Midwife standards for practice

Midwifery is a profession grounded in woman-centred and evidence-based maternal health care for the woman¹. Midwifery is provided through professional relationships and respectful partnerships. The midwife, as registered by the Nursing and Midwifery Board of Australia (NMBA) and defined by the International Confederation of Midwives (2017), is educated, competent and authorised to provide safe, effective delivery of quality services that promote health and wellbeing for pregnancy, birth, the postnatal period and transition to parenting.

The midwife is responsible and accountable for maintaining their capability for midwifery practice that may include:

• providing women’s health support, care and advice before conception, during pregnancy, labour, birth and the postnatal period
• promoting normal physiological childbirth and identifying complications for the woman and her baby²
• consultation with and referral to medical care or other appropriate assistance, and
• implementing emergency measures (International Confederation of Midwives 2017).

Using the principles of midwifery continuity of care, primary health care and cultural safety³, the midwife provides health counselling and education, which may include preparation for childbirth and parenthood. The midwife’s practice may extend to women’s health, reproductive and sexual health, and child and family health care⁴.

The midwife works with the woman and her baby, partner and family as identified and negotiated by the woman herself. The woman may be healthy or have health issues, or other challenges such as social disadvantage. The midwife is also responsible for their practice within the broader health system. Where relevant, this involves collaboration, consultation and referral to other services or health practitioners.

In Australia, the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law) protects the title ‘midwife’. A midwife is a regulated health practitioner who holds registration as a midwife with the NMBA.

Midwifery is not restricted to the provision of direct clinical care⁵. Midwifery practice extends to any role where the midwife uses midwifery skills and knowledge. This practice includes working in clinical and non-clinical relationships with the woman and other clients as well as working in management, administration, education, research, advisory, regulatory, and policy development roles.

Midwives recognise the importance of history and culture to the health and wellbeing of women and their families. Midwifery practice promotes culturally safe care as a fundamental right for all women. Midwives acknowledge the impact of colonisation on the lives of Aboriginal and/or Torres Strait Islander Peoples, which has contributed to significant health inequity in Australia.

The Midwife standards for practice are:

• Standard 1: Promotes health and wellbeing through evidence-based midwifery practice
• Standard 2: Engages in professional relationships and respectful partnerships
• Standard 3: Demonstrates the capability and accountability for midwifery practice
• Standard 4: Undertakes comprehensive assessments
• Standard 5: Develops plans for midwifery practice
• Standard 6: Provides safety and quality in midwifery practice
• Standard 7: Evaluates outcomes to improve midwifery practice

¹Use of the word woman refers to the person giving birth. The word woman in midwifery practice is generally understood to include the woman’s baby, and may include the partner and family as identified by the woman. See the glossary in these standards for the definitions of woman or women and woman-centred care.

²Use of the word baby refers to the newborn/s, infant/s and child or children as relevant to the individual midwife’s scope of practice.

³See the glossary in these standards for key definitions including midwifery continuity of care, primary health care and cultural safety.

⁴Midwives may extend their individual scope of practice beyond the postnatal period through additional education, competency and authorisation.

⁵See also the NMBA definition of practice in the glossary. This definition aligns with the Australian Health Practitioner Regulatory Agency definition of practice for all registered health practitioners.

These Midwife standards for practice provide a framework for midwifery practice in all contexts⁶. They also inform women, and others including consumers, those who regulate, educate, collaborate with and manage midwives on what to expect from a midwife’s practice.

Uses may include:

• annual renewal of registration
• professional conduct matters
• assessment of midwives educated overseas seeking registration and employment in Australia
• development of midwifery education standards and curricula
• assessment of midwifery student performance
• performance review and continuing professional development, and
• assessment of midwives returning to work after breaks in service.

These standards are to be read in conjunction with the applicable NMBA standards, codes and guidelines⁷. Reading the glossary in these standards is also important for understanding the definitions of key terms.

Figure 1 shows the seven interconnected standards that are framed within a woman-centred approach. Standards one, two and three relate to each other as well as to each dimension of practice within standards four, five, six and seven.

Each standard has criteria that specify how that standard is demonstrated. The criteria are to be interpreted in the context of the individual midwife’s practice. The criteria are not exhaustive and enable, rather than limit, the development of an individual midwife’s scope of practice.

Figure 1. Midwife standards for practice

⁶See the glossary for a definition of standards for practice.

⁷The NMBA website provides details of the regulatory standards, codes and guidelines for midwifery practice, including the Code of conduct for the midwife, Code of ethics for midwives, National framework for the development of decision-making tools for nursing and midwifery practice, Supervision guidelines for nursing and midwifery, Guidelines for mandatory notifications, and Safety and quality guidelines for privately practising midwives. Midwives will also be aware of other in sources such as clinical guidelines that underpin safe and quality midwifery practice.

