KNOWLEDGE KNOWLEDGE
• Complications/pathologic conditions related • Socio-cultural, behavioural, and economic
to health status conditions that often accompany violence
• Emergency interventions/life-saving and abuse
therapies • Resources in community to assist women
• Limits of midwifery scope of practice and and children
own experience • Risks of disclosure
• Available referral systems to access
medical and other personnel to manage SKILLS & BEHAVIOURS
complications • Protect privacy and confidentiality
• Community/facility plans and protocols for • Provide information to all women about
accessing resources in timely manner sources of help regardless of whether there
is disclosure about violence
SKILLS & BEHAVIOURS • Inquire routinely about safety at home, at
• Maintain up-to-date knowledge, life-saving work
skills, and equipment for responding to • Recognize potential signs of abuse from
emergency situations physical appearance, emotional affect,
• Recognize situations requiring expertise related risk behaviours such as substance
beyond midwifery care abuse
• Maintain communication with women about • Provide special support for adolescents and
nature of problem, actions taken, and victims of gender-based violence including
referral if indicated rape
• Determine the need for immediate • Refer to community resources, assist in
intervention and respond appropriately locating safe setting as needed
• Implement timely and appropriate
intervention, inter-professional consultation
and/or timely referral taking account of local
circumstances19
• Provide accurate oral and written information
to other care providers when referral is made.
• Collaborate with decision-making if possible
and appropriate
12 Category 1: General CompetenciesCATEGORY 2
PRE-PREGNANCY 2.a Provide pre-pregnancy care 2.b Determine health status of woman
AND ANTENATAL
KNOWLEDGE KNOWLEDGE
• Anatomy and physiology of female and • Physiology of menstrual and ovulatory cycle
Competencies in this category are
male related to reproduction and sexual • Components of a comprehensive health
about health assessment of the woman
development history including psycho-social responses to
and fetus, promotion of health and • Socio-cultural aspects of human sexuality pregnancy and safety at home
well-being, detection of complications • Evidence based screening for cancer • Components of complete physical exam
during pregnancy, and care of women of reproductive organs and other health • Health conditions including infections and
with an unexpected pregnancy. problems such as diabetes, hypertension, genetic conditions detected by screening
thyroid conditions, and chronic infections blood and biologic samples
that impact pregnancy
SKILLS & BEHAVIOURS
SKILLS & BEHAVIOURS • Confirm pregnancy and estimate gestational
• Identify and assist in reducing barriers age from history, physical exam, laboratory
related to accessing and using sexual and test and/or ultrasound
reproductive health services • Obtain comprehensive health history
• Assess nutritional status, current • Perform a complete physical examination
immunization status, health behaviours • Obtain biologic samples for laboratory tests
such as use of substances, existing (e.g. venipuncture, finger puncture, urine
medical conditions, and exposure to known samples, and vaginal swabs)
teratogens • Provide information about conditions that
• Carry out screening procedures for sexually may be detected by screening
transmitted and other infections, HIV, • Assess status of immunizations, and update
cervical cancer as indicated
• Provide counseling about nutritional • Discuss findings and potential implications
supplements such as iron and folic with woman and mutually determine
acid, dietary intake, exercise, updating plan of care
immunizations as needed, modifying risk
behaviours, and prevention of sexually
transmitted infections, family planning, and
methods of contraception.
