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Scope of Midwifery Practice: Concept Analysis

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DOI: 10.9790/1959-0603033842

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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 6, Issue 3 Ver. III (May. - June. 2017), PP 38-42
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Scope of Midwifery Practice: Concept Analysis

Abigail Kapfunde1, Clara Haruzivishe2, Christopher Samkange3,
Babill Stray-Pederson4
1-3
University of Zimbabwe. College of Health Sciences. Department of Nursing Science.
4
University of Oslo, Institute of Clinical medicine. Division of Women and Children. Norway

Abstract: The objective of the paper was to describe the concept Scope of Midwifery practice (SOMP). Scope
of midwifery practice remains dynamic and varies in many countries. It takes several forms ranging from listing
of services, interventions given to women during pregnancy, labour and delivery to competencies expected of
individual to practice. International confederation of Midwives (ICM) does not prescribe a fixed definition of
the concept SOMP but emphasized that it should be built upon its international definition of the midwife. This
position allows individual countries to come up with own variation. Existence of variations have compounded
negatively on midwifery practice leading to skill loss in some cases and lack of confidence to practice to full
capacity hence the need to describe the scope of midwifery practice by assigning measurable attributes for
standardisation in midwifery practise. A literature search was conducted using PubMed, journal of midwifery
and Medline which yielded 29 articles from 2006 to 2016. Filtering to consider only those describing the
concept in relation to Midwifery yielded 6. The identified attributes defining the scope of midwifery practice
were autonomy, leadership, competencies and practice setting (policy and regulations).
Keywords: Scope of Midwifery practice.

I. Introduction
The scope of practice remains a dynamic and variant concept in many professions. It can be considered
as something internal not consciously considered yet others link it to competency, training or level of knowledge
or professional conduct. [1] International Council Nursing (ICN) described the scope of practise for nurses as
dynamic and responsive to health care needs. [2] In midwifery practice it may take several forms and should be
in line with the international definition of the midwife. In view of the critical role played by the midwives in
health service delivery it is important for each practitioner to understand their Scope of practice. ICM defined a
midwife as a person who has successfully completed a midwifery education program which is duly recognised
in their country and based on the ICM competences for basic midwifery practice as well as the ICM global
standards for midwifery education, who acquired the requisite qualifications to be registered and or licenced to
practice midwifery and use the title “Midwife”, and who demonstrates competence in the practice of midwifery
[3]. The midwife therefore is recognised as a responsible and accountable professional who works with and in
partnership with women to give the necessary support, care and advice during pregnancy, labour and the post-
partum period. This care includes preventive measures, the promotion of normal birth, detection of
complications and emergency services. The role extends to counselling and education of women, family and
community [3] Regulatory authorities mandated to define scope of midwifery practice should emphasize
individual accountability, self-reliant, competence to enable practitioners to work to full scope of practice and
meet consumer needs. A clearly defined scope of practice does not only improve patient outcomes but can lead
to improved job satisfaction as well as positive migration along the competence continuum. On the contrary
practitioners guided by an unclear scope of practice are more likely to take up roles or tasks beyond own
competencies leading to increased patient risks and adverse outcomes [4]

II. Materials And Methods

An evolutionary approach was utilised as the concept of scope of midwifery practice and is dependent on the
context and needs different parameters to appear in the scientific context to be interpreted. [5]A search was conducted
using PubMed, Web of Science and MEDLINE. A preliminary search for terms scope of practice and Midwifery
practice using Boolean terms “AND” and “OR” was conducted. To achieve a more precise description an inclusion
and exclusion criteria was set. The inclusion criteria for final analysis were literature published in English from 2006
to 2016 in the context of midwifery practice. The year 2008 is when the ICM started developing the Global standards
for midwifery regulation. The 2 years prior allowed for identification of the antecedents. Excluded were articles in
non-English language and not related to midwifery practice. Preliminary search yielded 127 articles on Scope of
practice and after inclusion criteria the number reduced to 29. In the final stage after deleting duplicated items (4) only
6 articles remained which had the definition of scope of midwifery and defining attributes of the concept. All articles
in the context of nursing and midwifery were read, useful features, antecedents, consequences, related concepts and
definition of the concept were extracted. Key characteristics of the concept were identified.
DOI: 10.9790/1959-0603033842 www.iosrjournals.org 38 | Page
 Scope of Midwifery Practice: Concept Analysis

