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Objective to design a criterion-referenced assessment tool that could be used globally in a rapid assessment of good practices and bottlenecks in midwifery education programs. Design a standard tool development process was followed, to generate standards and reference criteria; followed by external review and field testing to document psychometric properties. Setting review of standards and scoring criteria were conducted by stakeholders around the globe. Field testing of the tool was conducted in Myanmar. Participants eleven of Myanmar׳s 22 midwifery education programs participated in the assessment. Findings the clinimetric tool was demonstrated to have content validity and high inter-rater reliability in use. Key conclusions a globally validated tool, and accompanying user guide and handbook are now available for conducting rapid assessments of compliance with good practice criteria in midwifery education programming.

Objective To obtain consensus amongst midwifery experts globally about the essential competencies for basic midwifery practice. Design A modified Delphi approach, involving a three-round online survey. Participants Midwifery leaders, educators and regulators in all ICM regions, along with representatives of organisations affiliated to ICM. Methods The research team worked closely with a Core Working Group and a Task Force. An initial set of competencies and components was developed through a content analysis of existing competency documents and presented to participants in Round 1 of the survey. Items identified as essential by at least 85% of participants were endorsed. Remaining items and new items identified by participants were returned to participants in Rounds 2 and 3 for further rating. Findings The study achieved a wide sample representative of midwifery experts across all ICM regions and countries, language groups, and income categories. Only a small number of competencies relating to the wider role of the midwife were endorsed as essential competencies. Competencies and components relating to professional and personal attributes were extended. Although most competencies and components relating to core midwifery practice were endorsed as essential competencies, several were rejected relating to abortion-related care, cancer screening, infertility, and gynaecology. Findings are, nevertheless, highly consistent with the scope of practice delineated in the current 2010/2013 version of the ICM Essential Competencies for Basic Midwifery Practice. Key conclusions and implications for practice The extension of professional and personal attributes reflects the recent emphasis on respectful midwifery care. The rejection of most of the additional competencies and components relating to the wider role of the midwife and endorsement of most of those considered to relate to core midwifery practice indicates that the scope of midwifery practice remains essentially unchanged through 2017.

Background many articles published in the decade since promulgation of the Millennium Development Goals have acknowledged the distinct advantages to maternal and newborn health outcomes that can be achieved as a result of expanding access to skilled birth attendant (including midwifery) services. However, these advantages are often predicated on the assumption that the midwifery workforce shares a common definition and identity. Regrettably, a clear delineation of midwifery competencies is rarely addressed. A core set of midwifery competencies is essential to providing the high quality services that lead to the desirable health outcomes described in that body of research. Attribution of improved outcomes to access to midwifery cannot be made without a common understanding of a defined set of services provided to standard by the midwifery workforce across the inter-conceptional and childbearing time frame. The International Confederation of Midwives (ICM) has developed a clear list of competencies that delineate the domains of practice for the fully qualified, professional midwife. These domains frame the educational outcomes that must be conveyed within competency-based education programmes. Purpose this article explores the concept of competency-based education for midwives; first exploring the concept of competency itself, then providing examples of what is already known about competency-based approaches to curriculum design, teacher preparation, teacher support and assessment of student learning. These concepts are linked to the ICM competencies as the unifying construct for education of individuals who share a common definition and identity as midwives.

Objective: a 2-year study was conducted to develop Global Standards for Midwifery Education in keeping with core documents of the International Confederation of Midwives. Elements of the standards were based on evidence available in the published and unpublished literature. Companion Guidelines to assist in implementing the standards were also developed. Design: a modified Delphi survey process was conducted in two rounds following item validation by a panel of midwifery education experts. Setting: a global survey conducted in 88 countries. Participants: midwifery educators and clinicians associated with midwifery education located in any of the ICM member association countries. Additional participants included an Expert Midwifery Resource Group, other Key Stakeholders, midwifery regulators and policy makers. A total of 241 individuals from 46 ICM member association countries and ten non-member countries responded to one or both of the survey rounds. Measurements: survey respondents expressed an opinion on whether to retain or to delete any of the proposed components of the standards. Version one had 109 proposed components and version two had 111 items for consideration. Findings: a majority consensus of .80 was required to accept an item without further deliberation. The Education Standards Task Force (expert panel) made final decisions in the four instances where this level of consensus was not reached, retaining all four items. The panel also amended the wording of selected items or added new items based on feedback received from survey respondents. The final document contains 10 Preface items, 35 glossary terms, and 37 discrete standards with 27 sub-sections.

