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In Croatia, the model of obstetrics-midwifery management of childbirth in maternity hospitals is still in effect, and this is how > 99% of Croatian women give birth. However, in my view, midwives are still not sufficiently educated for completely independent work notwithstanding their university education. The Law on Midwifery defined the role of the midwife in home birth without, however, setting out other organisational-communication and professional provisions. Then it began with sporadic midwifery home births of a few per year, which grew quite rapidly, especially with the impact of the Covid-19 virus pandemic, to about 100 out of a total of about 38,000 births that are performed annually in the Republic of Croatia in maternity hospitals. Since the start of planned home births many bad perinatal outcomes have been recorded in hospital maternity wards who have admitted women after such deliveries. These include puerperal sepsis, protracted labour of several days, neglected protracted labour with perinatal asphyxia and aspiration of meconium amniotic fluid and resuscitation of the newborn (who later developed cerebral palsy), severe postpartum haemorrhage with obstetric shock and postpartum hysterectomy, episiotomy infection, and stillbirth at term pregnancy. Therefore, planned home birth in Croatia should now be regarded as an unsafe birth in extraordinary circumstances and the person who takes charge of it must be professionally prepared, educated and have numerous social skills. Most Croatian gynaecologists and obstetricians give support to midwives in their efforts to be professional and independent when at work, including the controlled and legal implementation of the planned home birth. We unreservedly support self-aware midwives to maintain their profession as highly ethical and professional as possible above the wishes of non-professionals who call for autonomy, so that we do not have to discuss such problems of malpractice of Croatian midwifery in the 21st century., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This article examines whether the current termination laws of Australia and Aotearoa New Zealand align with the midwifery scope of practice. It begins with an introduction to termination of pregnancy from a health care perspective. An overview of previous and current legal frameworks in Australia and Aotearoa New Zealand that impact upon the provision of termination of pregnancy health services is provided. Midwives' scope of practice is explained and the legal and administrative factors obstructing midwives' ability to work to their full scope are discussed. Midwives' needs to enable the provision of termination care are considered. The article concludes that the current laws are not supportive of midwives as termination care providers and their needs to realise their full scope of practice are not being met., Competing Interests: None to declare.

With the recent enactment of the National Nursing and Midwifery Commission (NNMC) Act, 2023, significant changes are anticipated in the scope of practice and autonomy for registered nurses and midwives in India. However, alongside these anticipated advancements, concerns have emerged regarding various aspects of the Act, necessitating critical examination. In this article, we aim to explore expected changes in nursing education and service and concerns about the NNMC Act, providing insights into the implications of the NNMC Act on the regulation and advancement of the nursing and midwifery profession in India. The Act is anticipated to introduce uniform standards, implement entry and exit examinations, recognize midwifery as a distinct discipline, and determine the scope of practice for nurses and midwives. Moreover, the implementation of the Nurse Practitioner Program and guidelines for its limited prescribing authority is anticipated. Concerns exist regarding the composition of the commission and board members, adequate stakeholder representation, lacking provisions for ensuring continued competence, working conditions of nurses and midwives, nomenclature, integrating new terms, and clearly defining roles. These concerns emphasize the need for viable career pathways, uniform cadres, and a streamlined registration system, crucial for advancing nursing and midwifery profession in India. The coexistence of concerns and anticipation highlights the complexity of enacting regulatory reforms in nursing and midwifery. Policymakers can lay the foundation for a comprehensive, inclusive regulatory system that promotes excellence in nursing and midwifery practice, ultimately benefiting both healthcare providers and patients.

Improving health and achieving health equity includes access to sexual and reproductive health care for all populations, especially those most in need. However, access to life-saving and life-affirming contraception with an individual's chosen perinatal provider can be impeded by restrictive regulations that limit scope and practice authority. This is especially true for the majority of community and direct entry midwives in the United States who have historically been unable to legally provide effective contraceptive methods. Recently, licensed midwives in Washington state were the first in the nation to achieve prescriptive authority, enabling their clients to directly obtain contraception and access to medications for common prenatal and postpartum conditions. Sustained advocacy efforts in the state's capitol enabled the Midwives' Association of Washington State to build relationships over time with legislators and government agencies to achieve this long-term goal. We present a successful midwifery-led innovation that achieved scope expansion for licensed midwives whose practice authority was limited by restrictive laws. Lessons learned are described and strategies offered to aid midwives and their advocates in other locales who want to improve health equity and access to contraception. Midwives are well positioned to provide this essential care to individuals living in underserved rural and urban areas and those from historically marginalized communities, but their ability to do so is limited by restrictive legislation., (© 2024 by the American College of Nurse‐Midwives.)

