Essential
Competencies
for Midwifery Practice2019 UPDATE
Published October 20191

Contents
2

INTRODUCTION

3

THE REVIEW PROCESS3APPROACH TO THE COMPETENCIES

4COMPETENCY FRAMEWORK

5FRAMEWORK STRUCTURE

6EXPLANATION OF COMPETENCY COMPONENTS

7LANGUAGE

7ADVANCED, OPTIONAL,CONTEXT-SPECIFIC INDICATORS, AND
COMPETENCIES

8GENERAL COMPETENCIES

13

PRE-PREGNANCY AND ANTENATAL

17

CARE DURING LABOUR AND BIRTH

19

ONGOING CARE OF WOMEN AND NEWBORNS

22

ENDNOTES

Introduction
The International Confederation of Midwives (ICM) Essential Competencies
for Midwifery Practice outline the minimum set of knowledge, skills and professional behaviours required by an individual to use the designation of midwife
as defined by ICM1 when entering midwifery practice. The competencies arepresented in a framework of four categories that sets out thosecompetencies considered to be essential and that “represent those thatshouldbean
expectedoutcomeof
midwifery
pre-service
education”2.These competency statements are “linked to authoritative
clinical practice guidance documents used by the World HealthOrganization” 3, 4, 5, 6, 7, 8, 9
and ICM’s Core documents and Position
10
Statements.

2

Guidance documents undergo revision based on ever-evolving research.
ICM’s essential competency statements are also evaluated and amended
as the relevant evidence concerning sexual, reproductive, maternal andnewborn health care and midwifery practices emerges. The competencies
presented in this document have been updated through such a review
process.

position and that the midwife’s autonomy and role in managing
emergencies should be more strongly emphasised. Consequently, minor
amendments were made and an updated document (dated January 2019)was disseminated.

The Review Process
ICM’s ‘Essential Competencies for Basic Midwifery Practice’ were first developed in 2002 and updated in 2010 and 2013. Between 2014 – 2017 the competencies were reviewed through a research study led by a team from the
University of British Columbia (UBC) 11 and supported by a core working groupof midwifery educators12 and a taskforce of stakeholders.13 The research
pro-cess included a literature review, thematic analysis of policy and otherdoc-uments related to midwifery competencies, a modified Delphi
approach in-volving three rounds of an online survey and development of
a conceptual framework for presentation of the competencies. The threeround Delphi sur-vey was conducted online in French, English and Spanish
with an inclusive sample of invited participants drawn from ICM Member
Associations (across all ICM regions and language groups and from low,
middle and high-income countries), midwifery educators, midwifery
regulators, ICM Standing Commit-tees, the ICM Board and stakeholders.14

In August 2019 a further update was made to correct an error in competency
4e (skills and behaviours section) of the English version. Competency 4e wascorrect in the French and Spanish versions. At this time an
additional skill was added to competency 2i to make clear that midwives
in certain situations could perform abortions. This additional skill waspreviously included in the 2013 version of the ICM competencies. Minor edits
were made to competency 3.b in October 2019 to emphasise the role of a
midwife in preventing, detecting and stabilising complications.

Approach to the Competencies
The updated competencies are organised into a framework of four inter-related categories; general competencies that apply to all aspects of a midwife’s
practice, and competencies that are specific to care during pre-pregnancy,
antenatal, labour, birth and the postnatal period.

The ICM Board received the final draft report and updated competencies,
including a proposed new competency framework, from the research team in
April 2017. Council Members asked that the final format of the competencies
enhance simplicity, accessibility, usability and measurability of the competencies by multiple audiences including those for whom English is a second language. The incoming Board (2017 – 2020) established a sub-committee
to provide oversight to the process of finalising the updated competencies.
Two consultants, a learning designer15 and a midwife educational expert,16
were contracted to revise the format of the draft framework (2017) andthe draft competencies with the aim of increasing the simplicity,
accessibility, usability and measurability by multiple audiences. Changes
were to be based on the 2017 draft competencies and were to retain theirintegrative approach. The consultants redesigned the framework, andreworded and reorganised the competencies, drawing on ICM’s core
documents17 and position statements to ensure alignment. A team from
Laerdal Global Health designed the visual representation of thecompetencies and the final version was completed in April and accepted by
the Board in May 2018.
The updated competencies (2018) were disseminated in mid-October 2018
and ICM received extensive positive feedback from members and partners.
ICM also received feedback from a small number of respondents that the labour and birth icon should show the woman in a more upright birthing

The updated competencies are written as holistic statements that reflect the
ICM’s Philosophy and Model of Midwifery Care in addition to the ICM
Definition and Scope of Practice of a Midwife.18
As such thecompetencies promote:• the autonomy of midwives to practise within the full scope of midwifery practice and in all settings• the role of the midwife to support physiology and promote normal birth• the role of the midwife to uphold human rights and informed consent anddecision making for women• the role of the midwife to promote evidence-based practice, including reducing unnecessary interventions• the role of the midwife to assess, diagnose, act, intervene, consult and referas necessary, including providing emergency interventions.
The competencies are integrated statements and not a list of tasks. Examples
are illustrative and not an exhaustive list.

3

Midwife educators are expected to structure curricula and design learning activities that will enable midwifery students to learn the knowledge and develop
the skills and behaviours that are integrated within each competency.