13 Category 2: Pre-pregnancy and Antenatal2.e Promote and support health
2.c Assess fetal well-being 2.d Monitor the progression of pregnancy
behaviours that improve well being
KNOWLEDGE KNOWLEDGE KNOWLEDGE
• Placental physiology, embryology, fetal • Usual physiological and physical changes • Impact of adverse social, environmental, and
growth and development, and indicators of with advancing pregnancy economic conditions on maternal -fetal health
fetal well-being • Nutritional requirements of pregnancy • Effects of inadequate nutrition and heavy
• Evidence-based guidelines for use of • Common psychological responses to physical work
ultrasound pregnancy and symptoms of psychological • Effects of tobacco use and exposure to
distress second-hand smoke, use of alcohol and
• Evidence informed antenatal care policies addictive drugs
SKILLS & BEHAVIOURS
and guidelines, including frequency of • Effects of prescribed medications on fetus
• Assess fetal size, amniotic fluid volume, antenatal visits20
fetal position, activity, and heart rate from • Community resources for income support,
examination of maternal abdomen food access, and programs to minimize risks
SKILLS & BEHAVIOURS of substance abuse
• Determine whether there are indications
for additional assessment/examination and • Conduct assessments throughout pregnancy • Strategies to prevent or reduce risks of
refer accordingly of woman’s physical and psychological mother-to-child disease transmission including
• Assess fetal movements and ask woman well-being, family relationships, and health infant feeding options for HIV infection
about fetal activity education needs • Effects of gender-based violence, emotional
• Provide information regarding normal abuse, and physical neglect
pregnancy to woman, her partner, family
members, or other support persons SKILLS & BEHAVIOURS
• Suggest measures to cope with common • Provide emotional support to women to
discomforts of pregnancy encourage change in health behaviour
• Provide information (including written and/ • Provide information to woman and family
or pictorial) about danger signs, (e.g. vaginal about impact on mother and fetus of risk
bleeding, signs of preterm labour, prelabour, conditions.
rupture of membranes) emergency prepared- • Counsel women about and offer referral to
ness, and when and where to seek help appropriate persons or agencies for assis-
• Review findings and revise plan of care with tance and treatment
woman as pregnancy progresses • Respect women’s decisions about partici-
pating in treatments and programs
• Make recommendations and identify re-
sources for smoking reduction/cessation in
pregnancy
14 Category 2: Pre-pregnancy and Antenatal2.f Provide anticipatory guidance related
2.g Detect, stabilse, manage, and refer 2.h Assist the woman and her family to
to pregnancy, birth, breastfeeding,
women with complicated pregnancies plan for an appropriate place of birth
parenthood, and change in the family
KNOWLEDGE KNOWLEDGE KNOWLEDGE
• Needs of Individuals and families for • Complications of early pregnancy such • Evidence about birth outcomes in different
different information at different times in as threatened or actual miscarriage, and birthplace settings
their respective life cycles ectopic pregnancy • Availability of options in specific location;
• Methods of providing information to • Fetal compromise, growth restriction, limitations of climate, geography, means
individuals and groups malposition, preterm labour of transport, and resources available in
• Methods of eliciting maternal feelings and • Signs and symptoms of maternal pathologic facilities
expectations for self, infant, and family conditions such as pre-eclampsia, • Local policies and guidelines
gestational diabetes, and other systemic
SKILLS & BEHAVIOURS illnesses SKILLS & BEHAVIOURS
• Participate in--and refer women and support • Signs of acute emergencies such as • Discuss options, preferences and
persons to--childbirth education programs hemorrhage, seizures, and sepsis contingency plans with woman and support
• Convey information accurately and clearly persons and respect their decision
and respond to needs of individuals SKILLS & BEHAVIOURS • Provide information about preparing
• Prepare the woman, partner, and family to • Stabilise in emergencies and refer for birth site if in community, e.g. travel and
recognize labour onset, when to seek care, treatment as necessary21 admission to facility
and progress of labour • Collaborate in care of complications • Promote the availability of a full range of
• Provide information about postpartum • Implement critical care activities to support birth settings
needs including contraception, care of vital body functions (e.g. intravenous
newborn infants, and the importance of (IV) fluids, magnesium sulphate,
exclusive breast feeding for infant health antihemorrhagics)22
• Identify needs or problems requiring further • Mobilize blood donors if necessary
expertise or referral such as excessive fear, • Transfer to higher level facility if needed
and dysfunctional relationships
15 Category 2: Pre-pregnancy and Antenatal2.i Provide care to women with unintended or mistimed pregnancy
KNOWLEDGE
• Complexity of decision-making about unintended or mistimed
pregnancies
• Emergency contraception
• Legal options for induced abortion; eligibility and availability of medical
and surgical abortion services
• Medications used to induce abortion; properties, effects, and side
effects
• Risks of unsafe abortion
• Family planning methods appropriate for the post-abortion period.
• Care and support (physical and psychological) needed during and after
abortion
SKILLS & BEHAVIOURS
• Confirm pregnancy and determine gestational age; refer for ultrasound
if unknown gestation and/or symptoms of ectopic pregnancy
• Counsel woman about options to maintain or end the pregnancy and
respect the ultimate decision.