Background: In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms., Methods: We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective., Results: There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges., Conclusions: India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance., Competing Interests: I have read the Journal’s policy and the authors of this manuscript have no competing interests.

Background: The purpose of regulation of health professionals is public protection. Concerns regarding professional conduct or midwifery care can lead to clinical investigation. Midwifery literature reveals midwives feel ill-equipped and unprepared for clinical investigation and experience stress and abreaction., Aim: To explore the lived experience of clinical investigation and identify the personal and professional impact on Australian midwives., Method: Semi-structured interviews of a purposive sample of Australian midwives. Data analysis was informed by a phenomenological conceptual framework derived from Husserl, Heidegger and Merleau-Ponty., Findings: Twelve midwives were interviewed, with seven under current investigation. Discussion involved personal and professional experiences of three or more investigations each, over a period of three to five years. Most investigations were instigated by hospitals with two complaints from women. Seven participants were alleged negligent following adverse neonatal outcomes and five had misconduct allegations. Midwives were employed or in private practice and half provided homebirth services. Themes included being safe, being connected, time and being, perception and well-being., Discussion: The investigative process involves different health services, state and national bodies using varying powers and processes over protracted time periods. Participants discussed aspects such as disrespect, inequity, powerlessness, silence and ostracization. Midwives who successfully navigated clinical investigation developed resilience through reflection on clinical practice in a culture of safety., Conclusion: The process of regulating midwives, designed to protect the Australian public, may be harming investigated midwives. Understanding the personal and professional impact of clinical investigation needs to underpin midwifery education, clinical practice, inform policy and regulatory reform., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Background: In 2010, the Nursing and Midwifery Board of Australia introduced a new registration standard: Endorsement for scheduled medicines for midwives. The endorsement enables midwives to provide women with Medicare-rebatable care, prescribe relevant medications, and order relevant Medicare-rebatable diagnostics. Translating endorsement education into clinical midwifery practice has been slow, indicating the presence of barriers affecting midwives' ability to use this standard, despite it increasing their scope for service provision., Aim: To discover the mechanisms affecting midwives' ability to work to full scope of practice after completing a programme of study leading to endorsement., Methods: An observational (non-experimental) design was used. Midwives who had completed an education programme leading to endorsement were invited to complete a survey. Descriptive statistics were used to analyse the quantitative questions and content analysis was conducted on the qualitative data., Findings: Results indicated that barriers - such as the limitations of Medicare provisions for endorsed midwives and a general lack of support for the role - restrict endorsed midwives' ability to provide quality maternity services. Having some form of support for the role may act as an enabler, in addition to midwives having personal determination and confidence in their ability to use the endorsement. Recommendations to strengthen the endorsed midwife's role include facilitating endorsement use in the public sector, relaxing Medicare Benefit Schedule and Pharmaceutical Benefit Scheme restrictions, raising awareness of the role and scope, and improving midwives' pre-endorsement preparation., Conclusion: This study highlights the need for an all-of-system approach to support and develop the endorsed midwife's role., (Copyright © 2020 Australian College of Midwives. All rights reserved.)

Introduction and Objective: The aim of the study is to discuss the legal framework for telemedicine services in Poland, and to present telemedicine solutions used in selected European countries., Material and Methods: The analysis of legal cts was chosen as a research method in order to determine legal possibilities for medical professionals to use telemedicine services. A literature review was undertaken to demonstrate the possibilities of telemedicine as used in the United Kingdom, Germany, Norway, The Netherlands and Sweden., Results: The Act on the professions of a doctor and a dentist states that the doctor and the dentist can perform their profession via ICT systems or communication systems. The doctor is obliged to practice in accordance with current medical knowledge and available methods. 'Available methods' include considering information and communication measures that may allow prevention, recognition or treatment. The Act on the profession of a nurse and a midwife states that the nurse and midwife perform the professions using current medical knowledge and the mediation of ICT systems or communication systems. Thus, the legislator has clearly authorized persons performing these professions to provide services in the field of telemedicine. However, despite the existence of a legal basis for using telemedicine, its development in Poland is not as high as in the United Kingdom, Germany, Norway, The Netherlands or Sweden., Conclusions: The legislator gradually introduces legal solutions necessary for the development of telemedicine services, although the pace of these changes, as well as building the technical infrastructure that is the basis for the proper provision of telemedicine services, are too slow.

