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Scope of Practice for Registered Midwife (RM)

Health Regulation Department Dubai Health Authority (DHA)

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Introduction Health Regulation Department in DHA is responsible for regulating midwifery practice in the Emirate of Dubai, United Arab Emirates. Scope of Practice (SOP) refers to the activities that registered midwives are educated, authorized and competent to perform as well as their decision making capacity. Such activities are established through the legislated definition of licensed midwifery practice, complemented by standards, limits, conditions and education and influenced by setting, environment and health needs of the population. The Eastern Mediterranean Region (EMRO) of the World Health Organization (WHO) in its Global Advisory Group Meeting in 2000 identified lack of legislation as the most prevailing reason for nurses and midwives not working to their full potential. The primary purpose of this document is to guide and direct midwives practice within this environment. Through this framework DHA health regulation meets its responsibility to regulate midwifery practice in the public interest and address incompetent, impaired or unethical practice amongst midwives. DHA health regulation in recognising its further responsibilities to ensure public safety and in line with its published expectations of the registered nurse, equally expects that registered midwives must self assess their competence and make individual decisions about their practice within unique circumstances and settings. Furthermore midwives retain accountability for their own practice and are accountable to the woman and her newborn, the public, their employer and the regulatory authority. To ensure consistency in midwifery standards throughout the UAE the following Midwifery Competency Framework has drawn largely on the work undertaken in 2007 to develop the Scope of Practice (SOP) for the Midwife, which was endorsed by the Health Authority of Abu Dhabi (HAAD) Nursing and Midwifery Advisory Committee in December 2007 and the Federal Department of Nursing (FDON) Midwifery Committee in January 2008. During the collaborative development of the SOP by midwifery representatives throughout the UAE, the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice (2002) provided an international guide and benchmark. In order to provide more detailed evidence guidelines for midwifery practice in Dubai the Midwifery Competence Framework has been modified and expanded. The Scope of Practice for the Licensed Midwife is endorsed by DHA health regulation and should be read in conjunction with DHA health regulation Code of Conduct and Ethics for Nurses and Midwives. DHA health regulation upholds that no midwife should be directed or compelled to undertake any practice that falls short of DHA health regulation standards or code of conduct requirements.

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International Definition of a Midwife As accepted by the ICM Membership and Joint Study Group on Maternity Care, FIGO, WH0 A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. The sphere of practice: She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and postpartum period, to conduct deliveries on her own responsibility, and to care for the newborn and the infant. This care includes preventive measures, the detection of abnormal condition in mother and child, the procurement of medical assistance, and the execution of emergency measures in the absence of medical help. She has an important task in counseling and education, not only for the women, but also within the family and community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynecology, family planning, and child care. She may practice in hospitals, clinics, health units, domiciliary conditions or any other service. Competency Standards Four Domains of Practice have been identified. Core midwifery competency standards and associated performance criteria are located within these domains of practice which are guided by the ICM/WHO/FIGO (1992) and ICM (2005) Definitions of the Midwife and the ICM essential competency standards for the Midwife (2002). Domains of Practice 1. 2. 3. 4. Midwifery Practice and Comprehensive Care Professional, Legal and Ethical Practice Professional Development Quality Improvement and Collaborative Healthcare

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Competency Statements Each Domain of Practice has competency statements and associated performance criteria that a midwife must demonstrate to fulfil regulatory requirements. Evidence of safety to practice is demonstrated when the registered midwife meets the competency criteria within the domains. The indicators and evidence guides are neither comprehensive nor exhaustive but rather provide examples of evidence of competence. NB: For the purpose of this document she may mean he in specific circumstances

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Domain 1 Midwifery Practice and Comprehensive Care

Competency 1.1 Promotes health and provides education to the woman and her family Indicator Sub Indicator Evidence Guide Examples Knowledge of: Communication in establishing and maintaining helpful relationships Healthy life style behaviours Positive parenting strategies

1.1.1 Midwives provide high 1.1.1.1 Identifies, participates in and contributes to the development of health education programs in the community quality, culturally sensitive health education and services to the woman and her family in 1.1.1.2 Provides the woman and her family with accurate information order to promote healthy family life, planned pregnancies and 1.1.1.3 Supports the woman and her family to promote health and wellbeing birth spacing and positive parenting.

