Comparative assessment of Iranian midwifery education curriculum against ICM global standards for midwifery education

Document Type: Original Article

Authors

1 Department of Midwifery, faculty of medicine, Gonabad University of Medical Sciences< Gonabad< Iran

2 Department of Midwifery, School of Nursing and Midwifery, North Khorasan University of Medical Science, Boujnurd, Iran

3 Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background: The aim of this study was to evaluate the strengths and weaknesses of the midwifery curriculum in Iran according to ICM Global Standards for Midwifery Education.
Methods: In this comparative study the Iranian midwifery education curriculum in the part of ‘Competency in provision of care during pregnancy was compared against ICM Global Standards for Midwifery Education (2010) by three researchers using a checklist. In each item (35 items in knowledge domain and 26 item in the skill domain), the entire Iranian midwifery curriculum was searched for similar content, as well as the related courses by numbers. Also evaluation was done for ‘adequacy’ of each item by a 4 point Likert scale (Adequate, Relatively adequate, Relatively inadequate, Inadequate).
Results: Quality assessment distribution of the Iranian midwifery curriculum in terms of Basic knowledge and Skill domain in context of ‘Competency in Provision of Care during Pregnancy’ shows that from 35 items in basic knowledge domain, 47.57 % were adequate, 15 % relatively adequate, 2.85 % relatively inadequate and 2% were inadequate. In Skill domain from 26 items, 53.85% were adequate and 46.15% were relatively inadequate. In two items there is no related content in this curriculum including” Signs of female genital cutting and its effects on reproductive health” and “Normal limits of results from community-relevant laboratory tests commonly performed in pregnancy”.
 Conclusion: The curriculum of midwifery education in Iran covers ICM Global Standards for Midwifery Education (2010) in ‘Competency in Provision of Care during Pregnancy’ domain except for two items. Therefore, not covering these important issues is one of the most noteworthy weaknesses of this curriculum and should be considered in future reforms. 

Keywords

Main Subjects


Introduction

Every year, 10-15 million women suffer from severe or long-lasting illnesses or disabilities caused by complications during pregnancy or childbirth (1) and 358,000 women die annually due to pregnancy, intrapartum and postpartum complications and unfortunately 99% of these deaths occur in developing countries (2, 3), while 80% of them are preventable with skilled staffs (4).

Reduction of maternal mortality by 75% until 2015 is one of the most significant Millennium Development Goals (MDG5), and the proportion of births assisted by skilled staffs is one of the indicators to measure the achievement of this important goal (5). A quality midwifery service is central to reduce maternal, newborn and infant mortality and morbidity worldwide and to achieve this quality service, the recruitment and retention of an effective trained workforce is essential (6). The state of the World’s Midwifery report 2011 claims that strengthening midwifery capacities and services is the key to accelerate progress towards MDGs 4 and 5. Provided that they are trained, equipped, supported and authorized to do so, midwives can help to avert over 60% of all maternal and newborn deaths, which is equal to as many as 3.6 million lives saved by 2015 (7). It has been claimed that the availability of a health provider with specific midwifery skills and competencies, particularly life-savings skills, is acknowledged to be a key component of any safe motherhood strategy (8, 9). As identified in the International Confederation of Midwives (ICM), midwives are specialists in normal pregnancy, labor and birth and the postnatal period, with an important role to play as primary maternity care providers (3). Therefore midwives have a key role in achieving MDGs goal related to reduce the Maternal Mortality rate (MMR), Infant Mortality Rate (IMR) and health of communities (10). The United Nations pays special attention to the quality of midwifery service and to achieve this quality the recruitment and retention of educated and trained midwifery workforce is essential (11).

Empowerment in maternal and newborn health is achieved when midwifes receive a firm and standard education. This means that although curricula vary between and within countries, all must meet particular requirements of clinical and theoretical hours and specific skills (12). Standard and qualified training programs are suggested by the International Confederation of Midwives (ICM) and midwives must be educated and trained according to the Global Standards for Midwifery Education (13). The International Confederation of Midwives is a global association representing approximately 250,000 midwives in 108 member associations in 98 countries (14).