This work uses a field survey to analyze a plenary session of the Rio de Janeiro Legislative Assembly entitled "Humanized childbirth and the right to choose." Understanding this as a political space for conflicts of knowledge pertaining to the areas of medicine, nursing, and legislature, we consider the content of this session and discourses of power/knowledge surrounding the female body and reproduction. The article explores tensions around the political struggle for "humanized childbirth" via demands made by the Regional Council of Nursing. We also address the history of the medicalization of childbirth and the role of nurses, professionals specialized in low-risk births (obstetrizes), and midwives in this process.

Competing Interests: The authors declare that they have no competing interests.

Introduction: Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials., Methods: ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed., Results: Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey., Discussion: Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States., (© 2019 by the American College of Nurse-Midwives.)

Competing Interests: Competing interests: None declared.

Problem: There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia's Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use., Objective: To critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement., Method: A search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria., Findings: Although singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers., Conclusion: Barriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual's support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement's use in midwifery., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

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.

Introduction: Studies have linked midwifery practice laws to the availability of midwives but have generally not related workforce data to potential demand for reproductive health services. We examined state regulatory structure for midwives and its relationship to midwifery distribution and vital statistics data at the state and county level., Methods: Midwifery distribution data came from the Area Health Resources Files, distribution of women of reproductive age came from the US Census, and birth statistics came from US Natality Files from 2012 to 2016. Midwifery regulations were drawn from American College of Nurse-Midwives Annual Reports. We used bivariate analysis to examine the relationship between state midwifery practice regulations and the number of midwives available in states and counties to potentially meet women's health care needs., Results: Twenty states and the District of Columbia had autonomous practice regulatory frameworks, whereas 24 states had collaborative practice regulatory frameworks during the years between 2012 and 2016. Six states changed regulations during that period. In 2016, the number of midwife-attended births per number of midwives in a state was not related to the regulatory framework. However, states with autonomous frameworks had 2.2 times as many midwives per women of reproductive age (P < .0001) and 2.3 times as many midwives per total births when compared with states with collaborative statutory frameworks (P < .0001). At the county level, 70.1% of US counties had no midwife. Of those states with autonomous practice, only 59.7% of counties had no midwives, compared with 74.1% in states with collaborative models (P < .0001)., Discussion: Midwives have the potential to help address the shortage of maternity and reproductive health service providers. Our research suggests that increasing the number of states with autonomous regulatory frameworks can be one way to expand access to care for women in the United States., (© 2019 by the American College of Nurse-Midwives.)

Background: Few studies have explored ethical and legal issues in contraceptive counselling among women with intellectual disability (ID). This study aimed to gain a deeper understanding of these issues during midwifery contraceptive counselling., Method: The present authors interviewed 19 midwives in five focus groups in Sweden 2016 - 2017 and analysed data with content analysis., Results: The participants expressed that women with intellectual disability have equal right to relationships and sexual expressions, but feared exposure to sexual exploitation/abuse. They experienced ethical dilemmas related to principles of fairness and autonomy, but strived to provide assistance in spite of the women's cognitive impairment, presence of supporting persons and uncertainty of optimal counselling. Organizational support was insufficient., Conclusions: The midwives experienced ambivalence, uncertainty and ethical dilemmas in their counselling. They were, however, aware of legal aspects and strived for the women's best interest, right to self-determination and autonomous choices. The participants wanted better professional teamwork and support., (© 2019 John Wiley & Sons Ltd.)

Background:: This study was developed as a result of a court case involving conflicts between midwives' professional practice and their faith when caring for women undergoing abortions in Scotland., Research Questions:: What are practising Roman Catholics' perspectives of potential conflicts between midwives' professional practice in Scotland with regard to involvement in abortions and their faith? How relevant is the 'conscience clause' to midwifery practice today? and What are participants' understandings of Canon 1398 in relation to midwifery practice?, Research Design:: The theoretical underpinning of this study was Gadamer's hermeneutic out of which the method developed by Fleming et al. involving a five-stage approach was utilised., Participants and Research Context:: The research was conducted in the south of Scotland. A purposive sampling method was used. Eight participants who were practising Roman Catholics familiar with the subject of conscientious objection who were either midwives, lawyers (civil, canon or both) or priests contributed., Ethical Considerations:: The major ethical issues related to respect for autonomy, maintaining confidentiality and obtaining voluntary informed consent. Parish priests agreed to act as gatekeepers to prospective participants. All legal requirements were addressed regarding data collection and storage. Approval was given by the ethics committee of the university with which one of the researchers were associated., Findings:: Three key themes provide an understanding of the situation in which midwives find themselves when considering the care for a woman admitted for an abortion: competing legal systems, competing views of conscience and limits of participation., Conclusion:: Clear guidelines for practice should be developed by a multi-professional and consumer group based on an update of the abortion law to reflect the change from a surgical to medical procedure. Clarification of Canon 1398 in relation to what is and is not participation in the procurement of abortion would be of benefit to midwives with a conscientious objection.