Objective a 2-year study was conducted to update the core competencies for basic midwifery practice, first delineated by the International Confederation of Midwives in 2002. A competency domain related to abortion-related care services was newly developed. Design a modified Delphi survey process was conducted in two phases: a pilot item affirmation study, and a global field survey. Setting a global survey conducted in 90 countries. Participants midwifery educators or clinicians associated with midwifery education schools and programmes located in any of the ICM member association countries. Additional participants represented the fields of nursing, medicine, and midwifery regulatory authorities. A total of 232 individuals from 63 member association and five non-member countries responded to one or both of the surveys. The achieved sample represented 42% of member association countries, which was less than the 51% target. However, the sample was proportionally representative of ICM's nine global regions. Measurements survey respondents expressed an opinion whether to retain or to delete any of 255 statements of midwifery knowledge, skill, or professional behaviour. They also indicated whether the item should be a basic (core) item of midwifery knowledge or skill that would be included as mandatory content in a programme of midwifery pre-service education, or whether the item could be added to the fund of knowledge or acquired as an additional skill by those who would need or wish to include the item within the scope of their clinical practice. Findings a majority consensus of .85 was required to accept the item without further deliberation. An expert panel made final decisions in all instances where consensus was not achieved. The panel also amended the wording of selected items, or added new items based on feedback received from survey respondents. The final document contains 268 items organised within seven competency domains.

Objective to identify and better understand factors that influence care-seeking behaviour for women's health among indigenous Mayan populations in the highlands of Guatemala. Design adaptation of qualitative anthropological methods involving observations, key informant interviews and focus group discussions (FGDs). Setting Project Concern International's Casa Materna, Huehuetenango, Guatemala. Participants Interviews and FGDs were conducted among 21 clients (current or past) of the Casa Materna and traditional birth attendants; 17 female advocates/promoters of the Casa Materna and related services; and 12 male advocates, including spouses, non-government organisation staff and community health workers. Findings the following findings emerged from focus group data: Women's support groups (WSGs) provided an enabling environment in which women could form friendships, bond, discuss concerns about their reproductive health, and identify concrete ways of addressing them; Supportive friends, family members and advocates influenced women's decisions to seek health care at the Casa Materna; Women's decisions to seek care were often associated with their sense of self-worth and self-esteem, and women's self-esteem was enhanced by their participation in the WSGs; Women's decisions to seek care were influenced by the perception that women would be able to access culturally appropriate, safe and secure health care services at the Casa Materna; The learned behaviour of negotiation with key decision-makers and/or opinion leaders was an effective tool for convincing such individuals of the value of accessing facility-based care; The proven track record, high quality of services and cultural competence offered at the Casa Materna increased the confidence and level of trust of clients and their family members about the care that would be received; Couple-based education and health promotion were effective techniques for achieving behaviour and attitude change among both men and women. Key conclusions the Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the social fabric that characterises this high risk and vulnerable population. Implications for practice the Casa Materna model provides a foundation upon which to bridge and strengthen the relationship between community advocates, traditional community-based health care providers, and the government-funded system of health care. The findings of this study should be incorporated into future research to determine the potential for bringing the model to scale.

Summary Objective: to present the evidence for inclusion of selected midwifery tasks (skills) as essential practice competencies for midwives throughout the world. The tasks addressed are those presented to the International Confederation of Midwives (ICM) Council of Delegates in 2002 for discussion and adoption, based on the fact that during field-testing, notable variance was encountered. Key conclusions and implications for practice: evidence-based practice should be characterised by the use of best practices derived from rigorous research, combined with and balanced by client perspectives and the expert judgement based on the critical thinking of the clinician. Much of midwifery practice is considered an art based on common sense, tradition, and woman-centred approaches to caring, as most of the women who seek midwifery care are healthy and require a health-promotion model of care that may not easily lend itself to examination by scientists or clinicians. However, when intervention is indicated to save the lives of mother, baby, or both, those interventions must be based on the best available evidence from a variety of sources leading to the most effective choices for action. The ICM Essential Competencies for Midwifery Practice (2002) are based on evidence derived from a variety of quantitative and qualitative methodologies. Expert clinical consensus may serve as to the best form of evidence at certain points in the evolution of knowledge. Every midwife needs to understand where the gaps exist in supporting traditional practices that have yet to be fully examined in a scientific manner. In summary, a multi-matrix or triangulated approach may be most appropriate to the delineation of evidence underpinning best midwifery practice.

The political union between the countries of North and South Yemen prompted nurse-midwife educators to re-examine the midwifery curricula of both countries and define the roles midwives play as members of the health team, based on the unique circumstance in which Yemeni midwives operate within the health care system. The faculty of the Health and Manpower Institute (HMI), the main educational institution for the education of midwives, recognised that the delineation of tasks attributed to the practice of midwifery varied widely within Yemen, and between Yemen and other countries, despite the existing international definition of the role. In 1992, the Agency for International Development (AID) funded a workshop for the HMI faculty. Nineteen midwives, nurses and other health care professionals used task analysis techniques to define key knowledge, skills and attitudes that a midwife should be taught in Yemen. Task analysis, a psychometric (test development) technique, is a process that can be used to develop specific role delineations. This article describes in detail the process of task analysis in identifying key skills, knowledge and attitudes to be taught to student midwives in Yemen, clarifying the role of midwives and identifying the usefulness of a derived task listing in educational development and student evaluations.With the political union of North and South Yemen, Health and Manpower Institute (HMI) faculty noted a need to define tasks related to the practice of midwifery since these tasks differed greatly within Yemen and between Yemen and other countries. In 1992, USAID provided funds to the Family Health Training Project to put on a 3 day workshop in basic evaluation skills for 19 midwife teachers, nurses, and X-ray technicians. The workshop facilitators had the participants use the process of task analysis to define key knowledge, skills, and attitudes that a midwife should learn in Yemen. Task analysis is a psychometric (test development) technique. The steps of task analysis are data collection, development of a comprehensive document of the tasks, and evaluation of the task document. When task analysis is used as an evaluation methodology, the first step is making a detailed list of expected competencies (i.e., task statements) which are used to guide curriculum development. Program managers can use norm-referenced evaluation methods (i.e., comparing the pefformance of 1 midwife student or practitioner to that of others in the same or similar group) and/or criterion-referenced evaluation methods (i.e., an expected and predetermined standard of competent performance). The task statements can also be used for practicing midwives to perform self-assessment of their competency. The task list can also be used in more global evaluation strategies (e.g., licensure exams). HMI faculty learned and used task analysis during the workshop to identify core clinical competencies and to set goals and objectives (e.g., competency checklist aimed to improve midwifery instruction and improve quality of care). At the end of the workshop, the 2 groups built a consensus and finalized a Performance Assessment Instrument. Faculty members of midwifery schools throughout Yemen have field tested the instrument for validity.