The ICM Global Standards for Midwifery Education (2010) is one of the essential pillars of ICM’s efforts to strengthen midwifery worldwide by preparing fully qualified midwives to provide high quality, evidence-based health services for women, newborns, and childbearing families. ICM’s pillars include updated core competencies for basic midwifery practice, midwifery education, midwifery regulation and strong midwifery associations. The education standards were developed in tandem with the update of the Essential Competencies for Basic Midwifery Practice (2010) as these competencies define the core content of any midwifery education program. The education standards were also completed in harmony with midwifery standards of practice and regulation (15).

Having global standards for midwifery education available to countries and regions, most especially those without such standards currently, will help to set benchmarks for the preparation of a midwife based on global norms. Standards also help to define the expectations for the performance (competencies) and scope of midwifery practice for a given country or region needed to promote the health of women and childbearing families. These minimal education standards can be expanded to include higher expectations and to reflect country specific needs for curriculum content and cultural appropriateness (15).

ICM suggested that using the ICM Global Standards for Midwifery Education for countries with existing standards for midwifery education, who may wish to compare the quality of their programs to these minimum standards (15). The aim of this study was to evaluate strengths and weaknesses of midwifery curriculum in Iran according to ICM Global Standards for Midwifery Education in the section of ‘Competency in Provision of Care during Pregnancy’.

Methods

This comparative study was conducted using the ICM Global Standards for Midwifery Education (2010) to evaluate the educational curriculum of midwifery in Iran. The midwifery education standards were developed globally using a modified Delphi survey process during 2009-2010, and represent the minimum expected for a quality midwifery program, with emphasis on competency-based education rather than academic degrees (16). The ICM Global Standards for Midwifery Education (2010) suggest six categories for the evaluation including: organization and administration (6 sub-categories), midwifery faculty (8 sub-categories), student body (with 7 sub-categories), curriculum (6 sub-categories), resources; facilities and services (5 sub-categories) and assessment strategies (5 sub-categories) (13).

We assessed the midwifery education curriculum of Iran against the category of curriculum of ICM Global Standards for Midwifery Education (2010). We used the curriculum mapping tool. The wording of the ICM Essential Competencies for Basic Midwifery Practice has been amended in this document. This mapping tool is focused on the basic knowledge, professional behaviors and skills and/or abilities that the individual midwife should know/demonstrate/perform. This mapping tool is focused on the curriculum of studies (17). In this mapping tool competency-based midwifery education program is evaluated in seven main domains, including:

1-       Competency in the social, epidemiologic and cultural context of maternal and newborn care: this domain includes 21 items of knowledge, ten of specific professional behaviors and six item of skill or ability, 37 items in total.

2-       Competency in the pre-pregnancy care and family planning: this domain includes 15 items of knowledge, no item of specific professional behaviors and 11 items of skill or ability, 36 items in total.

3-       Competency in the provision of care during pregnancy: this domain includes 35 items of knowledge, no items of specific professional behaviors and 26 items of skill or ability, 61 items in total.

4-       Competency in the provision of care during labor and birth: this domain includes 26 items of knowledge, no item of specific professional behaviors and 43 items of skill or ability, 69 items in total.

5-       Competency in the provision of care for women during the postpartum period: this domain includes 22 items of knowledge, no item of specific professional behaviors and ten items of skill or ability, 32 items in total.

6-       Competency in the postnatal care of the newborn: this domain includes 18 items of knowledge, no item of specific professional behaviors and 18 items of skill or ability, 36 items in total.

7-       Competency in the facilitation of abortion- related care: this domain includes ten items of knowledge, no item of specific professional behaviors and eight items of skill or ability, 18 items in total.

In the current study, we compared the Iranian midwifery education curriculum in the third competency:  ‘competency in provision of care during pregnancy’ of ICM Global Standards for Midwifery Education (2010). The curriculum was examined against ICM standards by three researchers using a check list contained three columns including "the items", "number of related courses", and "adequacy". In both domains of basic knowledge (35 items) and skills (26 items) related to ‘competency in provision of care during pregnancy, we searched the entire Iranian midwifery curriculum for similar content, and then we identified related courses by numbers. Also we evaluated ‘adequacy’ of each item by a 4 point Likert scale (adequate, relatively adequate, relatively inadequate, and inadequate).