III. Results
The first stage of concept analysis is the Identification of the characteristics that leads to the definition
of the concept [5] The defining characteristics identified were collaborative practice [6; 7; 8] educational
preparation, experience and competences [3; 8], autonomy and accountability [6; 9; 10; 11; 3], practice
setting/policies and guidelines [3; 12; 13; 14; 15] and lastly leadership and support. (4; 16]

3.1 Defining characteristics of SOMP

3.1.1 Collaborative Practice
Midwives can realize their full SOP when they work collaboratively with other health professionals.
They can consult, collaborate, delegate and communicate with different health care practitioners in their
discharge of duties. The key aspects in collaborative practice is the relationship between professionals [6],
professionals need to have an understanding and knowledge of the other’s scope of practice as well as effective
communication of actions [7; 8]. The Code of conduct should set this standard and support this important aspect
of midwifery practice.

3.1.2. Educational preparation, experience and competences

The educational preparation of the midwives determines their SOP. The experience and the
competence each individual practitioner has set the parameters of their practice. The midwife should make own
judgement whether they or not competent to carry out a particular procedure. This is critical in determining
one’s SOP. ICM defines the midwife’s educational preparation, experiences and basic essential competences for
the individual prior to practice [3]. Each individual State will then set their specific requirements for registration
and educational standards which suit their national needs. The midwife should have successfully completed a
recognised and approved midwifery education programme in the country and should demonstrate and maintain
competency in the practice of midwifery to use the title “registered midwife”. [3]
Core competences for midwifery practices define the essential knowledge, skills and behaviours that all
midwives must possess as stipulated in their midwifery definition. It is the midwife’s sole responsibility to
maintain and acquire additional competences as mandated by their regulatory authorities hence it becomes
critical for them to be capable of assessing their own competence levels [8]

3.1.3 Autonomy and Accountability

Autonomy originates from a Greek word autos meaning ‘self’ and nemein or nomos” meaning to ‘hold
sway’. This is the origin of the concept of self-governance. This implies midwives determine and control the
standards for education, regulation and practice. Autonomy is a concept central to the definition of midwife
which means freedom to make choices of care and for the decision to be respected. [4; 3; 12] This remains
complex and the degree of autonomy demonstrated by midwives is variable and is dependent on the authority
they are given in their work places as well as their willingness to accept the freedom. [9]
Midwives who are autonomous in thought are most likely to be capable of finding their way to provide
women centred care regardless of the system or the working environment. Autonomous thinking may be
influenced by training and supportive supervision while on the other hand autonomy in practice require more
than independence of thought. A collaborative working relationship also fosters true autonomy as there is need
for a viable backup system to own decisions for smooth transition in cases of emergency. [6] American heritage
dictionary also defines an autonomous individual as one not controlled by other or outside forces, independent
in judgement, self-directed, self-governing with or without respect to local or internal affairs.
Midwifery autonomy means having the ability to make some decisions within their profession and the
right and responsibility to act according to shared standards. [11]. this implies having the competences to make
the informed decision and the capacity to accept responsibility and be accountable for the outcomes of the
decisions made. [3] Professional autonomy then refers to when there is ability to use various competences in a
critical manner for safe quality health care to the patient [10; 11].

