I was excited when I heard that the new NMC midwifery proficiencies were to be based on principles from the Lancet series, a series of international studies on midwifery which spell out the difference that a well-educated and well-regulated midwifery workforce can make to the lives of mothers and babies worldwide.
The series beautifully describes midwifery as ‘preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed’
However when I came to respond to the Future Midwife consultation my heart sank. The proposed standards have been produced in a specific historical and political context whereby the autonomy of midwives in the UK has been hugely diminished in recent years. The legislation that applied specifically to midwifery has been largely dismantled. The Midwives Rules and statutory supervision of midwifery no longer exist. The Midwifery Committee on the NMC is no longer required by law. And ironically the proposed Future Midwife Standards - although supposedly based on the excellent Lancet framework – are yet another step towards the demise of midwifery.
There are 2 documents out for consultation:
Draft standards of proficiency for midwives and Draft standards for pre-registration midwifery programmes.
Draft standards for pre-registration midwifery programmes.
I compared the old and the new programme standards and realised that the proposed new ones are mostly generic, with very little to say about midwifery. The current Standards include the WHO definition of the role of the midwife, and Standard 13 is clear about the role of the midwife as the expert in normal birth, stating that, ‘Where the opportunity is available, students should be involved in supporting women birthing in a variety of settings… The skills required for taking on the role of lead carer for women with complex medical and/ or obstetric needs is developmental and competence is to be achieved after initial registration’.
It also discusses the different aspects of midwifery practice and stipulates that students ‘should gain experience of supporting women birthing in settings other than acute maternity units, such as at home, at birth centres and at midwife-led units’. The draft new standards are much vaguer: Approved Educational Institutions must ‘ensure that students experience the variety of practice expected of midwives to meet the holistic needs of women and their families’. In the proposed programme standards, the WHO definition of a midwife is no longer included and no longer contain any definition of midwifery (the EEC directive which includes the activities of a midwife is included as an annexe). There are also fewer stipulations and explanations regarding the role of the Lead Midwife for Education (LME), thus ensuring the power of the LME role is likely to be reduced in approved education institutions in the future.
Draft standards of proficiency for midwives
The key difference between the current standards and the proposed standards is that the latter do not spell out the scope of midwifery practice. This runs counter to the thrust of the Lancet series - which graphically describes and demonstrates the value of midwifery - and to the WHO international definition of midwifery. The NMC has obviously chosen to avoid the Lancet term which states that midwifery involves the promotion of 'normal reproductive processes' and instead simply uses the term ‘processes’ throughout (22 times). Leaving out the adjective ‘normal reproductive (as used in the Lancet series) renders the term ‘processes’ so broad as to be meaningless.
The NMC is also desperate to avoid the contested term ‘normal birth’ (0 mentions) so instead uses vague terms such as ‘optimise physiological processes’ (5 mentions) or to ‘optimise normal processes’ (13 mentions). However, if our professional body abandons the term normal birth, midwives will no longer have a recognised distinct sphere of midwifery practice. If we no longer have a distinct sphere of midwifery practice, how will educators be able to state what a registered midwife must know on qualification? This problem is manifest in the many domains and learning outcomes of the proposed standards – many of them are very worthwhile, but by the time the reader reaches the 2 final domains the list of what a midwife must be able to do on qualification has become endless. For example, Domain 4 includes ‘insert, manage and remove oral/nasal/gastric tubes’ as well as assisting with the siting and management of epidural analgesia, and assisting with instrumental births, caesarean section and essential theatre procedures (4.12.8.).
As the WHO states in its definition of midwifery, 'Midwifery is the profession of midwives(…) It has a unique body of knowledge, skills and professional attitudes'. Similarly the Lancet series is clear that professional midwifery, with well-educated and well-regulated midwives in an integrated service, reduces maternal/neonatal mortality and morbidity as well as promoting psychological health.
In response to the House of Commons Select Committee on 17 July 2018, the outgoing CEO of the NMC promised to 'try to understand midwifery better’. The proposed NMC standards undermine the central tenet of the Lancet framework – the value of professional midwifery with its own distinct sphere of practice. The Future Midwife standards demonstrate the NMC’s continuing failure to understand and acknowledge the value of the profession of midwifery.
Renfrew, M. J., McFadden, A., Bastos, M. H., Campbell, J., Channon, A. A., Cheung, N. F., ... & McCormick, F. (2014). The Lancet, 384(9948), 1129-1145.Renfrew et al.