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Competency 1.2 Facilitates decision-making by the woman and her family Indicator Sub Indicator Evidence Guide Examples Knowledge of: The effect of culture on communication, such as when physical contact is appropriate and when it is not and how to address people The different forms and range of effective communication, including verbal and non-verbal communication, touch, symbols and images Theories that inform and enhance understanding of communication and the effective use of relationship and interpersonal skills

1.2.1 Midwives provide 1.2.1.1 Offers advice and midwifery care that respects the cultural and social needs of each woman evidence-based information to and her family the woman and her family facilitating them to make informed choices regarding their 1.2.1.3 Communicate relevant information effectively, using language that is readily understood care. 1.2.1.4 Actively listens to the woman and her family and responds to their needs 1.2.1.5 Facilitates learning opportunities through sharing of information 1.2.1.5 Advocates informed choice and shared decision-making

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Competency 1.3 Provides safe and effective antenatal care Indicator 1.3.1 Promotes the health and 1.3.1.1 well-being of the pregnant woman and the fetus 1.3.1.2 Evidence Guide Examples Knowledge of: Plan, implement and evaluate holistic antenatal care in Commonly used clinical protocols, collaboration with the woman and her family pathways, assessment frameworks and maternity care guidelines. Educates the woman and families about normal physiological changes of pregnancy and advise on strategies to relieve The importance of giving constructive, common discomforts positive feedback to others Assesses the growth and well-being of the fetus Provides nutritional advice for pregnancy and lactation Interprets and acts upon information from antenatal assessments Interprets and analyses basic screening laboratory/ultrasound studies Identifies health risk factors and refers care as necessary Factors that impact positively and negatively on womens during pregnancy and well-being. The physiological changes that occur during pregnancy & their impact on health. Care for the pregnant woman from conception to birth Care for the normal newborn Potential risk pregnancy. factors during Sub Indicator

1.3.1.3 1.3.1.4 1.3.1.5 1.3.1.6 1.3.1.7

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Competency 1.3 Provides safe and effective antenatal care Sub Indicator Evidence Guide Examples Evidence Guide Examples Knowledge of: 1.3.2 Prepares the woman for 1.3.2.1 Educates the woman about the onset and process of labour labour, birth and parenting 1.3.2.2 Provides information about pain relief, birth positions and delivery options to facilitate informed choices 1.3.2.3 Protects, promotes and supports breastfeeding in alignment with current WHO/UNICEF guidelines Care of the woman during labour Pain relief during labour Baby Friendly Accreditation guidelines

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Competency 1.4 Provides safe and effective intrapartum care Indicator Sub Indicator Evidence Guide Examples Knowledge of: 1.4.1 Demonstrates an understanding of the physiology of labour 1.4.1.1 Recognizes the relevant critical diameters and landmarks of the maternal reproductive anatomy 1.4.1.2 Identifies the signs which indicate onset and progress of labour 1.4.1.3 Identifies the measures to assess fetal and maternal well-being in labour 1.4.1.4 Identifies the signs normal/complications and indicators of deviations from The physiology of normal labour Evidenced based midwifery skills for appropriate interventions

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Competency 1.4 Provides safe and effective intrapartum care Indicator Sub Indicator Evidence Guide Examples Knowledge of: 1.4.2 Demonstrates competency 1.4.2.1 Promotes normal physiological childbirth in the skills needed to support 1.4.2.2 Identifies complications or deviations from normal the woman during childbirth 1.4.2.3 Implements midwifery care which reduces risk and harm to the woman and fetus 1.4.2.4 Encourages and respects the womans preferences throughout labour and delivery, within safe parameters of practice or safe delivery in an environment conducive to well being of mother and newborn as requested 1.4.2.5 Recognizes emergency situations and intervenes in an appropriate and timely manner. Support for the woman during labour and delivery Evidenced based midwifery skills for appropriate interventions during emergency situations Advocacy Informed consent