• Provide supportive antenatal care if pregnancy continued; refer to
agencies, and social services for support and assistance when needed
• Identify from obstetric, medical and social history, contraindications to
medication or aspiration methods
• Provide information about legal regulations, eligibility, and access to
abortion services
• Provide information about abortion procedures, potential complications,
management of pain, and when to seek help
• Refer to provider of abortion services upon request
• Provide post-abortion care
̶̶ Confirm expulsion of products of conception from history, ultrasound, or
levels of HCG
̶̶ Review options for contraception and initiate immediate use of method
̶̶ Explore psychological response to abortion
16 Category 2: Pre-pregnancy and AntenatalCATEGORY 3
CARE DURING 3.a Promote physiologic labour and birth
LABOUR AND BIRTH
KNOWLEDGE
• Anatomy of maternal pelvis and fetus; mechanisms of labour for different fetal presentations
Competencies in this category are
• Physiologic onset and progression of labour
about assessment and care of
• Evidence informed intrapartum care policies and guidelines, including avoidance of routine
women during labour that facilitates interventions in normal labour and birth23,24
physiological processes and a • Cultural and social beliefs and traditions about birth
safe birth, the immediate care of • Signs and behaviours of labour progress; factors that impede labour progress
the newborn infant, detection of • Methods of assessing fetus during labour
complications in mother or infant,
stabilisation of emergencies, and SKILLS & BEHAVIOURS
referral as needed. • Provide care for a woman in the birth setting of her choice, following policies and protocols
• Obtain relevant obstetric and medical history
• Perform and interpret focused physical examination of the woman and fetus
• Order and interpret laboratory tests if needed
• Assess woman’s physical and behavioural responses to labour
• Provide information, support, and encouragement to woman and support persons throughout
labour and birth
• Provide respectful one-to-one care
• Encourage freedom of movement and upright positions
• Provide nourishment and fluids
• Offer and support woman to use strategies for coping with labour pain, e.g. controlled breathing,
water immersion, relaxation, massage, and pharmacologic modalities when needed
• Assess regularly parameters of maternal-fetal status, and e.g. vital signs, contractions, cervical
changes, and fetal descent
• Use labour progress graphic display to record findings and assist in detecting complications, e.g.
labour delay, fetal compromise, maternal exhaustion, hypertension, infection
• Augment uterine contractility judiciously using non-pharmacological or pharmacological agents to
prevent non-progressive labour
• Prevent unnecessary routine interventions, e.g. amniotomy, electronic fetal monitoring, directed
closed glottis pushing, episiotomy
17 Category 3: Care during Labour and Birth3.b Manage a safe spontaneous vaginal birth and prevent complications 3.c Provide care of the newborn immediately after birth
KNOWLEDGE KNOWLEDGE
• Manage a safe spontaneous vaginal birth; prevent complications, stabilise in • Normal transition to extra-uterine environment
emergencies, and refer as necessary • Scoring systems to assess newborn status
• Evidence about conduct of third stage, including use of uterotonics • Signs indicating need for immediate actions to assist
• Potential complications and their immediate treatment e.g. shoulder dystocia, and transition
excessive bleeding, fetal compromise, eclampsia, retained placenta • Interventions to establish breathing and circulation as
• Management of emergencies as covered in emergency skills training programmes covered in training programs such as HBS27
such as BEmONC,25 HMS26 • Appearance and behaviour of healthy newborn infant
• Signs of placental separation; appearance of normal placenta, membranes, and • Method of assessing gestational age of newborn infant
umbilical cord • Needs of small for gestational age and low birth weight
• Types of perineal and vaginal trauma requiring repair and suturing techniques infants
SKILLS & BEHAVIOURS SKILLS & BEHAVIOURS
• Support the woman to give birth in her position of choice • Use standardized method to assess newborn condition in
• Ensure clean environment, presence of clean necessary supplies and source of the first minutes of life (Apgar or other); refer if needed
warmth • Institute actions to establish and support breathing and
• Coach woman about pushing to control expulsion of presenting part, avoid routine oxygenation, refer for continuing treatment as needed
episiotomy • Provide a safe warm environment for initiating breastfeeding
• Undertake appropriate manoeuvers and use maternal position to facilitate vertex, and attachment (bonding) in the first hour of life
face, or breech birth • Conduct a complete physical examination of newborn in
• Expedite birth in presence of fetal distress presence of mother/family; explain findings and expected
• Delay cord clamping changes e.g. colour of extremities, moulding of head. Refer
• Manage nuchal cord for abnormal findings.