3.1.4 Practice setting, policies and Guidelines.

A midwife can practice in any setting including in the home, in the community, in health institutions
such as hospitals, clinics and maternity homes, [3]. Authority to practice is mandated by the individual society
hence the primary motivation for practice should focus on patient’s needs, safety and respect for their dignity. A
good relationship with the patient is the fundamental aspect of midwifery practice as it fosters individual patient
autonomy, informed choices and evidence based decision-making. In high risk or emergency situations the
midwife’s critical role in management focuses on assessing, collecting data and communicating it. They may
have input in management in a collaborative pattern of care as they optimize normality. Clinical parameters are
determined basically by the community in which one practices. This involves the lived experiences, the
philosophy of the individual practitioner, community needs, nature of collaborative relationships and the

DOI: 10.9790/1959-0603033842 www.iosrjournals.org 39 | Page

 Scope of Midwifery Practice: Concept Analysis

practice guidelines of the area. Practice setting like SOP vary from place to place and with timing for example
in central hospitals midwifery practice is limited to normal prenatal, intra and post-partum whereas out in the
primary health care settings and communities the scope becomes broader to include managing complications,
[13;14; 15]. practice environment is largely regulated by state laws, policies and guidelines. Regulations are a
set of criterion or processes arising from legislation and usually prescribed by the regulatory authority. State
laws defining midwifery practice vary from state to state, national boards and national standards or codes of
conduct. ICM has Code of ethics and code of conduct for midwifery professionals.

3.1.5 Leadership and supervision

Midwives need support systems for them to grow professionally and to recognise their full potential.
Evidence has shown that nurses and midwives who practice without guidance and supportive leadership are
likely to take responsibilities beyond own SOP and competences putting patient’s lives at risk. [4]. Leadership
and support supervision becomes critical in midwifery practice and competence development. A strong and
supportive leadership play an important role in ensuring safe and effective care as well as boost confidence
among practitioners, [16].

IV. Definitions
The scope of midwifery practice is defined as the range of roles, functions, responsibilities and
activities which a registered midwife is educated, competent and has the authority to perform in the context of
the midwifery definition.[17; 3]. The SOMP can also be defined as the extent or limits of intervention that a
midwife can perform, [18; 25]. The attributes to the current definition is centred on education, competence and
authority. There is need for one to be educated to practice midwifery. Another important dimension is the
competence expected of the individual to be authorised to practice midwifery care. The apparent weakness with
this definition is that education, competence and authority are dynamic variables which are not constant. The
dynamic demographics of the community influence the scope of the practice. The defining attributes for the
SOMP therefore should consider that the SOMP is an evolving process which is responsive to clinical service,
demographic changes and fiscal changes of a given setting, [19; 26; 27]

V. Discussion
The evolutionary concept analysis involves identification of surrogate terms, related concepts, attributes,
antecedents and consequences of the concept. Model cases or exemplars can also be used to clarify the concept.

5.1 Surrogate and related concepts

Surrogate terms are terms expressing the same meaning of the desired concept [20]. The terms which
are used interchangeable for SOMP are range or extent of midwife’s practice, professional regulation, roles and
functions of a midwife [21; 3; 22; 4; 23] Related terms refer to the terms used to describe concepts that are
related to the desired concept but do not necessarily have similar characteristics. [5]. Related terms which are
commonly used are legal parameters, boundaries, limits, competences, standards of practice, professional
conduct [3; 13; 14; 7; 8]

5.2 Antecedents of SOMP

The next stage in the evolutionary concept analysis involves determination of the antecedents and consequences
of the concept. Antecedents are defined as events that precedes occurrence of the event and consequences occur
as a result of the antecedents. [5; 29] Identified antecedents fall under three groups: legal issues, economic
issues and professional issues.
5.2.1 Legal factors
Fear of legal consequences, need to balance practise restrictions with practice expansion and right to practice
within defined parameters [13; 8; 9; 3]. The need for and internationally accepted standards, policies and
guidelines, code of conduct and the need to respond to the aesthetic aspect of patients’ safety, needs and choices,
regulatory requirements [3; 24; 10; 11]
5.2.2 Economic factors
Economic pressure, staff shortages, limited resources, time fiscal changes has led to variability of SOMP and
expansion of practice. [24; 28; 19; 23; 4; 30]
5.2.3 Professional factors
Professional accountability, expectations around responsibility, perception and experience of practice expansion
influence decision making. [8; 19; 13] Professional autonomy, role confusion, lack of recognition, need for new
reforms like continuity of care to childbearing women [8; 19; 28; 1; 13; 25]. Identified is also the need to
develop and maintain competence, collaborative practice and educational preparation for safe and quality
practice [8; 1; 14; 3; 7; 22]