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Competency 1.5: Provides safe and effective postnatal care Evidence Guide Examples Knowledge of: 1.5.1 Demonstrates an 1.5.1.1 Identifies the normal process of involution and healing following Physiology of the post natal period childbirth understanding of the physiology of the post natal period Care of the mother and new born 1.5.1.2 Facilitates the process of lactation and bonding, supporting the post partum. mother-newborn dyad Evidenced based midwifery skills for 1.5.1.3 Recognizes maternal nutritional, physiological and emotional appropriate interventions needs and acts accordingly 1.5.1.4 Educates the woman about discomforts of the puerperium and advises on strategies to relieve them 1.5.1.5 Recognizes deviations from normal and acts accordingly Indicator Sub Indicator

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Competency 1.6: Provides safe and effective care of the newborn Indicator Sub Indicator Evidence Guide Examples Knowledge of: Physiology and needs of the new born 1.6.1.3 Identifies variations in the normal newborn and acts accordingly appropriately 1.6.1.4 Implements health promotion and disease prevention strategies Infection Control

1.6.1 Demonstrates a 1.6.1.1 Recognizes signs of newborn adaptation to extra-uterine life knowledge of the physiology 1.6.1.2 Identifies factors relevant to growth and development and needs of the newborn

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Competency 1.6: Provides safe and effective care of the newborn Indicator Sub Indicator Evidence Guide Examples Knowledge of: Newborn assessment and care 1.6.2.4 Performs interventions to facilitate adaptation to extra-uterine life 1.6.2.5 Recognizes deviations from normal and acts accordingly 1.6.2.6 Initiates emergency measures when necessary Infection control Health and safety and environmental control Evidenced based midwifery skills for appropriate interventions Neonatal resuscitation

1.6.2 Demonstrates competency 1.6.2.1 Immediately assesses the newborns condition in the skills needed to safely care 1.6.2.2 Performs a detailed physical examination of the newborn for the newborn 1.6.2.3 Promotes early breastfeeding

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Competency 1.7 Performs safe and effective pharmacological interventions Indicator Sub Indicator Evidence Guide Examples Knowledge of: Medication administration and management protocols (the rights of drug administration). Formula for calculating drug dosages (all routes) Pain management

1.7.1 Demonstrates evidence 1.7.1.1 Educates the woman about the potential effects of medication during pregnancy, birth and lactation based practice in use of pharmacological preparations 1.7.1.2 Educates the woman about any medications required by the relevant to midwifery practice newborn 1.7.1.3 Accurately calculates medication doses for administration

1.7.1.4 Safely administers medications during pregnancy, birth and lactation 1.7.1.5 Recognizes contra-indications and side effects and acts accordingly 1.7.1.6 Documents medication administration accurately

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Domain 2: Professional, legal and ethical practice

Competency 2.1 Functions in accordance with legislative and policy guidelines relevant to midwifery practice Indicator Sub Indicator Evidence Guide Examples Knowledge of: Regulatory and licensing requirement and self regulation Legislation governing midwifery practice Scope of Practice and scope of practice decision making tool Code of conduct and ethics for nurses and midwives Organisation policies Practice setting standards

2.1.1 To practice within a 2.1.1.1 Maintains current license to practice as an outcome of selfscope of competency and an regulation ability to work independently and in collaboration with others. 2.1.1.2 Identifies unsafe practice and intervenes accordingly . 2.1.1.3 Functions within a set midwifery scope of practice as delineated by this document 2.1.1.4 Practices only to the level for which s/he is adequately prepared, supervised and supported to perform 2.1.1.5 Utilizes relevant codes of conduct as a guide to midwifery practice 2.1.1.6 Contributes to policy development impacting on midwifery practice 2.1.1.7 Interacts with policy makers and legislators to influence legislation and regulation pertaining to midwifery practice