Introduction:: Midwives play an important role in maintaining and increasing women's health and well-being. Training professional midwives is one of the main policies of any healthcare system. Since the number of complaints against midwives has increased recently, this study was conducted to explore the perspectives of midwives regarding patients' complaint to authorities and their impacts on the profession of midwifery., Methods:: Being conducted in 2013, this qualitative study was the first of its type in Iran. Data were collected through in-depth semi-structured interviews with 14 midwives working in different cities across the country. The participants were selected using a purposive sampling method. Interviews were transcribed verbatim and analyzed following a qualitative content analysis approach. Written text was then coded, and themes were extracted from the data. Ethical considerations: The study was conducted with midwives' free informed consent and was approved by Ethics Committee of Tehran University of Medical Sciences., Findings:: By analyzing the data, four main themes regarding the impact of complaint on midwifery profession were developed. These included the following: "dissatisfied of midwifery, professional deviation, obsession with work, and weakening of the professional status.", Conclusion:: The experience of patients' complaint to legal authorities against midwives was described, by participants, as a painful experience. Lack of midwives' knowledge about professional rules and litigation process created many problems for them and could negatively affect their practice and the society's attitude toward midwifery. Thus, we suggest that in order to prevent such problems, midwives and midwifery students should be educated regarding factors that have the potential to create such problems and also prevention strategies.

Aim: A theoretical discussion using categorisation theory to discuss the final analysis of findings from research which investigated midwives' responses to the changed registration-renewal requirements in Australia after the introduction of national registration., Background: In 2010 the Health Practitioner Regulation National Law Act introduced national registration to standardise the regulation of health professionals in Australia. Annual registration-renewal standards required all health professionals to meet the same standards of clear police check, insurance for scope of practice, Continuing Professional Development (CPD) and Recency of Practice (ROP)., Question: How did dual registered midwives respond to the changed registration-renewal requirements when national registration was introduced?, Methods: A longitudinal single case study was conducted in two phases between 2011-2013 with a purposive sample of 24 midwives from five states of Australia to perform individual or group interviews., Findings: Participants used inclusion and exclusion criteria to create boundaries around practice to illustrate how they met the registration-renewal standards. Accentuation (exaggeration) of practice helped them define their separate professional registrations. Boundaries included the type of person being cared for, practice activities. and place of practice., Conclusion: The theory of categorisation helped explain the dual registrants' behaviour and rationalise their midwifery responses., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: An allegation of negligence or an adverse outcome during childbirth can lead to clinical investigation of a midwife's practice. Anecdotal evidence suggests midwives find this stressful and disturbing., Aim: Synthesise the evidence relating to midwives' experiences of investigation and the effects on clinical practice and personal wellbeing., Methods: Two database searches were conducted between 2015 and 2016 to identify primary research published between 1990 and 2016. Studies were evaluated for quality using standard instruments., Findings: Despite numerous references to 'litigation' in peer-reviewed journals, little substantive research related specifically to midwives. 11 inclusions comprised three qualitative studies (one with two publications), reporting litigation experiences of midwives and seven quantitative studies (four research groups), identifying risk liability through cyclic surveys of midwives and law reports. Failure to identify deterioration in foetal well-being was a common finding among researchers examining reasons for litigation. Experienced midwives were at highest risk of litigation. Researchers found high levels of distress and abreaction among participants who either stopped working in birth suite or left midwifery. They also identified a level of ambiguity around defensive practices associated with fear of litigation., Conclusion: There is little research regarding experiences of midwives and clinical investigation. Midwives under investigation need appropriate support. Continuing to work during prolonged investigative processes is stressful as reported by midwives who described being "ill-equipped" and "unprepared." Midwives in the review preferred the support of colleagues over counsellors. Educators, employers and regulators need to work collaboratively and incorporate reflective practice in targeted support., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Objective: This study aims to outline the progress of midwifery-related policies in contemporary and modern China as well as the obstacles in this process, and to provide recommendations for policy makers in the establishment of Chinese midwifery policies, ultimately promoting the development of midwifery in China., Background and Introduction: Policy plays an increasingly important role in midwifery development, particularly needed in modern China. A review of policies of midwifery could help policy makers develop effective strategies to address current problems in China, including the insufficient numbers of midwives, the shrinking of responsibility and the degradation of midwives' competency., Methods: The Policy Triangle was used to examine through literature the laws and regulations regarding midwifery from 1928 in China and was conducted from April to September in 2013. This was followed by insider interviews with two senior policy makers from the National Health Commission to explain nursing policy progress, thereby identifying the reasons why midwifery has developed more slowly than nursing., Results: The development of midwifery in China could be classified into four stages: (1) the beginning period (1928-1949), beginning with the first midwifery rules; (2) the development period (1949-1979), in which the quality and quantity of midwives were significant; (3) the unclear positioning period (1979-2008), without clear midwifery policy; and (4) the subordination to nursing period (2008-present), with the Nurse Byelaw 2008 stating that midwives must apply for nursing licenses., Discussion: The main factors influencing midwifery policies are: (1) social background, such as the changes of different governments and health care reform, and (2) the powers of the actors. Currently, it is an appropriate time to develop strategies for policy makers to facilitate midwifery development in China., Conclusions and Implications for Health Policy: Midwifery policy should be independently included in the frame of national medical industry reform because midwives are an indispensable part of the health care workforce. In-depth research should be conducted to confirm the position of midwifery in China to ensure its sustainable development., (Copyright © 2018. Published by Elsevier Ltd.)