The results were reported using descriptive statistics in terms of the related courses for each item and also number (percent) in terms of adequacy of items.

Results

The results of comparing the Iranian midwifery curriculum against ICM standards, the number of related courses and quality assessment for each item in Basic knowledge domain in the context of ‘competency in provision of care during pregnancy’ are shown in Table 1. This table demonstrates the majority of items covered by the Iranian midwifery curriculum; but in two items there is no related content in this curriculum. These items are:” signs of female genital cutting and its effects on reproductive health” and “normal limits of the results from community-relevant laboratory tests commonly performed in pregnancy”.

Table 1. Competency in provision of care during pregnancy in the domain of basic knowledge 

ICM Competency

Course number

Adequacy

Basic knowledge

1

Human anatomy and physiology

01- 03- 04- 05- 06- 25- 27

Adequate

2

Biology of human reproduction

02-07-25-26-27-67

Adequate

3

Signs and symptoms of pregnancy

27-28-31-38- 39

Relatively  adequate

4

Tests for confirmation of pregnancy

27- 28

Relatively  adequate

5

Diagnosis of ectopic pregnancy

31

Relatively  adequate

6

Principles and methods for dating pregnancy

27- 28- 31- 38

Adequate

7

Components of  antenatal history and physical examination

27- 28- 38- 39

Adequate

8

Signs of female genital cutting and effects on reproductive health

-

Inadequate

9

Normal limits of results from community-relevant laboratory tests commonly performed in pregnancy

-

Inadequate

10

Normal changes related to progression of pregnancy

27- 28- 29- 38- 45

Adequate

11

Indications and implications of deviations from expected fundal growth patterns

27- 28

Relatively  adequate

12

Fetal risk factors requiring transfer of women to higher levels of care during the antenatal period

23- 27- 34- 36

Adequate

13

Normal psychological changes in pregnancy; indicators of stress

27- 38- 39

Relatively  adequate

14

Non-pharmacological measures for relief of common discomforts of pregnancy

27- 46- 70

Relatively  adequate

15

Assessment of fetal well-being (heart tones, activity)

27- 28- 29- 30- 31- 46

Adequate

16

Nutritional needs during pregnancy

21-27- 46- 55- 71

Adequate

17

Health education topics relevant during pregnancy

27- 46

Relatively  adequate

18

Principles of pharmacokinetics of drugs commonly taken during pregnancy

13-14

Adequate

19

Maternal and fetal effects of prescribed and illicit drugs taken during pregnancy

14- 33- 46

Relatively  adequate

20

Maternal and fetal effects of smoking and alcohol during pregnancy

17- 27- 46

Relatively  adequate

21

Topics important to birth planning

27- 29- 60

Adequate

22

Topics important to preparation of home for the newborn

18- 29- 46- 70

Relatively  adequate

23

Signs and symptoms of the onset of labor

27- 28- 29- 30-

Adequate

24

Relaxation and pain relief methods for use during labor

27- 29- 30- 38- 39- 56

Adequate

25

Signs and symptoms of conditions that are life-threatening to woman or fetus during pregnancy

11- 23- 27- 29- 31- 38- 73

Adequate

26

Information relevant to counseling or care of the HIV+ woman, and prevention of maternal to child transmission

19- 42

Relatively inadequate

Signs and symptoms and indications for referral for complications that arise during pregnancy

27

 Diabetes

19- 33- 41

Adequate

28

 Cardiac conditions

19- 33- 41- 42

Adequate

29

 Mal-presentations/abnormal lies

29- 31

Relatively  adequate

30

 Placental disorders

29- 31

Adequate

31

 Pre-term labor

31

Relatively  adequate

32

 Post-dates pregnancy

31

Relatively  adequate

33

Principles of malaria prevention and control

09- 42

Adequate

34

Pharmacology of de-worming in pregnancy

09- 13- 19- 33- 42

Adequate

35

Preparation for breastfeeding

46-55

Relatively  adequate

Table 2 shows the results of comparing Iranian midwifery curriculum against ICM standards, the number of related courses and quality assessment for each item in skills domain in the context of ‘Competency in provision of care during pregnancy’. This table demonstrates all of the items covered by the Iranian midwifery education curriculum.