Competency Framework
The competencies are organised into four inter-related categories as outlined below

1. GENERAL COMPETENCIES
Competencies in this category are about the midwife’s
autonomy and accountabilities as a health professional,
the relationships with women and other care providers
and care activities that apply to all aspects of midwifery
practice. All General Competencies are intended to
be used during any aspect of midwifery care whereas
competencies in categories 2, 3, and 4 are each specificto a part of the reproductive process and must be viewed
as subsets of the General Competencies, not stand-alone
subsets. Educational and/or training providers should
ensure that the General competencies are interwoven
in any curriculum. Assessment of the competencies in
categories 2, 3, and 4 must include assessment of thecompetencies in category 1.

2. COMPETENCIESSPECIFIC TO PREPREGNANCY AND
ANTENATAL CARE

3. COMPETENCIESSPECIFIC TO CARE
DURING LABOUR
AND BIRTH

Competencies in thiscategory are about
health assessment of
the woman and fetus,
promotion of health andwell-being, detection ofcomplications during
pregnancy and careof women with anunintended pregnancy.

Competencies inthis category areabout assessment
and care of women
during labour thatfacilitates physiologicalprocesses and a safe
birth, the immediatecare of the newborn
infant, and detection
and management ofcomplications in motheror infant.

4

4. COMPETENCIESSPECIFIC TO THE
ONGOING CARE
OF WOMEN AND
NEWBORNS
Competencies in thiscategory address
the continuing healthassessment of motherand infant, healtheducation, support forbreast feeding, detectionof complications, andprovision of familyplanning services.

Framework Structure
The diagram below provides a visual representation of the framework structure.

GENERALCOMPETENCIES

PRE-PREGNANCYAND ANTENATAL
CARE

CARE DURING
LABOUR AND
BIRTH

ONGOING CARE
OF WOMEN AND
NEWBORNS

5

Explanation of Competency Components
This graphic outlines the components of the competency framework.

CATEGORY

CATEGORY #CATEGORY
TITLE# Competency title

COMPETENCYKNOWLEDGEDESCRIPTORSINDICATORS

Category descriptors outline theprimary focus of each category.
The high-level description acts asa linking mechanism between the
category and the competencies
clearly showing the relationshipbetween the higher order groupings(i.e. categories) and the moredetailed information concerning
the actual competencies (i.e thecompetency description and its
associated components/indicators).

SKILLS & BEHAVIOURS

6Each competency is accompanied
by a list of indicators that outline
the necessary knowledge, skills
and behaviours required to achieve
the performance measure of
the competency. In formulating
indicators, skills and behaviours aregrouped together since they are
the observable components of acompetency. Indicators for attitudes
were not stipulated since attitudes are
not easily observable or measurable.

CATEGORY #COMPETENCIES
TITLE

Language# Competency title

The competencies and indicators were evaluated for clarity of language,
measurability, and ease of translation. Concrete verbs were used to facilitate the measurement of the competency and/or indicator. All competencies
and indicators are written to:

KNOWLEDGE••••SKILLS & BEHAVIOURSShow alignment between the competency and indicators;
Contain verbs appropriate for the level required and that are measurable;
Use consistent language that is clear and free of jargon; andProvide sufficient detail for comprehension.

Advanced, optional,
context-specific indicators,
and competencies
Competencies and indicators previously designated as advanced/optional/context specific are not included as a separate category in the framework for essential competencies. Such statements are conceptually inconsistent with defining
the competencies that are expected of all midwives. ICM will consider if it isnecessary to develop, in the future, competencies that extend/expand beyond
those deemed as essential.
7

CATEGORY 1
GENERALCOMPETENCIES
Competencies in this category
are about the midwife’s autonomy
and accountabilities as a healthprofessional, the relationships withwomen and other care providers,and care activities that apply to all
aspects of midwifery practice. GeneralCompetencies apply across each of
categories 2, 3 and 4.

1.a Assume responsibility for own
decisions and actions as an autonomous
practitioner

1.b Assume responsibility for
self-care and self-development
as a midwife

KNOWLEDGEKNOWLEDGE• Principles of accountability andtransparency• Principles and concepts of autonomy• Principles of self-assessment and reflective
practice• Personal beliefs and their influence onpractice• Knowledge of evidence-based practices• Strategies for managing personal safety
particularly within the facility or community
setting

SKILLS & BEHAVIOURS• Demonstrate behaviour that upholds the
public trust in the profession• Participate in self-evaluation, peer review
and other quality improvement activities• Balance the responsibility of the midwife toprovide best care with the autonomy of thewoman to make her own decisions• Explain the midwife’s role in providing carethat is based on relevant law, ethics, andevidence

8

SKILLS & BEHAVIOURS• Display skills in management of self in
relation to time management, uncertainty,change and coping with stress• Assume responsibility for personal safety invarious practice settings• Maintain up-to-date skills and knowledge
concerning protocols, guidelines and safe
practice• Remain current in practice by participatingin continuing professional education(for example, participating in learning
opportunities that apply evidence to practice
to improve care such as mortality reviews orpolicy reviews.)• Identify and address limitations in personal
skill, knowledge, or experience• Promote the profession of midwifery,
including participation in professionalorganizations at the local and national level