Introduction: 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., Methods: 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., Results: 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., Discussion: 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., (© 2018 by the American College of Nurse-Midwives.)

In 1928 members of the South Dakota State Medical Association (SDSMA or the Association) held a special meeting in Huron to consider a basic science bill that conformed "…in its entirety to the conditions existing in our state." Their draft bill proposed a standardized examination for all practitioners of the healing arts. A legislative committee, with its attorney, "…was in Pierre during the early part of the 1929 legislative session to make sure the bill was properly launched and in effective channels." Shortly after its introduction, the bill was withdrawn due to opposition from one SDSMA district whose legislative representatives were among the most influential in the legislature. A similar bill promoted by the SDSMA in 1933 also failed. It would be another six years before a basic science bill was enacted by the legislature. Eighty-nine years later, a bill governing the practice of certified nurse practitioners (NP) and certified nurse midwives (NM), including a board independent of the South Dakota Board of Medical and Osteopathic Examiners, was considered (Senate Bill 61). Introduced by a senator who characterized herself as representing the "House of Nursing," the bill challenged "…the overarching role that medicine thinks and perceives that they may have regarding advanced practice nursing practice." SB 61 passed in the senate and house and was signed by the governor. For this legislation in the 1930s and in 2017, the SDSMA's interest was defining and maintaining control of medical practice under the twin rubrics of quality and patient welfare. In both circumstances, legislators and other health care professional organizations contested not only the SDSMA's motivations, but also the evidence supporting their efforts. Our research explored (1) whether the collective viewpoints and conduct of the legislature, the SDSMA, and non-physician medical professionals are comparable in the two circumstances; and (2) if the circumstances are comparable, can we derive a useful concept or theme that could help guide the SDSMA in the future?, (Copyright© South Dakota State Medical Association.)