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Competency 2.2 Assumes responsibility and accountability for own actions and clinical decision making Indicator Sub Indicator Evidence Guide Examples Knowledge of: 2.2.1.2 Consults and performs referrals as necessary 2.2.1.3 Assumes responsibility for delegation and supervision of midwifery care (direct and indirect), which is relevant to the context and the competence of the person to whom care is delegated 2.2.1.4 Accepts responsibility for delegated activities relevant to the context and own level of competence 2.2.1.5 Works collaboratively with other health care professionals to improve the delivery of services to the woman and her family 2.2.1.6 Advocates for the woman and families to ensure promotion of a healthy and safe birth Appropriate delegation Woman and family rights Differences in cultural and religious practices/needs Self assessment techniques Referral process/s

2.2.1.1 Performs ongoing self-evaluation to determine strengths and limitations in knowledge and skills

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Competency 2.3 Delivers care and practices midwifery within an ethical framework and social context Indicator Sub Indicator Evidence Guide Examples Knowledge of: 2.3.1.2 Bases midwifery practice on ethical decision making 2.3.1.3 Works in partnership with the woman to support them in making informed choices about their health 2.3.1.4 Acts to strengthen the woman in promoting health of self and others 2.3.1.5 Communicates effectively with the woman, significant others and health care professionals to optimize care 2.3.1.6 Advocates to protect rights of the woman and families in relation to midwifery care Advocacy Code of Conduct and Ethics for nurses and midwives Woman and family rights

2.3.1.1 Implements midwifery care in a culturally respectful and non-judgmental manner

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Domain 3: Professional development

Competency 3.1 Demonstrates a commitment to development of self Indicator 3.1.1 The midwife is accountable for establishing, maintaining and evaluating her own life long learning needs to ensure continuing competence to practice. Sub Indicator 3.1.1.1 Maintains knowledge and skills through actively participating in continuing professional development programs 3.1.1.2 Uses valid research to inform midwifery practice 3.1.1.3 Actively engages in continuous self-assessment to evaluate and enhance own practice 3.1.1.4 Maintains record of all learning and professional development activities attended Evidence Guide Examples Knowledge of: Technological and scientific advances Life long learning Reflective practice Sources of evidence based research Professional practice portfolio

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Competency 3.2 Demonstrates a commitment to development of others and the profession Indicator Sub Indicator Evidence Guide Examples Knowledge of: 3.2.1.3 Participates in facilitating and co-coordinating learning opportunities for others 3.2.1.4 Contributes to health care policy as relevant to midwifery practice Preceptor ship Mentoring Maternity care policies and standards. Research and midwifery knowledge

3.2.1 Contributes to the support, 3.2.1.1 Collaborates and shares professional knowledge with others direction and teaching of colleagues to enhance 3.2.1.2 Supports others less experienced or new to the profession professional development through formal and informal preceptor and mentor programs

3.2.1.5 Identifies opportunities and contributes to nursing research 3.2.1.6 Refers to and disseminates current research to guide midwifery practice

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Domain 4: Quality Improvement and Collaborative Healthcare: This domain contains competencies to demonstrate that, as a member of the healthcare team, the midwife evaluates the effectiveness of care and promotes a midwifery perspective within the inter-professional activities of the team

Competency 4.1 Recognizes and values quality improvement activities to monitor and improve standards of midwifery Indicator 4.1.1 Participates in improvement activities. quality Sub Indicator 4.1.1.1 Recognizes that quality improvement involves ongoing consideration, use and review of practice in relation to practice outcomes, standards and guidelines and new developments 4.1.1.2 Participates in case review activities 4.1.1.3 Participates in clinical audits 4.1.1.4 Uses appropriate risk assessment tools to identify actual and potential risks Evidence Guide Examples Knowledge of: Safe administration of therapeutic substances Risk assessment tools Quality Management Performance indicators (key quality characteristics)