CATEGORY 1: GEnERAL COMPETEnCIEs

1.c Appropriately delegate aspects ofcare and provide supervision

1.d Use research to inform practice

1.e Uphold fundamental human rights
of individuals when providing midwifery
care

KNOWLEDGEKNOWLEDGEKNOWLEDGE• Policies and regulation related to delegation• Supportive strategies to supervise others• Role of midwives as preceptors, mentors,
supervisors, and role models• Principles of research and evidence-based
practice• Epidemiologic concepts relevant to maternal
and infant health• Global recommendations for practice andtheir evidence base (e.g. World HealthOrganisation guidelines)• Laws and/or codes that protect human rights• Sexual, reproductive health rights of womenand girls• Development of gender identity and sexual
orientation• Principles of ethics and Human Rights
within midwifery practice

SKILLS & BEHAVIOURSSKILLS & BEHAVIOURS• Discuss research findings with women andcolleagues• Support research in midwifery byparticipating in the conduct of research• Provide information to women about theirsexual and reproductive health rights• Inform women about the scope of
midwifery practice and women’s rights andresponsibilities• Provide information and support toindividuals in complex situations where there
are competing ethical principles and rights• Practice in accordance with philosophy
and code of ethics of the ICM and national
standards for health professionals• Provide gender sensitive care

SKILLS & BEHAVIOURS• Provide supervision to ensure that practiceis aligned with evidence-based clinicalpractice guidelines• Support the profession’s growth throughparticipation in midwifery education in
the roles of clinical preceptor, mentor,
and role model

9

CATEGORY 1: GEnERAL COMPETEnCIEs

1.f Adhere to jurisdictional laws,
regulatory requirements, and codesof conduct for midwifery practice

1.g Facilitate women to makeindividual choices about care

1.h Demonstrate effective interpersonal communication
with women and families, health care teams, andcommunity groups

KNOWLEDGEKNOWLEDGEKNOWLEDGE• The laws and regulations of thejurisdiction regarding midwifery• National/state/local community
standards of midwifery practice• Ethical principles• ICM and other midwifery
philosophies, values, codes of ethics• Cultural norms and practices
surrounding sexuality, sexual
practices, marriage, the childbearing
continuum, and parenting• Principles of empowerment• Methods of conveying healthinformation to individuals, groups,
communities• Role and responsibilities of midwives and other maternal –infant health providers• Principles of effective communication• Principles of effectively working in health care teams• Cultural practices and beliefs related to childbearing andreproductive health• Principles of communication in crisis situations, e.g. griefand loss, emergencies

SKILLS & BEHAVIOURSSKILLS & BEHAVIOURS• Advocate for and support women
to be the central decision makers intheir care
• Assist women to identify theirneeds, knowledge, skills, feelings,
and preferences throughout thecourse of care
• Provide information and anticipatory
guidance about sexual andreproductive health to assist
women’s decision making• Collaborate with women indeveloping a comprehensive plan ofcare that respects her preferencesand decisions• Listen to others in an unbiased and empathetic manner• Respect one others’ point of view
• Promote the expression of diverse opinions andperspectives• Use the preferred language of the woman or an interpreterto maximise communication• Establish ethical and culturally-appropriate boundaries
between professional and non-professional relationships• Demonstrate cultural sensitivity to women, families, andcommunities• Demonstrate sensitivity and empathy for bereaved womenand family members• Facilitate teamwork and inter-professional care with othercare providers (including students) and community groups/
agencies• Establish and maintain collaborative relationships withindividuals, agencies, institutions that are part of referral
networks• Convey information accurately and clearly and respond to
the needs of individuals

SKILLS & BEHAVIOURS• Practise according to legal
requirements and ethical principles• Meet requirements for maintenanceof midwifery registration• Protect confidentiality of oral
information and written records
about care of women and infants• Maintain records of care in themanner required by the healthauthority• Comply with all local reporting
regulations for birth and deathregistration• Recognize violations of laws,
regulations, and ethical codes andtake appropriate action• Report and document incidents andadverse outcomes as required whileproviding care

10

CATEGORY 1: GEnERAL COMPETEnCIEs

1.i Facilitate normal birth processes ininstitutional and community settings,
including women’s homes

1.j Assess the health status, screen for
health risks, and promote general healthand well-being of women and infants

1.k Prevent and treat common healthproblems related to reproduction andearly life

KNOWLEDGEKNOWLEDGEKNOWLEDGE• Normal biologic, psychologic, social, andcultural aspects of reproduction and early life
• Practices that facilitate and those thatinterfere with normal processes• Policies and protocols about care of womenin institutional and community settings• Availability of resources in various settings• Community views about and utilization ofhealth care facilities and place(s) of birth• Health needs of women related toreproduction• Health conditions that pose risks during
reproduction• Health needs of infants and common risks• Common health problems related tosexuality and reproduction• Common health problems and deviations
from normal of newborn infants• Treatment of common health problems• Strategies to prevent and control
the acquisition and transmission ofenvironmental and communicable diseases

SKILLS & BEHAVIOURS• Promote policies and a work culture thatvalues normal birth processes• Utilize human and clinical care resources toprovide personalized care for women andtheir infants• Provide continuity of care by midwives
known to woman

SKILLS & BEHAVIOURS• Conduct a comprehensive assessment ofsexual and reproductive health needs• Assess risk factors and at-risk behaviour• Order, perform, and interpret laboratory and/or imaging screening tests• Exhibit critical thinking and clinicalreasoning informed by evidence when
promoting health and well being• Provide health information and advice
tailored to individual circumstances ofwomen and their families• Collaborate with women to develop andimplement a plan of care