Objectives: Currently maternity care organisation is developing worldwide. Therefore insight in the position of the midwife is important. The 'Midwife Profiling Questionnaire' (MidProQ) measures women's preferred perinatal care professional and their knowledge of midwives' legal competences. MidProQ is based on the European legal framework and was tested in a pilot study. This study aims to determine its content and face validity., Study Design: A two-phase validation study with a Delphi method questioning content experts (n = 10) on items relevance and clarity as well as its scale and face validity. Further semi-structured interviews were performed with lay experts (n = 10) to evaluate the questionnaire's clarity, layout, phrasing and wording., Results: After round one, most questions (42/47) were considered content valid for relevance and clarity (Item Content Validity Index 0.80-1.00). Scale (Scale Content Validity Index 0.92) and face validity (Face Validity Index 0.89) of the entire instrument was obtained. Five questions were revised until item content (0.83-1.00), scale content (0.92) and face validity (1.00) were appropriate. Lay experts' suggestions for improving the readability and usability were taken into account., Conclusions: We developed a valid instrument to elicit women's preferred health professional for uncomplicated pregnancy, labour and childbirth and to determine their knowledge about midwives' legal competences. Our instrument can be valuable in identifying knowledge gaps and improving the knowledge of the general population about the midwifery profession and maternity care. Finally, the MidProQ may improve research in the domain of maternity care culture, scale up midwifery and facilitate a more women-centred care., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Priorities of the National Maternity Services Plan (NMSP) are a significant contrast to current standard hospital maternity service provision. This paper demonstrates the applicability of case study methods to explore the views of midwives during a period of midwifery reform., Aim: This research aims to highlight key findings and insights surrounding recommended changes facing midwives that can be shared with education providers to incorporate strategies into education programs to ensure contemporary midwifery practice., Methods: Exploratory Case Study methodology was employed using ethical processes and designing semi-structured interview questions to explore participants' views. Purposive sampling ensured participants were currently practicing midwives in order to reflect the perspective and intent of this study. Data were analysed and findings presented in categories and subcategories., Results: Case Study methodology enables an in-depth understanding of a phenomenon to be explored within a natural context. The participants of this study formed a single unit of analysis to ensure the research makes a worthwhile contribution to the profession of midwifery., Conclusion: This paper demonstrates that Case Study methodology is a valid research approach to exploring the views of midwives employed in standard care settings during a period of national reform. The rigorous processes and versatility of Case Study methodology ensured a systematic, critical enquiry was undertaken to gain understanding of the views of participants in implementing the NMSP. This understanding is reflective of the real life contexts of midwives to promote understanding and provide a body of knowledge where there is ambiguity and uncertainty., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Australian midwives are regulated under the National Registration and Accreditation Scheme. Unregistered birth workers may provide midwifery services at homebirths without any regulatory oversight. To address this issue, several states have passed legislation enabling prohibition orders to be made (negative licensing) against unregistered health practitioners who fail to comply with a statutory code of conduct developed for those not covered by the National Scheme., Aim: To explore the consequences for the availability of birth choices for women that arise from the introduction of negative licensing., Discussion: An analysis of the regulatory framework and recent cases of unregistered birth workers attending homebirths reveals problems with equitable access to homebirth support, arising from issues with professional indemnity insurance, geography, and poor integration with hospitals and the wider healthcare system. These problems contribute to women choosing to employ the services of unregistered birth workers., Conclusion: Negative licensing provides a useful additional tool for improving the safety of homebirths for mothers and babies, but it does not address the issues leading expectant parents to choose an unregistered birth worker to attend their births, and may contribute to an increase in high-risk behaviours, such as freebirthing., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Errors and notices to appear in court are a reality of life for many midwives and exert significant effects on both their professional and personal lives. Given the increasing population policies in place, this study was conducted to examine midwives' experiences of litigation in Iran., Methods: A qualitative study was conducted in 2014 using an interpretive phenomenological approach. The interviews were recorded and transcribed and were then analyzed using the Diekelmann method., Findings: Midwives who participated had professional experience ranging from 3 to 22 years at the time of the complaints. Five participants had received more than one complaint, and 10 participants were judged as guilty creating/leaving significant effects on various dimensions of their lives., Conclusion: The present research disclosed four main themes from the interviews including feeling ruined by the complaints, being conflicted between denial and belief, having shattered hopes of release, and experiencing the slowed-down rhythm of midwifery. From these, a basic pattern of "living in despair" was extracted. Litigation is a painful experience for midwives. Anxiety regarding compensation for the patients' losses, public judgment, prolonged litigations, and undermined professional dignity create physical and psychological ramifications for these midwives. Negative feelings about litigation, compounded by the lack of legal support from the authorities, cause a sense of hopelessness regarding the future of the midwifery profession.

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study., (© The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Report review runs alongside Guideline commentary and the other evidence series articles, examining local, national and international reports that have implications directly or indirectly for midwives. It helps readers to understand what reports mean for midwifery practice and to place report recommendations into context. As with all our evidence series articles, report reviews support you to critique recommendations and implications for your own practice. In 2016, Ireland launched its first ever maternity strategy (Department of Health (IDH) 2016). This followed many high-profile controversies, including maternal and neonatal deaths due to medical misadventure. This article reviews Ireland's history of maternity services, the new strategy and current perinatal mental health services.

In addition to the regulation of prescriptive authority and prescribing practices conducted by individual states, the prescription of controlled substances is also regulated at the federal level by the US Drug Enforcement Administration (DEA). While there are variations in state laws relative to controlled substance prescribing, federal law is uniform across states as established by the Controlled Substances Act (21 United States Code § 801-890) and the DEA Regulations (Title 21, Code of Federal Regulations). The only controlled substance for which states have authorized use that is outside the regulations set forth in the Controlled Substances Act is marijuana for the treatment of certain medical conditions. A review of statutes and administrative rules for all 50 states and the District of Columbia revealed that certified midwives (CMs) are authorized to prescribe controlled substances only in the state of New York, and there are variations across states in the regulation of controlled substance prescribing by certified nurse-midwives (CNMs). The purpose of this article is to examine the federal regulation of controlled substance prescribing by the US DEA and common variations in state regulations relative to controlled substance prescribing., (© 2017 by the American College of Nurse-Midwives.)