• Assess immediate condition of newborn • Institute newborn prophylaxis e.g. ophthalmic infection, and
• Provide skin to skin contact and warm environment hemorrhagic disease, according to policies and guidelines
• Deliver placenta and membranes and inspect for completeness • Promote care by mother, frequent feeding and close
• Assess uterine tone, maintain firm contraction, and estimate and record maternal observation
blood loss; manage excessive blood loss including administration of uterotonics • Involve partner/support persons in providing newborn care
• Inspect vaginal and perineal areas for trauma, and repair as needed, following
policies and protocols
• Refer for continuing treatment of any complications as needed
18 Category 3: Care during Labour and BirthCATEGORY 4 4.a Provide postnatal care for the healthy 4.b Provide care to healthy newborn
ONGOING CARE woman infant
OF WOMEN AND
NEWBORNS
KNOWLEDGE KNOWLEDGE
• Physiological changes following birth, • Appearance and behaviour of infant in early
uterine involution, onset of lactation, healing life; cardio-respiratory changes related to
of perineal-vaginal tissues adapting to extra-uterine life
Competencies in this category address
• Common discomforts of the postnatal period • Growth and development in initial weeks
the continuing health assessment of and comfort measures and months of life
mother and infant, health education, • Need for rest, support, and nutrition to • Protocols for screening for metabolic
support for breast feeding, detection of support lactation conditions, infectious conditions, and
complications, stabilisation and referral • Psychological responses to mothering role, congenital abnormalities
in emergencies, and provision of family addition of infant to family • Protocols/guidelines for immunizations in
planning services. infancy
SKILLS & BEHAVIOURS • Evidence-based information about infant
• Review history of pregnancy, labour, and birth circumcision; family values, beliefs, and
• Conduct a focused physical exam to assess cultural norms
breast changes and involution. Monitor
blood loss and other body functions SKILLS & BEHAVIOURS
• Assess mood and feelings about • Examine infant at frequent intervals
motherhood and demands of infant care to monitor growth and developmental
• Provide pain control strategies if needed for behaviour
uterine contractions, and perineal trauma • Distinguish normal variation in newborn
• Provide information about self-care appearance and behaviour from those
that enables mother to meet needs of indicating pathologic conditions
newborn, e.g. adequate food, nutritional • Administer immunizations, carry out
supplements, usual activities, rest periods, screening tests as indicated
and household help • Provide information to parents about a safe
• Provide information about safe sex, family environment for infant, frequent feeding,
planning methods appropriate for the care of umbilical cord, voiding and stooling,
immediate postnatal period, and and close physical contact
pregnancy spacing
19 Category 4: Ongoing care of women and newborns4.d Detect, treat, and stabilise postnatal complications in woman
4.c Promote and support breastfeeding
and refer as necessary
KNOWLEDGE KNOWLEDGE
• Physiology of lactation • Signs and symptoms of:
• Nutritional needs of newborn infants, including low birth weight infants ̶̶ conditions in the postnatal period that may respond to early intervention
• Social, psychological, and cultural aspects of breastfeeding (e.g. sub-involution, anaemia, urinary retention, and localized infection)
• Evidence about benefits of breastfeeding ̶̶ complications that need referral to more specialized provider or
• Indications and contraindications to use of drugs and substances facility (e.g. hematoma, thrombophlebitis, sepsis, obstetric fistula, and
during lactation incontinence)
• Awareness of lactation aids ̶̶ life threatening complications requiring immediate response and
specialized care (hemorrhage, amniotic fluid embolus, seizure, and
SKILLS & BEHAVIOURS stroke)
• Promote early and exclusive breastfeeding while respecting a woman’s • Signs and symptoms of postnatal depression, anxiety, and psychosis
choice regarding newborn feeding • Mourning process following perinatal death
• Provide information about infant needs, frequency and duration of
feedings, and weight gain SKILLS & BEHAVIOURS
• Provide support and information about breastfeeding for a minimum of • Provide information to woman and family about potential complications
six months, including combining with work, maintaining milk supply, and and when to seek help.