Table 2. Competency in provision of care during pregnancy in the domain of skills

 

ICM Competency

Course number

Adequacy

Skills

1

Conduct of an interval antenatal history

27- 28- 33- 38- 39

Adequate

2

Physical examination

27- 28- 33- 38- 39

Adequate

3

Assessment of maternal vital signs

27- 28- 33- 38- 39

Adequate

4

Assessment of and provision of advice about maternal nutrition

21- 27- 46- 55- 71

Adequate

5

Abdominal assessment

27- 28- 38- 39

Adequate

6

Fetal growth assessment (manual)

27- 28- 38- 39

Adequate

7

Assessment of fetal growth, placental placement, and amniotic fluid volume (ultrasound) (optional)

27- 51

Relatively  adequate

8

Assessment of fetal heart rate and activity

27- 28- 29- 31

Adequate

9

Monitoring of fetal heart rate (ultrasound) (optional)

27- 28- 29- 51

Adequate

10

Pelvic examination, including uterine sizing

27- 28

Adequate

11

Clinical pelvimetry

27- 28- 29

Adequate

12

Calculation of the estimated date of delivery

27- 28

Relatively  adequate

13

Counseling and health education about pregnancy progression and danger signs

27- 28- 33- 46- 65- 70

Relatively  adequate

14

Teaching/demonstrating methods to decrease common discomforts of pregnancy

27- 28- 45- 70

Relatively  adequate

15

Providing guidance for preparation for labor, birth and parenting

18- 27- 28- 29- 46- 60- 65- 66- 70

Relatively  adequate

 

Identification of variations from normal pregnancy; independent or collaborative management of:

16

 Low or inadequate maternal nutrition

21- 27- 33- 34- 45- 55- 72

Relatively  adequate

17

 Inadequate of excessive uterine growth

27- 28- 38- 39

Relatively  adequate

18

 Signs and symptoms indicating onset of pre-eclampsia

31- 32

Relatively  adequate

19

 Vaginal bleeding

29- 31- 32- 43

Relatively  adequate

20

 Multiple gestation and/or abnormal lie

31- 32- 34

Relatively  adequate

21

 Intrauterine fetal death

11- 23- 27- 29- 31- 38- 73

Adequate

22

 Rupture of membranes prior to term

31- 32

Relatively  adequate

23

 HIV positive status and/or AIDS

02- 08- 19- 42

Adequate

24

 Hepatitis B and/or C positive

08- 19- 42

Adequate

25

Midwifery provision of selected, life-saving drugs (in accord with legal/regulatory authority)

13- 33- 56- 73

Adequate

26

Identification of deviations from normal pregnancy progression and how to implement referral

23- 29- 31- 33- 42- 73

Relatively  adequate

 

Quality assessment distribution of the Iranian midwifery curriculum in terms of basic knowledge and skill domain in the context of ‘competency in provision of Care during pregnancy’ shows that from 35 items in basic knowledge domain, 47.57 % were adequate, 15 % relatively adequate, 2.85 % relatively inadequate and 2% were inadequate. In Skill domain from 26 items, 53.85% were adequate and 46.15% were relatively inadequate (table 3).