The midwife supports women’s wellbeing by providing safe, quality midwifery health care using the best available evidence and resources, with the principles of primary health care and cultural safety as foundations for practice.

The midwife:

The midwife establishes and maintains professional relationships with the woman by engaging purposefully in kind, compassionate and respectful partnerships. The midwife will also engage in professional relationships with other health practitioners, colleagues and/or members of the public. These relationships are conducted within a context of collaboration, mutual trust, respect and cultural safety⁸ .

The midwife:

The midwife is accountable to the woman for safe and competent practice. The midwife is also accountable to themselves, the NMBA, their employer, the public and the profession for practice that includes ongoing improvement, self-management, and responding to concerns about other health professionals’ capability for practice.

The midwife:

The midwife in all contexts of practice continuously gathers, critically analyses and uses information and evidence to inform, validate and/ or improve midwifery practice.

The midwife:

The midwife critically analyses information and evidence to make professional judgements in planning for practice.

The midwife:

The midwife uses comprehensive knowledge and skills to safely and effectively achieve the best possible midwifery practice outcomes.

The midwife:

The midwife takes responsibility for the evaluation and continuous improvement of practice.

The midwife:

These definitions relate to the use of terms in these standards and align with the definitions in the NMBA standards, codes and guidelines.

Accountability means that midwives answer to the persons in their care, the NMBA, their employers and the public. Midwives are accountable for their decisions, actions, behaviours and the responsibilities that are inherent in their midwifery role. Accountability cannot be delegated. The midwife who delegates activities to be undertaken by another person remains accountable for the decision to delegate, for monitoring the level of performance by the other person, and for evaluating the outcomes of what has been delegated (Nursing and Midwifery Board of Australia, 2013). See below for the related definition of ‘Delegation’.

Allocation or assignment is different from delegation and involves asking another person to provide care on the assumption that the required care activities are normally within that person’s responsibility and scope of practice. See also the definition of delegation below and the NMBA’s National framework for the development of decision-making tools for nursing and midwifery practice (Nursing and Midwifery Board of Australia, 2013).

Criteria in this document refers to the expectations of the actions and behaviours of the midwife that demonstrate these Midwife standards for practice.

Collaboration refers to all members of the health care team working in partnership with women and other consumers of midwifery practice, and each other to facilitate access to the highest standard of health care. Collaborative relationships depend on mutual respect. Successful collaboration depends on communication, consultation and joint decision making within a risk management framework, to enable appropriate referral and to ensure effective, efficient and safe health care (Nursing and Midwifery Board of Australia, 2013, p. 16).

Competence is the possession of required skills, knowledge, education and capacity (Nursing and Midwifery Board Australia, 2017).

Consultation or consult refers to the seeking of professional advice from a qualified, competent source and making decisions about shared responsibilities for care provision. It is dependent on the existence of collaborative relationships, and open communication, with others in the multidisciplinary health care team (Nursing and Midwifery Board of Australia, 2013, p. 16).

Cultural safety was developed in a First Nations’ context and is the preferred term for midwifery and nursing. Cultural safety is endorsed by the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), who emphasise that cultural safety is as important to quality care as clinical safety. However, the ‘presence or absence of cultural safety is determined by the recipient of care, it is not defined by the caregiver’ (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, 2014b, p. 9). Cultural safety is a philosophy of practice that is about how a health professional does something, not [just] what they do. It is about how persons are treated in society, not about their diversity as such, so its focus is on systemic and structural issues and on the social determinants of health. Cultural safety represents a key philosophical shift from providing care regardless of difference, to care that takes account of persons’ unique needs. It requires nurses and midwives to undertake an ongoing process of self-reflection and cultural self-awareness, and an acknowledgement of how a nurse’s/ midwife’s personal culture impacts on care. In relation to Aboriginal and Torres Strait Islander health, cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgment of white privilege. These actions are a means to challenge racism at personal and institutional levels, and to establish trust in health care encounters (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, 2017a, p. 11). In focusing on clinical interactions, particularly power inequity patient and health professional, cultural safety calls for a genuine partnership where power is shared between the individuals and cultural groups involved in health care. Cultural safety is also relevant to Aboriginal and/or Torres Strait Islander health professionals. Non-Indigenous nurses and midwives must address how they create a culturally safe work environment that is free of racism for their Aboriginal and/or Torres Strait Islander colleagues (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, 2017b).

Delegation is the relationship that exists when a midwife devolves aspects of midwifery practice to another person. Delegations are made to meet the woman and her baby’s or babies’ health needs. The midwife who is delegating retains accountability for the decision to delegate. The midwife is also accountable for monitoring of the communication of the delegation to the relevant persons and for the practice outcomes. Both parties share the responsibility of making the delegation decision, which includes assessment of the competence and risks. For further details see the NMBA’s National framework for the development of decision-making tools for nursing and midwifery practice (Nursing and Midwifery Board Australia, 2017).