Objective: this paper uses comparisons and contrasts identified during an assessment of pre-service education for midwives in three countries in sub-Saharan Africa. The purpose of the paper is to stimulate discussion about issues that must be carefully considered in the context of midwifery educational programming and the expansion of the midwifery workforce. Design and setting: a mixed qualitative and quantitative participatory assessment was conducted in Ethiopia, Ghana and Malawi, in the context of a final review of outcomes of a USAID-funded global project (ACCESS). Quantitative surveys were distributed. Individual and focus group interviews were conducted. Participants: participants included key informants at donor, government and policy-making levels, representatives of collaborating and supporting agencies, midwives and students in education programmes, and midwives in clinical practice. Findings: information is presented concerning the challenges encountered by those responsible for midwifery pre-service education related to issues in programming including: pathways to midwifery, student recruitment and admission, midwifery curricula, preparation of faculty to engage in academic teaching and clinical mentorship, modes of curriculum dissemination and teaching/learning strategies, programme accreditation, qualifications for entry-into practice and the assessment of continued competence. Key conclusions: quality issues must be carefully considered when designing and implementing midwifery pre-service education programmes, and planning for the integration of new graduates into the health workforce. These issues, such as the availability of qualified tutors and clinical teachers, and measures for the implementation of competency-based teaching and learner-assessment strategies, are particularly relevant in countries that experience health manpower shortages. Implications for practice: this review highlights important strategic choices that can be made to enhance the quality of pre-service midwifery education. The deployment, appropriate utilisation and increased number of highly qualified midwifery graduates can improve the quality of maternal and newborn health-care service, and reduce maternal and newborn mortality.

Examination for certification or licensure of health professionals (credentialing) in the United States is almost exclusively of the multiple choice format. The certification examination for entry into the practice of the profession of nurse-midwifery has, however, used a modified essay format throughout its twenty-year history. The examination has recently undergone a revision in the method for score interpretation and for pass/fail decision-making. The revised method, described in this paper, has important implications for all health professional credentialing agencies which use modified essay, oral or practical methods of competency assessment. This paper describes criterion-referenced scoring, the process of constructing the essay items, the methods for assuring validity and reliability for the examination, and the manner of standard setting. In addition, two alternative methods for increasing the validity of the pass/fail decision are evaluated, and the rationale for decision-making about marginal candidates is described.

Objective: to delineate the knowledge, skills, and behaviours that would characterise the domain of competencies of the midwife who is educated according to the international definition of the profession. Design: Phase I: a qualitative Delphi study; Phase II: a descriptive survey research process. Participants: a stratified random sample of member organisations of the International Confederation of Midwives (ICM) and regulatory representatives from these same countries. Findings: a list of basic (essential) and additional competencies for midwives who have been educated in keeping with the ICM/WHO/FIGO international definition of the midwife was developed through an interative Delphi process, and then affirmed, using a survey research method. The final list includes 214 individual task statements within six domains of midwifery practice. Implications for practice: this list of competencies can serve as a basis for educational curriculum design, as a guideline for regulatory policy development, as a reference document for individual practitioners in an assessment of their initial and continued competency and by the ICM and its member associations as a resource for advocating for the role of midwifery within health-care systems world-wide.

A task analysis was conducted by the American College of Nurse-Midwives' Division of Competency Assessment. Task analysis is a technique derived from the psychometric (test construction) field which is used to determine the knowledge, skills and abilities which comprise the domain and scope of practice of a profession, usually within the context of competency assessment. Data derived from this investigation can be used to support the theoretical construct of nurse-midwifery as a professional practice discipline. Data can also be used for purposes of self-assessment, peer review, direction for continuing education, and within the structure of the regulatory process for professional practice, including considerations of reciprocal licensure. Selected data from this research are presented. Several skills and abilities are identified which represent tasks either newly assumed within the scope of American nurse-midwifery practice, or now infrequently practised. Skills which are critical to competency are also identified.