11

SKILLS & BEHAVIOURS• Maintain/promote safe and hygienic
conditions for women and infants• Use universal precautions consistently• Provide options to women for coping withand treating common health problems• Use technology and interventions
appropriately to promote health and prevent
secondary complications• Recognize when consultation or referral
is indicated for managing identified healthproblems, including consultation with othermidwives• Include woman in decision-making aboutreferral to other providers and services

CATEGORY 1: GEnERAL COMPETEnCIEs

1.l Recognise abnormalities andcomplications and institute appropriate
treatment and referral

1.m Care for women who experience
physical and sexual violence and abuse

KNOWLEDGEKNOWLEDGE• Complications/pathologic conditions related
to health status• Emergency interventions/life-saving
therapies• Limits of midwifery scope of practice andown experience• Available referral systems to accessmedical and other personnel to manage
complications• Community/facility plans and protocols foraccessing resources in timely manner• Socio-cultural, behavioural, and economic
conditions that often accompany violence
and abuse• Resources in community to assist womenand children• Risks of disclosure

SKILLS & BEHAVIOURS• Maintain up-to-date knowledge, life-saving
skills, and equipment for responding toemergency situations• Recognize situations requiring expertisebeyond midwifery care
• Maintain communication with women about
nature of problem, actions taken, andreferral if indicated• Determine the need for immediate
intervention and respond appropriately• Implement timely and appropriate
intervention, inter-professional consultation
and/or timely referral taking account of local
circumstances19• Provide accurate oral and written information
to other care providers when referral is made.
• Collaborate with decision-making if possible
and appropriate

12

SKILLS & BEHAVIOURS• Protect privacy and confidentiality• Provide information to all women aboutsources of help regardless of whether there
is disclosure about violence• Inquire routinely about safety at home, atwork• Recognize potential signs of abuse fromphysical appearance, emotional affect,
related risk behaviours such as substanceabuse• Provide special support for adolescents andvictims of gender-based violence includingrape• Refer to community resources, assist in
locating safe setting as needed

CATEGORY 1: GEnERAL COMPETEnCIEs

CATEGORY 2
PRE-PREGNANCYAND ANTENATAL
Competencies in this category areabout health assessment of the woman
and fetus, promotion of health andwell-being, detection of complications
during pregnancy, and care of womenwith an unexpected pregnancy.

2.a Provide pre-pregnancy care

2.b Determine health status of woman

KNOWLEDGEKNOWLEDGE• Anatomy and physiology of female andmale related to reproduction and sexual
development• Socio-cultural aspects of human sexuality• Evidence based screening for cancerof reproductive organs and other healthproblems such as diabetes, hypertension,
thyroid conditions, and chronic infections
that impact pregnancy• Physiology of menstrual and ovulatory cycle• Components of a comprehensive healthhistory including psycho-social responses topregnancy and safety at home
• Components of complete physical exam
• Health conditions including infections andgenetic conditions detected by screening
blood and biologic samples
SKILLS & BEHAVIOURSSKILLS & BEHAVIOURS• Identify and assist in reducing barriers
related to accessing and using sexual andreproductive health services• Assess nutritional status, current
immunization status, health behaviours
such as use of substances, existing
medical conditions, and exposure to known
teratogens• Carry out screening procedures for sexuallytransmitted and other infections, HIV,cervical cancer• Provide counseling about nutritional
supplements such as iron and folicacid, dietary intake, exercise, updating
immunizations as needed, modifying risk
behaviours, and prevention of sexuallytransmitted infections, family planning, andmethods of contraception.

13• Confirm pregnancy and estimate gestationalage from history, physical exam, laboratory
test and/or ultrasound• Obtain comprehensive health history• Perform a complete physical examination• Obtain biologic samples for laboratory tests(e.g. venipuncture, finger puncture, urine
samples, and vaginal swabs)• Provide information about conditions that
may be detected by screening• Assess status of immunizations, and update
as indicated• Discuss findings and potential implications
with woman and mutually determine
plan of care

CATEGORY 2: PRE-PREGnAnCY And AnTEnATAL

2.c Assess fetal well-being

2.d Monitor the progression of pregnancy

2.e Promote and support healthbehaviours that improve wellbeing

KNOWLEDGEKNOWLEDGEKNOWLEDGE• Placental physiology, embryology, fetal
growth and development, and indicators of
fetal well-being• Evidence-based guidelines for use ofultrasound
SKILLS & BEHAVIOURS• Assess fetal size, amniotic fluid volume,
fetal position, activity, and heart rate fromexamination of maternal abdomen• Determine whether there are indications
for additional assessment/examination andrefer accordingly• Assess fetal movements and ask woman
about fetal activity• Usual physiological and physical changes
with advancing pregnancy• Nutritional requirements of pregnancy• Common psychological responses topregnancy and symptoms of psychologicaldistress• Evidence informed antenatal care policies
and guidelines, including frequency ofantenatal visits20
SKILLS & BEHAVIOURS• Conduct assessments throughout pregnancy
of woman’s physical and psychologicalwell-being, family relationships, and healtheducation needs• Provide information regarding normal
pregnancy to woman, her partner, family
members, or other support persons• Suggest measures to cope with common
discomforts of pregnancy• Provide information (including written and/or pictorial) about danger signs, (e.g. vaginal
bleeding, signs of preterm labour, prelabour,
rupture of membranes) emergency preparedness, and when and where to seek help
• Review findings and revise plan of care withwoman as pregnancy progresses