This article provides information on recent changes in the US Food and Drug Administration (FDA) labeling and safety regulations for mifepristone (Mifeprex). The revised label now permits midwives, advanced practice nurses, and physician assistants to order and prescribe mifepristone, eliminating the requirement for physician supervision. The updated label also extends eligibility for use from 49 to 70 days' gestation and decreases the number of required visits from 3 to 2. The recommended dose of mifepristone has been reduced, and the dosage, timing, and route of administration for misoprostol have also been changed to reflect current research. These changes have implications for clinical practice and may lead to expanded access for women in the United States., (© 2017 by the American College of Nurse-Midwives.)

Current changes in midwifery raise concerns about the erosion of women's choices and midwives' autonomy. This article is an exploration of women's legal rights that relate to consent and declining care. Using examples of poor practice, women's negative experiences are highlighted. However, this article demonstrates how midwifery practice can be grounded in the current legal framework in such a way that women's decisions are upheld and midwives feel supported in their advocacy role.

Background: In Australia the choice to birth at home is not well supported and only 0.4% of women give birth at home with a registered midwife. Recent changes to regulatory requirements for midwives have become more restrictive and there is no insurance product that covers private midwives for intrapartum care at home. Freebirth (planned birth at home with no registered health professional) with an unregulated birth worker who is not a registered midwife or doctor (e.g. Doula, ex-midwife, lay midwife etc.) appears to have increased in Australia. The aim of this study is to explore the reasons why women choose to give birth at home with an unregulated birth worker (UBW) from the perspective of women and UBWs., Methods: Nine participants (five women who had UBWs at their birth and four UBWs who had themselves used UBWs in the past for their births) were interviewed in-depth and the data analysed using thematic analysis., Results: Four themes were found: 'A traumatising system', 'An inflexible system'; 'Getting the best of both worlds' and 'Treated with love and respect versus the mechanical arm on the car assembly line'. Women interviewed for this study either experienced or were exposed to mainstream care, which they found traumatising. They were not able to access their preferred birth choices, which caused them to perceive the system as inflexible. They interpreted this as having no choice when choice was important to them. The motivation then became to seek alternative options of care that would more appropriately meet their needs, and help avoid repeated trauma through mainstream care., Conclusion: Women who engaged UBWs viewed them as providing the best of both worlds - this was birthing at home with a knowledgeable person who was unconstrained by rules or regulations and who respected and supported the woman's philosophical view of birth. Women perceived UBWs as not only the best opportunity to achieve a natural birth but also as providing 'a safety net' in case access to emergency care was required.

This article analyzes the national discourse over "the problem" of midwifery in medical literature and examines the impact of this dialogue on Rhode Island from 1890 to 1940. Doctors did not speak as a monolithic bloc on this "problem": some blamed midwives while others impugned poorly trained physicians. This debate led to curricula reform and to state laws to regulate midwifery. The attempt to eliminate midwives in the 1910s failed because of a shortage of trained obstetricians, and because of cultural barriers between immigrant and mainstream communities. A decrease in immigration, an increase in trained obstetricians, the growing notion of midwives as relics of an outdated past, and the emergence of insurance plans to cover "modern" hospital births led to a decline in midwifery.

Background: In 2010 the government of the republic of Zambia stopped training traditional birth attendants and forbade them from conducting home deliveries as they were viewed as contributing to maternal mortality. This study explored positive and negative maternal health related experiences and effects of the ban in a rural district of Kazungula., Methods: This was a phenomenological study and data were collected through focus group discussions as well as in-depth interviews with trained traditional birth attendants (tTBAs) and key informant interviews with six female traditional leaders that were selected one from each of the six zones. All 22 trained tTBAs from three clinic catchment areas were included in the study. Content analysis was used to analyse the data after coding it using NVIVO 8 software., Results: Home deliveries have continued despite the community and tTBAs being aware of the ban. The ban has had both negative and positive effects on the community. Positive effects include early detection and management of pregnancy complications, enhanced HIV/AIDS prevention and better management of post-natal conditions, reduced criticisms of tTBAs from the community in case of birth complications, and quick response at health facilities in case of an emergency. Negatives effects of the ban include increased work load on the part of health workers, high cost for lodging at health facilities and traveling to health facilities, as well as tTBAs feeling neglected, loss of respect and recognition by the community., Conclusion: Countries should design their approach to banning tTBAs differently depending on contextual factors. Further, it is important to consider adopting a step wise approach when implementing the ban as the process of banning tTBAs may trigger several negative effects.