Evidence-based practice involves accessing and making judgements to translate the best available evidence into practice. Evidence-based practice is based on the most current, valid, and available research, and considers the midwife’s clinical experience and the woman’s expectations.

Midwife is a person with prescribed educational preparation and competence for practice who is registered by the NMBA. The NMBA has endorsed the following ICM definition of a midwife and applied it to the Australian context (Nursing and Midwifery Board Australia, 2017).
The International Confederation of Midwives definition of a midwife is ‘A midwife is a person who has successfully completed a midwifery education programme that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn, and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practise in any setting including the home, community, hospitals, clinics or health units.’ (International Confederation of Midwives, 2017, p. 1).

Midwifery continuity of care refers to a continuous woman-centred professional relationship provided to the woman by a midwife or midwives. It is the cooperative achievement of quality care over time through integration, coordination and the sharing of information. This relationship may extend from preconception to the postnatal period with relevant referral to ongoing health services.

Person or people in these standards refers to those individuals who have entered a professional relationship with a midwife. These individuals will sometimes be midwifery or health care consumers, at other times they may be colleagues or students, this will vary depending on who is the focus of practice at the time. Therefore, the words person or persons include all the women, newborns, infants, clients, consumers, families, carers, groups and/or communities, however named, that are within the midwife’s scope and context of practice.

Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a midwife. Practice is not restricted to the provision of direct clinical care. It also includes working in a nonclinical relationship with women, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession and/or use their professional skills (Nursing and Midwifery Board Australia, 2017).

Primary health care principles include universal access to care and coverage on the basis of need, commitment to health equity as part of development oriented to social justice, community participation in defining and implementing health agendas, and intersectoral approaches to health (World Health Organisation, 2003). Primary health care in midwifery involves a woman-centred and holistic approach to care that is made accessible by being provided as close as possible to where the woman lives, and supports the woman’s full participation in care.

Professional relationship is an ongoing interaction that observes a set of established boundaries or limits that is deemed appropriate under governing standards. The midwife is sensitive to a woman’s situation and purposefully engages with her using knowledge and skills with respect, compassion and kindness. In the relationship, the woman’s rights and dignity are recognised and respected. The professional nature of the relationship involves recognition of professional boundaries and issues of unequal power (Nursing and Midwifery Board Australia, 2017).

Referral involves a midwife sending the person to obtain an opinion or treatment from another health professional or entity. Referral usually involves the transfer (all, or in part) of responsibility for the care of the woman, usually for a defined time and for a particular purpose, such as care that is outside the referring practitioner’s expertise or scope of practice (Nursing and Midwifery Board Australia, 2017).

Scope of practice refers to the boundaries within which the profession of midwifery is educated, competent and permitted to perform by law. The actual scope of the individual midwife’s practice will vary depending on the context in which the midwife works, the health needs of women and the baby or babies, the level of competence and confidence of the midwife and the policy requirements of the service provider (Nursing and Midwifery Board Australia, 2016b; Nursing and Midwifery Board of Australia, 2013).

Standards for practice are the expectations of the midwife’s practice in all contexts. They inform the education accreditation standards for midwives, the regulation of midwives and determination of the midwife’s capability for practice. These standards guide consumers, employers and other stakeholders on what to reasonably expect from a midwife regardless of the area of practice or years of experience. They replace the previous National competency standards for the midwife (Nursing and Midwifery Board Australia, 2006).

Supervision includes managerial supervision, professional supervision and clinically focused supervision as part of delegation. For details see the NMBA Supervision guidelines for nursing and midwifery (Nursing and Midwifery Board of Australia, 2015).

Woman or women in these standards refers to the person giving birth. Woman or women is used to refer to those individuals who have entered into a therapeutic and/or professional relationship with a midwife. The word woman in midwifery is generally understood to be inclusive of the woman’s baby, partner and family. Therefore, the words woman or women include all the women, babies, newborn, infants, children, families, carers, groups and/or communities, however named, that are within the midwife’s scope and context of practice. Baby in this document refers to the newborn/s, infant/s and child/children as relevant to the midwife’s scope of practice (Nursing and Midwifery Board Australia, 2017).

Woman-centred care recognises the woman’s baby or babies, partner, family, and community, and respects cultural and religious diversity as defined by the woman herself. Woman-centred care considers the woman’s individual circumstances, and aims to meet the woman’s physical, emotional, psychosocial, spiritual and cultural needs. This care is built on a reciprocal partnership through effective communication. It enables individual decision-making and self-determination for the woman to care for herself and her family. Woman-centred care respects the woman’s ownership of her health information, rights and preferences while protecting her dignity and empowering her choices. Woman-centred care is the focus of midwifery practice in all settings.