14• Impact of adverse social, environmental, andeconomic conditions on maternal -fetal health• Effects of inadequate nutrition and heavy
physical work
• Effects of tobacco use and exposure tosecond-hand smoke, use of alcohol andaddictive drugs• Effects of prescribed medications on fetus• Community resources for income support,
food access, and programs to minimize risksof substance abuse• Strategies to prevent or reduce risks ofmother-to-child disease transmission including
infant feeding options for HIV infection• Effects of gender-based violence, emotional
abuse, and physical neglect
SKILLS & BEHAVIOURS• Provide emotional support to women toencourage change in health behaviour• Provide information to woman and family
about impact on mother and fetus of risk
conditions.
• Counsel women about and offer referral toappropriate persons or agencies for assistance and treatment• Respect women’s decisions about participating in treatments and programs• Make recommendations and identify resources for smoking reduction/cessation inpregnancy

CATEGORY 2: PRE-PREGnAnCY And AnTEnATAL

2.f Provide anticipatory guidance related
to pregnancy, birth, breastfeeding,parenthood, and change in the family

2.g Detect, stabilse, manage, and refer
women with complicated pregnancies

2.h Assist the woman and her family toplan for an appropriate place of birth

KNOWLEDGEKNOWLEDGEKNOWLEDGE• Needs of Individuals and families fordifferent information at different times intheir respective life cycles• Methods of providing information toindividuals and groups• Methods of eliciting maternal feelings andexpectations for self, infant, and family• Complications of early pregnancy suchas threatened or actual miscarriage, andectopic pregnancy• Fetal compromise, growth restriction,
malposition, preterm labour• Signs and symptoms of maternal pathologic
conditions such as pre-eclampsia,
gestational diabetes, and other systemic
illnesses• Signs of acute emergencies such as
hemorrhage, seizures, and sepsis• Evidence about birth outcomes in different
birthplace settings• Availability of options in specific location;
limitations of climate, geography, meansof transport, and resources available infacilities• Local policies and guidelines

SKILLS & BEHAVIOURS• Participate in--and refer women and support
persons to--childbirth education programs• Convey information accurately and clearly
and respond to needs of individuals• Prepare the woman, partner, and family torecognize labour onset, when to seek care,and progress of labour• Provide information about postpartum
needs including contraception, care ofnewborn infants, and the importance of
exclusive breast feeding for infant health• Identify needs or problems requiring further
expertise or referral such as excessive fear,and dysfunctional relationships

SKILLS & BEHAVIOURS• Stabilise in emergencies and refer fortreatment as necessary21• Collaborate in care of complications• Implement critical care activities to support
vital body functions (e.g. intravenous(IV) fluids, magnesium sulphate,antihemorrhagics)22• Mobilize blood donors if necessary• Transfer to higher level facility if needed

15

SKILLS & BEHAVIOURS• Discuss options, preferences andcontingency plans with woman and support
persons and respect their decision• Provide information about preparing
birth site if in community, e.g. travel andadmission to facility• Promote the availability of a full range ofbirth settings

CATEGORY 2: PRE-PREGnAnCY And AnTEnATALADDITIONAL SKILL*

2.i Provide care to women with unintended or mistimed pregnancy• Prescribe, dispense, furnish or administer drugs according to scopeof practice and protocol (however authorized to do so in thejurisdiction of practice) in dosages appropriate to induce medicationabortion• Perform manual vacuum aspiration of the uterus up to 12 completed
weeks of pregnancy

KNOWLEDGE• Complexity of decision-making about unintended or mistimed
pregnancies• Emergency contraception• Legal options for induced abortion; eligibility and availability of medical
and surgical abortion services• Medications used to induce abortion; properties, effects, and side
effects• Risks of unsafe abortion• Family planning methods appropriate for the post-abortion period.
• Care and support (physical and psychological) needed during and after
abortion• An additional skill is performed by midwives under either of two
circumstances:a) Midwives who elect to engage in a broader scope of practice
and/orb) Midwives who have to implement certain skills to make adifference in maternal or neonatal outcome

SKILLS & BEHAVIOURS• Confirm pregnancy and determine gestational age; refer for ultrasound if
unknown gestation and/or symptoms of ectopic pregnancy• Counsel woman about options to maintain or end the pregnancy andrespect the ultimate decision.
• Provide supportive antenatal care if pregnancy continued; refer toagencies, and social services for support and assistance when needed• Identify from obstetric, medical and social history, contraindications to
medication or aspiration methods• Provide information about legal regulations, eligibility, and access toabortion services• Provide information about abortion procedures, potential complications,management of pain, and when to seek help
• Refer to provider of abortion services upon request• Provide post-abortion care̶ Confirm expulsion of products of conception from history, ultrasound, orlevels of HCG
̶ Review options for contraception and initiate immediate use of method
̶ Explore psychological response to abortion

16

CATEGORY 2: PRE-PREGnAnCY And AnTEnATALCATEGORY 3
CARE DURING
LABOUR AND BIRTH
Competencies in this category areabout assessment and care ofwomen during labour that facilitatesphysiological processes and asafe birth, the immediate care of
the newborn infant, detection ofcomplications in mother or infant,stabilisation of emergencies, andreferral as needed.