DOI: 10.9790/1959-0603033842 www.iosrjournals.org 40 | Page

 Scope of Midwifery Practice: Concept Analysis

5.3 Consequences of the concept

Scope of practice should provide a very public statement about the state of a profession in any given
area hence an unclear definition may result in skill loss, deskilling, un-utilized staff potential and unmet patient
needs, [13]. The midwife may suffer stagnation as they fear litigation if they expand practice or perceive they
are encroaching into others territories. There is loss of confidence and no progress along the competence
continuum. The end result is acceptance of reforms due to failure to understand own roles. This may
consequently lead to powerlessness, inability to make professional decisions and accepting responsibility to act
in accordance to shared standards. [9; 10; 11]

5.4 Model case

A model case is necessary to clarify the concept and delineate it from related concepts. After synthesis of
literature model cases were identified to clarify defining attributes of SOMP.
Case 1: Chipo a 35 year old presents at a rural hospital with bleeding following a home delivery. She is pale,
semi-conscious and Blood Pressure reading 70/30mmhg.
Midwife A: at rural hospital where there is no doctor, no blood or blood products, no ambulance and laboratory
to do cross match. The midwife does a rapid assessment excluded all causes of bleeding and identified retained
placenta, collects blood specimens, put up 2 intravenous lines with plasma expanders to replace lost fluids,
administer an oxytocic and try to remove retained placenta while awaiting ambulance to take her to next level.
She explains condition to relative and continuously reassures patient that the personnel will do their best.
Midwife B: level 2 Hospital with all basic emergency facilities, laboratory, physicians, operating theatre and
blood and blood products. She admits patient, checks vital signs and call doctor for management notifies
laboratory and operating theatre of the emergency while continuously reassuring patient. She sets a trolley with
intravenous insertion requirements, specimen collection tubes and gives an oxytocic intramuscularly.
The cases demonstrate the varying scopes of Midwifery practice. Midwife A has the competences to respond to
an emergency though works within a limiting clinical parameters and is authorised to make decisions in
response to patient’s needs and consider patient safety. Practice parameters are influenced by availability of
resources and patient needs. Midwife B follows guidelines and collaboratively manage the patient. Her practice
is influenced by practice setting and limited authority. She cannot demonstrate her full competences. However
the care received by the patient in both cases was within each midwife’s SOP compatible with national
standards.

VI. Working Definition

The proposed definition of SOMP after appraisal of literature is:- the range of midwifery roles and
responsibilities responsive to patient/community needs in different situations and practice settings as authorised
for midwives according to nationally expected competences and professional standards. The SOMP though
varying according to competence level, setting and country specific should be more consumers driven. That is it
should respond to the individual patient/community needs.

Relevancy To Clinical Practice

Midwives play a critical role in maternal and child health therefore it is vital to have a clear definition
of the concept to empower and enable them to practice to their full potential. The individual midwifes’
understanding of SOMP fosters accountability and autonomy which positively impacts on the patient care
outcomes and results in positive migration towards clinical competence continuum.

VII. Conclusion
Scope of midwifery practice though an evolving concept emphasise the response to patient/community
needs and should be flexible to suit all practice settings. The regulatory authorities should ensure that they
review their standards to keep in line with dynamic needs of the patients and communities. Individual midwives
also need to migrate positively with the continuum.

Conflict of Interest
The author has no conflict of interest.

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