Background: There are lay midwives worldwide, interchangeably and universally called traditional birth attendants or traditional midwives by organisations such as the World Health Organization and the International Confederation of Midwives., Aim: This study aimed to explore the history of lay midwives (village midwives) in Brunei, describe the evolution from their previous to current roles and determine if they are still needed by women today., Methods: This qualitative, descriptive study included in-depth, semi-structured interviews with eight women who had received care from village midwives. Data analysis was based on the principles underpinning thematic analysis and used a constant comparative method., Findings: Village midwives have been popular in Brunei since the 1900s, with their major role being to assist women with childbirth. However, since the 1960s, their roles and practices have changed to focus on pre-conception, antenatal, postnatal and women's general healthcare. Traditional practices were influenced by religion, culture and the social context of and within Brunei., Discussion: The major changes in village midwives' roles and practices resulted from the enforcement of the Brunei Midwives' Act in 1956. Village midwives' traditional practices became juxtaposed with modern complementary alternative medicine practices, and they began charging a fee for their services., Conclusion: Brunei village midwives are trusted by women, and their practices may still be widely accepted in Brunei. Further research is necessary to confirm their existence, determine the detailed scope and appropriateness of their practices and verify the feasibility of them working together with healthcare professionals., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Teenage pregnancy is a psychosocial and multifactorial problem described as a lack of exercise of rights in sexual and reproductive health. There are important aspects in the doctor-patient relationship and confidentiality that directly affect the continuity and quality of care. There are controversies in the laws relating to the provision of contraception and confidentiality, and those that protect the sexual indemnity, especially in adolescents under 14 years., Aim: To describe the implications of the legal framework for professional midwives in the care of adolescents younger than 14 years in sexual and reproductive health., Material and Methods: In-depth interviews were conducted to 13 female and 2 male midwives working at Primary Health Care Centers in the Metropolitan Region., Results: The attention of adolescents younger than 14 years in sexual and reproductive health involves medical-legal issues for health professionals. All professionals recognize that mandatory reporting sexual activity is a complex situation. All professionals notify pregnancies. In relation to the delivery of contraception, clinical care is problematic since professionals should take shelter from a legal standpoint., Conclusions: The medical-legal context of pregnant women under 14 years of age care generates a context of uncertainty and fear for professionals and becomes a source of conflict and insecurity in the exercise of the profession.

Objective: Through the critical application of social theory, this paper will scrutinise how the operations of risk management help to constitute midwives׳ understandings of childbirth in a particular way., Design and Setting: Drawing from rich ethnographic data, collected in the southeast of England, the paper presents empirical evidence to critically explore how institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth. Observational field notes, transcribed interviews with various midwives, along with material culture in the form of documentary evidence will be used to explore the unintended consequences of clinical governance and its risk management technologies., Key Conclusions: Through this analysis the fear factor of risk in midwifery talk and practice will be introduced to provide an insight into how risk management impacts midwifery practice in the UK., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Education, regulation and association (ERA) are the supporting pillars of an enabling environment for midwives to provide quality care. This study explores these three pillars in the 73 low- and middle-income countries who participated in the State of the World's Midwifery (SoWMy) 2014 report. It also examines the progress made since the previous report in 2011., Methods: A self-completion questionnaire collected quantitative and qualitative data on ERA characteristics and organisation in the 73 countries. The countries were grouped according to World Health Organization (WHO) regions. A descriptive analysis was conducted., Results: In 82% of the participating countries, the minimum education level requirement to start midwifery training was grade 12 or above. The average length of training was higher for direct-entry programmes at 3.1 years than for post-nursing/healthcare provider programmes at 1.9 years. The median number of supervised births that must be conducted before graduation was 33 (range 0 to 240). Fewer than half of the countries had legislation recognising midwifery as an independent profession. This legislation was particularly lacking in the Western Pacific and South-East Asia regions. In most (90%) of the participating countries, governments were reported to have a regulatory role, but some reported challenges to the role being performed effectively. Professional associations were widely available to midwives in all regions although not all were exclusive to midwives., Conclusions: Compared with the 2011 SoWMy report, there is evidence of increasing effort in low- and middle-income countries to improve midwifery education, to strengthen the profession and to follow international ERA standards and guidelines. However, not all elements are being implemented equally; some variability persists between and within regions. The education pillar showed more systematic improvement in the type of programme and length of training. The reinforcement of regulation through the development of legislation for midwifery, a recognised definition and the strengthening of midwives' associations would benefit the development of other ERA elements and the profession generally.