3.a Promote physiologic labour and birth

KNOWLEDGE• Anatomy of maternal pelvis and fetus; mechanisms of labour for different fetal presentations• Physiologic onset and progression of labour• Evidence informed intrapartum care policies and guidelines, including avoidance of routineinterventions in normal labour and birth23,24• Cultural and social beliefs and traditions about birth• Signs and behaviours of labour progress; factors that impede labour progress• Methods of assessing fetus during labour
SKILLS & BEHAVIOURS

•
•
•
•
•
•
•
•
•
•
•
•
•
•

Provide care for a woman in the birth setting of her choice, following policies and protocols
Obtain relevant obstetric and medical history
Perform and interpret focused physical examination of the woman and fetus
Order and interpret laboratory tests if needed
Assess woman’s physical and behavioural responses to labour
Provide information, support, and encouragement to woman and support persons throughout
labour and birth
Provide respectful one-to-one care
Encourage freedom of movement and upright positions
Provide nourishment and fluids
Offer and support woman to use strategies for coping with labour pain, e.g. controlled breathing,water immersion, relaxation, massage, and pharmacologic modalities when needed
Assess regularly parameters of maternal-fetal status, and e.g. vital signs, contractions, cervicalchanges, and fetal descent
Use labour progress graphic display to record findings and assist in detecting complications, e.g.
labour delay, fetal compromise, maternal exhaustion, hypertension, infection
Augment uterine contractility judiciously using non-pharmacological or pharmacological agents toprevent non-progressive labour
Prevent unnecessary routine interventions, e.g. amniotomy, electronic fetal monitoring, directedclosed glottis pushing, episiotomy

17

CATEGORY 3: CARE dURInG LABOUR And BIRTH

3.b Manage a safe spontaneous vaginal birth;prevent, detect and stabilise
complications

3.c Provide care of the newborn immediately after birth

KNOWLEDGEKNOWLEDGE• Manage a safe spontaneous vaginal birth.
• Evidence about conduct of third stage, including use of uterotonics• Potential complications and their immediate treatment e.g. shoulder dystocia, andexcessive bleeding, fetal compromise, eclampsia, retained placenta• Management of emergencies as covered in emergency skills training programmessuch as BEmONC,26 HMS27• Signs of placental separation; appearance of normal placenta, membranes, andumbilical cord
• Types of perineal and vaginal trauma requiring repair and suturing techniques• Normal transition to extra-uterine environment• Scoring systems to assess newborn status• Signs indicating need for immediate actions to assist
transition• Interventions to establish breathing and circulation ascovered in training programs such as HBS25• Appearance and behaviour of healthy newborn infant• Method of assessing gestational age of newborn infant• Needs of small for gestational age and low birth weight
infants

SKILLS & BEHAVIOURSSKILLS & BEHAVIOURS• Support the woman to give birth in her position of choice• Ensure clean environment, presence of clean necessary supplies and source of
warmth• Coach woman about pushing to control expulsion of presenting part, avoid routine
episiotomy• Undertake appropriate manoeuvers and use maternal position to facilitate vertex,
face, or breech birth• Expedite birth in presence of fetal distress• Delay cord clamping• Manage nuchal cord
• Assess immediate condition of newborn• Provide skin to skin contact and warm environment• Deliver placenta and membranes and inspect for completeness• Assess uterine tone, maintain firm contraction, and estimate and record maternal
blood loss; manage excessive blood loss including administration of uterotonics• Inspect vaginal and perineal areas for trauma, and repair as needed, following
policies and protocols• Use standardized method to assess newborn condition in
the first minutes of life (Apgar or other); refer if needed• Institute actions to establish and support breathing andoxygenation, refer for continuing treatment as needed• Provide a safe warm environment for initiating breastfeeding
and attachment (bonding) in the first hour of life
• Conduct a complete physical examination of newborn inpresence of mother/family; explain findings and expectedchanges e.g. colour of extremities, moulding of head. Refer
for abnormal findings.
• Institute newborn prophylaxis e.g. ophthalmic infection, andhemorrhagic disease, according to policies and guidelines• Promote care by mother, frequent feeding and close
observation• Involve partner/support persons in providing newborn care

• Provide first line measures to treat or stabilise identified conditions• Refer for continuing treatment of any complications as needed
18

CATEGORY 3: CARE dURInG LABOUR And BIRTHCATEGORY 4
ONGOING CARE
OF WOMEN AND
NEWBORNS
Competencies in this category address
the continuing health assessment ofmother and infant, health education,
support for breast feeding, detection ofcomplications, stabilisation and referralin emergencies, and provision of familyplanning services.

4.a Provide postnatal care for the healthy
woman

4.b Provide care to healthy newborn
infantKNOWLEDGEKNOWLEDGE• Physiological changes following birth,
uterine involution, onset of lactation, healingof perineal-vaginal tissues• Common discomforts of the postnatal period
and comfort measures• Need for rest, support, and nutrition to
support lactation• Psychological responses to mothering role,
addition of infant to family• Appearance and behaviour of infant in early
life; cardio-respiratory changes related toadapting to extra-uterine life
• Growth and development in initial weeks
and months of life
• Protocols for screening for metabolic
conditions, infectious conditions, andcongenital abnormalities• Protocols/guidelines for immunizations ininfancy• Evidence-based information about infant
circumcision; family values, beliefs, andcultural norms