Table 3. Frequency distribution of quality assessment of Iranian midwifery curriculum in term of basic knowledge and skill domains related to ‘Competency in Provision of Care during Pregnancy’

Competency

 

Adequate

Number (%)

 

Relatively

Adequate

Number (%)

 

Relatively Inadequate

Number (%)

 

Inadequate

Number (%)

Basic knowledge

(35 items)

17 (47.57)

15 (42.85)

1 (2.85)

2 (5.71)

Skills

(26 items)

14 (53.85)

12 (46.15)

0 (0)

0 (0)

 

Discussion

This study showed that the Iranian curriculum of midwifery education regarding ‘competency in provision of care during pregnancy’ covers the ICM Global Standards for Midwifery Education (2010). With respect to the knowledge domain, 90.42% of the items were “adequate” or “relatively adequate” and only 8.56% of items were “relatively inadequate” or “inadequate”. In the domain of skills related to ‘competency in provision of care during pregnancy’, the Iranian curriculum of midwifery education had a better condition compared to the knowledge domain; as 100% of items were covered by the Iranian curriculum.

The Iranian curriculum of midwifery education in comparison with some countries in Asia and the Middle East has a better situation and this curriculum covers the ICM Global Standards for Midwifery Education (2010) carefully.

The International Confederation of Midwives (ICM) and United Nations Population Fund (UNPAF) evaluated the situation of midwifery education, regulation and association in six South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Nepal, and Pakistan) in 2010. According to this study only Afghanistan and Bangladesh had a midwifery curriculum based on ICM’s essential competences for basic midwifery practice (18). Also in the mentioned study, a content analysis was done on the open questions. The results showed that in Afghanistan, the main concern of participants was ‘Inadequate formal midwifery education’. In Pakistan comments reflected the inadequacy of formal midwifery education and inadequacies in competency-based education curriculum. Respondents from Bangladesh highlighted that legislation to address the education and deployment of midwives is required (18). Bogren and et.al suggested that midwifery education curriculum in these countries should be reformed based on international standard programs such as ICM Global Standards for Midwifery Education (18).

Also Apay et.al (2012) assessed the situation of midwifery education in Turkey. They stated that “midwifery education in Turkey has reached to undergraduate level through a gradual and slow progress “(19). Shaban and Leap (2012) reviewed midwifery education curriculum documents in Jordan. According to their findings, they suggested that there is no regulatory standards for the accreditation of midwifery education program in Jordan, including competency standards   and   minimum   clinical   practice requirements (20). Another study was done in order to assess the quality of training of community midwives in Pakistan. Results showed that the knowledge and skills of community midwives are insufficient. Due to the findings, the researcher recommended to allocate more time to clinical training and the theory to practice ratio of 25:75 that should reach to 40:60. They suggested to provide additional support to teachers for developing academic calendars and course plans (21).

Considering the ICM Global Standards for Midwifery, education of midwives is important due to WHO statement, which emphasizes that qualified midwives provide one of the most effective interventions to reduce deaths in pregnancy and childbirth (22, 23). Fullerton et al. stated that in order to be considered as a fully qualified midwife, a formal education is required based on ICM Essential Competencies for basic midwifery (24). Conversely, a health care system that relies on midwives who are less than competent to provide care throughout their professional careers is dangerous to women, newborns, families and communities (1).

The curriculum of midwifery education in Iran covers ICM Global Standards for Midwifery Education (2010) in relation to ‘competency in provision of care during pregnancy’ except for two items. One of the items that was not found in the Iranian curriculum is:” Signs of female genital cutting and its effects of reproductive health”, although this matter is very important due to high incidence of female genital cutting in the west and southwest region of Iran. The incidence of female genital cutting had been reported to be 55.7% to 70% in these regions (25,26). So not covering this important issue by the Iranian curriculum of midwifery education is one of the most noteworthy weaknesses of this curriculum and should be considered in future reforms.

Another item that is not covered by the Iranian curriculum of midwifery education is: “Normal limits of results from community-relevant laboratory tests commonly performed in pregnancy”. Nowadays using pregnancy kits is very common, so it is necessary that midwifery students have enough information about these kits and interpretation of their results in order to help women and counsel them. We suggest that this item be considered in the future reforms of midwifery education curriculum of Iran.

Acknowledgement

We specially thank all the researchers and scientists that have developed ICM Global Standards for Midwifery Education as a valuable reference for midwifery education and have provided us a treasure of valuable knowledge in this field.

Conflicts of interest:

There were no conflicts of interest in conducting this research.

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