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

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 

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

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’

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.