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Competency 4.2 Demonstrates accountability for communication, consulting and collaborating with other health professionals and health providers regarding activities of care planning, implementation and evaluation of care Indicator 4.2.1 Recognizes that the 4.2.1.1 membership and roles of healthcare teams and service providers will vary depending 4.2.1.2 on an individuals/groups needs and healthcare setting Sub Indicator Recognizes when to negotiate with, or refer to other healthcare or service providers Establish positive and productive working relationships with colleagues Evidence Guide Examples Knowledge of: Health care systems Roles and responsibilities of various models of interdisciplinary health teams

Knowledge of: 4.2.2 Recognizes that the 4.2.2.1 membership and roles of healthcare teams and service providers will vary depending 4.2.2.2 on an individuals/groups needs and healthcare setting 4.2.3 Demonstrates knowledge 4.2.3.1 of effective inter-professional work practices which respect and utilize the contributions of 4.2.3.2 members of the health team Recognizes when to negotiate with, or refer to other healthcare or service providers Establish positive and productive working relationships with colleagues Health care systems Roles and responsibilities of various models of interdisciplinary health teams

Knowledge of: Participates with members of the healthcare team in decision- Decision making frameworks making Processes for referrals Reviews and evaluates care with members of the healthcare team

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SCOPE OF PRACTICE DECISION MAKING

Decision making in midwifery practice is complex and relies on a number of factors. The Midwife should use the following steps to assist in making appropriate and accountable decisions. Step 1. Is the function within the scope of practice of the registered midwife? Midwifery practice in Dubai is guided by contemporary standards and policy endorsed by DHA HEALTH REGULATION and benchmarked against standards and procedures endorsed by national and international associations. IDENTIFY Is the activity within the scope of practice of the registered midwife? Does the practice comply with midwifery standards, is it supported by policy and is it supported by research/evidence based practice for this situation? Are there other standards or regulatory policy that I must consider and will the practice comply with these? Do I require regulatory authorization to perform this activity?

Step 2. Is the function within the individuals scope of practice? It is the responsibility of every midwife to understand and apply the relevant standards of professional practice within their own scope of practice. In making decisions in relation to their scope of practice midwives must actively engage in continuous self assessment and self regulation to ensure continuing competence to practice. IDENTIFY Do I possess the current knowledge, training, skill and experience to perform the function? Are these skills and abilities documented in my employment file? Do I have required authorization to perform this activity? Do I require the expert assistance of other health professionals? Have I met the requirements for delegation? Have I met the requirements for supervision?

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Step 3. Is there an identified client/patient need or benefit? Midwifery care should occur in consultation with the woman and her family. IDENTIFY Is there a legitimate need by the woman for this service? Will the woman benefit from my performing this service? Has the woman been consulted in the decision process?

Step 4. Does the employing facility support this function? Midwives have the responsibility to practice within professional standards and guidelines which are supported by appropriate policies and procedures provided by employers. Is this function identified within my role/job description? Do I have the support of my supervisor to perform this function? Is there organizational policy or procedure in place?

Step 5. Am I willing to accept accountability and responsibility for my decision?

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SCOPE OF PRACTICE DECISION MAKING STEPS Question: How do I know what my current Scope of Midwifery Practice is? ASK Step 1 Is the function within licensed midwifery practice? EVALUATE Is the activity within the licensed midwifery practice? Does the practice complies with midwifery standards and supported by policy and is it supported by research/evidence based practice for this situation? No

YES

Step 2 Is the function within the individual's scope of practice? YES

Do I possess the current knowledge, training, skill and experience to perform the function? Are these skills and abilities documented in my employment file? Do I have required authorized to perform this No activity? Do I require the expert assistance of other health professionals? Have I met the requirements for delegation? Have I met the requirements for supervision? Is there a legitimate need by the woman for this service? No Will the woman benefit from my performing this service? Has the woman been consulted in the decision process? Is this function identified within my role/job No description? Do I have the support of my supervisor to perform this function? Do I accept responsibility for the performance and No outcome of this function in this context and mindful of any competence? DO NOT PROCEED Review & consult resources & seek

Step 3 Is there an identified need by the woman or identified benefit? YES Step 4 Does the employing facility support this function? Yes
Step 5 Am I willing to accept accountability for my decision?