SKILLS & BEHAVIOURS• Review history of pregnancy, labour, and birth• Conduct a focused physical exam to assessbreast changes and involution. Monitor
blood loss and other body functions• Assess mood and feelings aboutmotherhood and demands of infant care
• Provide pain control strategies if needed foruterine contractions, and perineal trauma• Provide information about self-carethat enables mother to meet needs ofnewborn, e.g. adequate food, nutritional
supplements, usual activities, rest periods,
and household help
• Provide information about safe sex, familyplanning methods appropriate for theimmediate postnatal period, andpregnancy spacing

19

SKILLS & BEHAVIOURS• Examine infant at frequent intervals
to monitor growth and developmental
behaviour• Distinguish normal variation in newborn
appearance and behaviour from thoseindicating pathologic conditions• Administer immunizations, carry out
screening tests as indicated• Provide information to parents about a safe
environment for infant, frequent feeding,care of umbilical cord, voiding and stooling,
and close physical contact

CATEGORY 4: OnGOInG CARE OF WOMEn And nEWBORns

4.c Promote and support breastfeeding

4.d Detect, treat, and stabilise postnatal complications in woman
and refer as necessary

KNOWLEDGEKNOWLEDGE

•
•
•
•
•

• Signs and symptoms of:̶ conditions in the postnatal period that may respond to early intervention(e.g. sub-involution, anaemia, urinary retention, and localized infection)
̶ complications that need referral to more specialized provider or
facility (e.g. hematoma, thrombophlebitis, sepsis, obstetric fistula, andincontinence)̶ life threatening complications requiring immediate response andspecialized care (hemorrhage, amniotic fluid embolus, seizure, andstroke)• Signs and symptoms of postnatal depression, anxiety, and psychosis• Mourning process following perinatal deathPhysiology of lactation
Nutritional needs of newborn infants, including low birth weight infantsSocial, psychological, and cultural aspects of breastfeeding
Evidence about benefits of breastfeeding
Indications and contraindications to use of drugs and substances
during lactation• Awareness of lactation aids
SKILLS & BEHAVIOURS• Promote early and exclusive breastfeeding while respecting a woman’s
choice regarding newborn feeding• Provide information about infant needs, frequency and duration of
feedings, and weight gain
• Provide support and information about breastfeeding for a minimum ofsix months, including combining with work, maintaining milk supply, andstoring breast milk
• Identify and manage breastfeeding problems (e.g. mastitis, low milk
supply, engorgement, improper latch)• Provide information to women breastfeeding multiple newborns• Refer women to breastfeeding support as indicated• Advocate for breastfeeding in family and community

SKILLS & BEHAVIOURS• Provide information to woman and family about potential complications
and when to seek help.
• Assess woman during postnatal period to detect signs and symptoms ofcomplications• Distinguish postnatal depression from transient anxiety about caring
for baby, assess availability of help and support at home, and provide
emotional support• Provide counseling and follow-up care for women and family members
who experience stillbirth, neonatal death, serious infant illness, andcongenital conditions• Provide first line measures to treat or stabilize identified conditions• Arrange referral and/or transfer as needed

20

CATEGORY 4: OnGOInG CARE OF WOMEn And nEWBORns

4.e Detect, stabilise, and manage health problems in newborn
infant and refer if necessary

4.f Provide family planning services

KNOWLEDGEKNOWLEDGE••••• Anatomy and physiology of female and male related to reproduction
and sexual development• Socio-cultural aspects of human sexuality• Family planning methods including natural, barrier, hormonal,
implantable; emergency contraception, sterilization; their possible side
effects, risk of pregnancy, and contraindications to use28, 29,30• Available written and pictorial resources for teaching about familyplanning methods31,32• Pregnancy options for HIV positive women or couples

Congenital anomalies, and genetic conditions
Needs of pre-term and low birth weight infants
Symptoms and treatment of withdrawal from maternal drug use
Prevention of mother-to-child transmission of infections such as HIV,hepatitis B and C• Signs and symptoms of common health problems and complications;
their immediate and ongoing treatment
SKILLS & BEHAVIOURS• Assess and recognise abnormal findings• Implement protocols for care of low birth weight infants, e.g. ensure
warmth, nutrition, monitor condition, “Kangaroo” care as appropriate• Provide information to mother and support persons about infantcondition• Provide support in situations where infant separated from mother for
special care
• Recognise indications of the need for specialized care in the newborn• Stabilise and transfer the at-risk newborn to emergency care facility

SKILLS & BEHAVIOURS• Provide and protect privacy and confidentiality for discussions aboutfamily planning knowledge, goals for limiting and/or spacing of children,and concerns and myths about methods• Obtain relevant history of use of methods, medical conditions, sociocultural values, and preferences that influence choice of method• Provide information about how to use, effectiveness, and cost of various
methods to support informed decision-making• Provide methods according to scope of practice and protocols, or refer
to another provider• Provide follow-up assessment of use, satisfaction, and side-effects• Refer for woman or partner for sterilization procedure

21

CATEGORY 4: OnGOInG CARE OF WOMEn And nEWBORns

Endnotes
11 Michelle M Butler, Judith Fullerton, Cheryl Aman, (with the support

19 World Health Organization. (2017). Managing Complications in

Definition of the Midwife [online]. Available from: https://www.

of BMW students Melanie Dowler, Tobi Reid, and Caitlin Frame).

Pregnancy and Childbirth: A Guide for Midwives and Doctors. 2nd ed.

internationalmidwives.org/our-work/policy-and-practice/icm-definitions.

Update of the International Confederation of Midwives’ Essential

Geneva: World Health Organization.

html [accessed 20 December 2018].