storing breast milk • Assess woman during postnatal period to detect signs and symptoms of
• Identify and manage breastfeeding problems (e.g. mastitis, low milk complications
supply, engorgement, improper latch) • Distinguish postnatal depression from transient anxiety about caring
• Provide information to women breastfeeding multiple newborns for baby, assess availability of help and support at home, and provide
• Refer women to breastfeeding support as indicated emotional support
• Advocate for breastfeeding in family and community • Provide counseling and follow-up care for women and family members
who experience stillbirth, neonatal death, serious infant illness, and
congenital conditions
• Provide first line measures to treat or stabilize identified conditions
• Arrange referral and/or transfer as needed
20 Category 4: Ongoing care of women and newborns4.e Detect, stabilise, and manage health problems in newborn
4.f Provide family planning services
infant and refer if necessary
KNOWLEDGE KNOWLEDGE
• Congenital anomalies, and genetic conditions • Anatomy and physiology of female and male related to reproduction
• Needs of pre-term and low birth weight infants and sexual development
• Symptoms and treatment of withdrawal from maternal drug use • Socio-cultural aspects of human sexuality
• Prevention of mother-to-child transmission of infections such as HIV, • Family planning methods including natural, barrier, hormonal,
hepatitis B and C implantable; emergency contraception, sterilization; their possible side
• Signs and symptoms of common health problems and complications; effects, risk of pregnancy, and contraindications to use28, 29,30
their immediate and ongoing treatment • Available written and pictorial resources for teaching about family
planning methods31,32
SKILLS & BEHAVIOURS • Pregnancy options for HIV positive women or couples
• Provide information to woman and family about potential complications
and when to seek help. SKILLS & BEHAVIOURS
• Assess woman during postnatal period to detect signs and symptoms of • Provide and protect privacy and confidentiality for discussions about
complications family planning knowledge, goals for limiting and/or spacing of children,
• Distinguish postnatal depression from transient anxiety about caring and concerns and myths about methods
for baby, assess availability of help and support at home, and provide • Obtain relevant history of use of methods, medical conditions, socio-
emotional support cultural values, and preferences that influence choice of method
• Provide counseling and follow-up care for women and family members • Provide information about how to use, effectiveness, and cost of various
who experience stillbirth, neonatal death, serious infant illness, and methods to support informed decision-making
congenital conditions • Provide methods according to scope of practice and protocols, or refer
• Provide first line measures to treat or stabilize identified conditions to another provider
• Arrange referral and/or transfer as needed • Provide follow-up assessment of use, satisfaction, and side-effects
• Refer for woman or partner for sterilization procedure
21 Category 4: Ongoing care of women and newbornsEndnotes
1 International Confederation of Midwives. (2017). ICM International 11 Michelle M Butler, Judith Fullerton, Cheryl Aman, (with the support 19 World Health Organization. (2017). Managing Complications in
Definition of the Midwife [online]. Available from: https://www. of BMW students Melanie Dowler, Tobi Reid, and Caitlin Frame). Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2nd ed.
internationalmidwives.org/our-work/policy-and-practice/icm-definitions. Update of the International Confederation of Midwives’ Essential Geneva: World Health Organization.
html [accessed 20 December 2018]. Competencies for Basic Midwifery Practice: Final (DRAFT) Report.
20 World Health Organization. (2016). WHO Recommendations on
Vancouver: UBC Midwifery Program. April 2017.
2 Butler et al. (2017). Update of the International Confederation of Antenatal Care for a Positive Pregnancy Experience.
Midwives’ Essential Competencies for Basic Midwifery Practice. Draft 12 Michelle Butler, Judith Fullerton, Mary Barger, Carol Nelson,
21 World Health Organization. (2017). Managing Complications in
Final Report. Internal ICM Report. Unpublished, p. 2. Camilla Schneck, Marianne Nieuwenhuijze, Rita Borg-Xuereb (ICM
Pregnancy and Childbirth.