YES PROCEED

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DELEGATION WITHIN THE SCOPE OF PRACTICE OF THE REGISTERED MIDWIFE

DELEGATION BY REGISTERED MIDWIVES For the purpose of this document delegation is the conferring of authority to perform specific functions or tasks/activities in a specific situation, to a person whose role/job description and training allows them to perform such functions but does not have the authority to perform such functions without supervision. Only REGISTERED MIDWIVES are able to delegate. It is not permitted for Registered Nurses or Assistant Nurses to delegate tasks that are the domain of the qualified midwife. Registered Midwives who delegate health care tasks retain accountability for the decision to delegate and the subsequent performance of the delegated task. The decision to delegate is based on the midwifes professional judgment and determination that the person to whom the delegation is to be given is competent to perform the function. DELEGATION must not be given in circumstances which involve a compromise to the woman or new born safety or a breach of legislation or professional standards. SUPERVISION Supervision is defined as the activities of oversight, direction, advice, guidance, support, monitoring or evaluating. Supervision can be of the individual or a group of persons and is usually for a defined time as determined by the licensed nurse depending on the situation and activity. Supervision can be direct where the Registered Midwife works with the Registered Nurse, Assistant Nurse or Health Care Assistant or Student Midwife and can provide observation and intervention where necessary. Supervision can be indirect where the Registered Midwife is not present and supervision is provided other than by direct observation. Processes which are the shared responsibility of the licensed midwife as well as the employer must be in place to support the Registered Nurse, Assistant Nurse or Health Care Assistant or Student Midwife in this situation.

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GLOSSARY OF TERMS ACCOUNTABILITY A Registered Midwife is answerable to the woman and her newborn, the employer, the regulator and the public for her decisions, actions and behaviours and for the consequences of those decisions, actions and behaviours. ASSISTANT NURSE A Person registered under the registered assistant nurse scope of practice COMPETENT Having the required abilities or qualities COMPETENCE The combination of skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse DUTY OF CARE A duty to use care toward others that would be exercised by an ordinarily reasonable and prudent person in order to protect them from unnecessary risk of harm PUBLIC The community of the Emirate of Dubai, United Arab Emirates REGISTERED NURSE A person registered under the registered nurse scope of practice SELF ASSESSMENT Self assessment of competence is a continuous process of examination against professional standards and guidelines. The midwife has the responsibility to maintain and further develop the competence necessary for their area of practice. The focus should be on improvement. SELF REGULATION Self regulation is a dynamic process for the health professional which involves accountable practice and sound decision making. Critical continuous self assessment of competence to practice and actions to maintain and enhance competence is its foundation.

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References 1. Australian Nursing & Midwifery Council (2006) National Competency Standards for the Registered Midwife, www.anmc.org.au 2. ACMI (2001) Australian College of Midwives Incorporated Competency Standards for Midwives http://www.acmi.org.au 3. Australian Nursing and Midwifery Council (2006) National Competency standards for the Midwife 4. Department of Health & Medical Services (2008); Job Description/ Performance 5. Appraisal Midwife 6. Buscher, A., Wagner, L. (2004) Munich Declaration: nurses and midwives: A force for health. An Analysis of implementation of the Munich Declaration 2004 (WHO publication) http://www.euro.who.int/document/e86640.pdf 7. Federal Department of Nursing, Ministry of Health United Arab Emirates (2007); Scope of practice for the Midwife 8. Health Authority Abu Dhabi (2007); Scope of Practice for the Midwife, www.haad.ae 9. ICM/WHO/FIGO International Definition of the Midwife, ICM, The Hague International Confederation of Midwives (2002) Essential Competencies for Basic Midwifery Practice http://www.internationalmidwives.org/modules.php?op=modload&name=News& file=article&sid=27 10. Nurses Board South Australia (2006); A Scope of Practice Decision Making Tool

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