Competencies for Basic Midwifery Practice: Final (DRAFT) Report.

12International Confederation of Midwives. (2017). ICM International

Butler et al. (2017). Update of the International Confederation of

Vancouver: UBC Midwifery Program. April 2017.

Midwives’ Essential Competencies for Basic Midwifery Practice. Draft

12 Michelle Butler, Judith Fullerton, Mary Barger, Carol Nelson,

Final Report. Internal ICM Report. Unpublished, p. 2.

Camilla Schneck, Marianne Nieuwenhuijze, Rita Borg-Xuereb (ICM

3World Health Organization. (2016). WHO Recommendations:

Antenatal Care for a Positive Pregnancy Experience. Geneva: World
Health Organization.
4

World Health Organization. (2018). WHO Recommendations:Intrapartum Care for a Positive Childbirth Experience. Geneva: World
Health Organization.

Board Member), Rafat Jan (ICM Board Member), Atf Gherissi, Lorena
Binfa, Mizuki Takegata, Caroline Homer. Update of the International
Confederation of Midwives’ Essential Competencies for Basic
Midwifery Practice: Final (DRAFT) Report. Vancouver: UBC Midwifery
Program. April 2017.

Workforce Alliance), Fran McConville (WHO – Maternal & Child HealthCommittee), Gloria Metcalfe (Jhpiego MNH consultant), Gerard Visser

Postnatal Care of the Mother and Newborn. Geneva: World Health(Chair FIGO Safe Motherhood Committee), Petra ten Hoope-Bender

Organization.

(UNFPA), Sarah Williams (Save the Children), Joeri Vermeulen

6World Health Organization Department of Reproductive Healthand Research (WHO/RHR) and Johns Hopkins Bloomberg Schoolof Public Health/Center for Communication Programs (CCP). (2018).
Knowledge for Health Project. Family Planning: A Global Handbook for
Providers. Baltimore and Geneva: CCP and WHO.
7

World Health Organization. (2015). Medical Eligibility Criteria forContraceptive Use. 5th ed. Geneva: World Health Organization.
8

World Health Organization. (2016). Selected Practice

Recommendations for Contraceptive Use. 3rd ed. Geneva: World
Health Organization.
9

World Health Organization. (2017). Quality of Care inContraceptive Information and Services, based on Human Rights
Standards: A Checklist for Health Care Providers. Geneva: World
Health Organization
10 International Confederation of Midwives. ICM Position Statements[online]. Available from: https://www.internationalmidwives.org/

Antenatal Care for a Positive Pregnancy Experience.
21 World Health Organization. (2017). Managing Complications in
Pregnancy and Childbirth.
22 Ibid.
23 WHO recommendations: intrapartum care for a positive childbirthexperience. Geneva: World Health Organization; 2018. Licence: CC
BY-NC-SA 3.0 IGO.

13 Jim Campbell (Director and Executive Director of the Global HealthWorld Health Organization. (2013). WHO Recommendations:5

20 World Health Organization. (2016). WHO Recommendations on(Secretary European Midwifery Association), Kimberley Pekin (NARM& MANA), Joy Lawn (Paediatrician), Sarah Moxon (Neonatal Nurse).
Update of the International Confederation of Midwives’ Essential
Competencies for Basic Midwifery Practice: Final (DRAFT) Report.
Vancouver: UBC Midwifery Program. April 2017.

24 World Health Organization. (2017). Managing Complications in
Pregnancy and Childbirth: A Guide for Midiwves and Doctors. 2nd ed.
Geneva. World Health Organization.
25 Basic Emergency Obstetric and Newborn Care.
26 Helping Mothers Survive.
27 Helping Babies Survive.
28 World Health Organization Department of Reproductive Healthand Research (WHO/RHR) and Johns Hopkins Bloomberg School

14 Butler et al. (2017), Update of the International Confederation ofof Public Health/Center for Communication Programs (CCP). (2018).

Midwives’ Essential Competencies for Basic Midwifery Practice: Final

Knowledge for Health Project. Family Planning: A Global Handbook for(DRAFT) Report. Vancouver: UBC Midwifery Program. April 2017

Providers.

15 Carolyn Levy, Blank Design and Project Management, Vancouver,

29 World Health Organization. (2015). Medical Eligibility Criteria for

Canada.

Contraceptive Use. 5th ed. Geneva: World Health Organization.

16 Karyn Kaufman, retired Professor and Head of Midwifery,

30 World Health Organization. (2016). Selected Practice

McMaster University, Hamilton, Canada; Professor Emeritus,

Recommendations for Contraceptive Use. 3rd ed. Geneva: World

McMaster University

Health Organization.

17 International Confederation of Midwives. ICM Policy and Practice

31 World Health Organization. (2017). Quality of Care in[online]. Available from: https://www.internationalmidwives.org/our-Contraceptive Information and Services, based on Human Rights

work/policy-and-practice/ [accessed 20 December 2018].

Standards: A Checklist for Health Care Providers. Geneva: World
Health Organization.

our-work/policy-and-practice/icm-position-statements/ [accessed 20

18 International Confederation of Midwives. ICM Definitions [online].

December 2018].

Available from: https://www.internationalmidwives.org/our-work/policy-

32 World Health Organization. (2015). Medical Eligibility Criteria for

and-practice/icm-definitions.html [accessed 20 December 2018]

Contraceptive Use.

22

Endnotes