Board Member), Rafat Jan (ICM Board Member), Atf Gherissi, Lorena
3 World Health Organization. (2016). WHO Recommendations:
Binfa, Mizuki Takegata, Caroline Homer. Update of the International 22 Ibid.
Antenatal Care for a Positive Pregnancy Experience. Geneva: World
Confederation of Midwives’ Essential Competencies for Basic
Health Organization. 23 WHO recommendations: intrapartum care for a positive childbirth
Midwifery Practice: Final (DRAFT) Report. Vancouver: UBC Midwifery
experience. Geneva: World Health Organization; 2018. Licence: CC
4 World Health Organization. (2018). WHO Recommendations: Program. April 2017.
BY-NC-SA 3.0 IGO.
Intrapartum Care for a Positive Childbirth Experience. Geneva: World
13 Jim Campbell (WHO-Director and Executive Director of the Global
Health Organization. 24 World Health Organization. (2017). Managing Complications in
Health Workforce Alliance), Fran McConville (WHO – Maternal & Child
Pregnancy and Childbirth: A Guide for Midiwves and Doctors. 2nd ed.
5 World Health Organization. (2013). WHO Recommendations: Health Committee), Gloria Metcalfe (Jhpiego MNH consultant), Gerard
Geneva. World Health Organization.
Postnatal Care of the Mother and Newborn. Geneva: World Health Visser (Chair FIGO Safe Motherhood Committee), Petra ten Hoope-
Organization. Bender (UNFPA), Sarah Williams (Save the Children), Joeri 25 Basic Emergency Obstetric and Newborn Care.
Vermeulen
6 World Health Organization Department of Reproductive Health 26 Helping Mothers Survive.
(Secretary European Midwifery Association), Kimberley Pekin (NARM
and Research (WHO/RHR) and Johns Hopkins Bloomberg School
& MANA), Joy Lawn (Paediatrician), Sarah Moxon (Neonatal Nurse). 27 Helping Babies Survive.
of Public Health/Center for Communication Programs (CCP). (2018).
Update of the International Confederation of Midwives’ Essential
Knowledge for Health Project. Family Planning: A Global Handbook for 28 World Health Organization Department of Reproductive Health
Competencies for Basic Midwifery Practice: Final (DRAFT) Report.
Providers. Baltimore and Geneva: CCP and WHO. and Research (WHO/RHR) and Johns Hopkins Bloomberg School
Vancouver: UBC Midwifery Program. April 2017.
of Public Health/Center for Communication Programs (CCP). (2018).
7 World Health Organization. (2015). Medical Eligibility Criteria for
14 Butler et al. (2017), Update of the International Confederation of Knowledge for Health Project. Family Planning: A Global Handbook for
Contraceptive Use. 5th ed. Geneva: World Health Organization.
Midwives’ Essential Competencies for Basic Midwifery Practice: Final Providers.
8 World Health Organization. (2016). Selected Practice (DRAFT) Report. Vancouver: UBC Midwifery Program. April 2017
29 World Health Organization. (2015). Medical Eligibility Criteria for
Recommendations for Contraceptive Use. 3rd ed. Geneva: World
15 Carolyn Levy, Blank Design and Project Management, Vancouver, Contraceptive Use. 5th ed. Geneva: World Health Organization.
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Canada.
30 World Health Organization. (2016). Selected Practice
9 World Health Organization. (2017). Quality of Care in
16 Karyn Kaufman, retired Professor and Head of Midwifery, Recommendations for Contraceptive Use. 3rd ed. Geneva: World
Contraceptive Information and Services, based on Human Rights
McMaster University, Hamilton, Canada; Professor Emeritus, Health Organization.
Standards: A Checklist for Health Care Providers. Geneva: World
McMaster University
Health Organization 31 World Health Organization. (2017). Quality of Care in
17 International Confederation of Midwives. ICM Policy and Practice Contraceptive Information and Services, based on Human Rights
10 International Confederation of Midwives. ICM Position Statements
[online]. Available from: https://www.internationalmidwives.org/our- Standards: A Checklist for Health Care Providers. Geneva: World
[online]. Available from: https://www.internationalmidwives.org/
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22 EndnotesYou can also read
