Midwifery 79 (2019) 102534

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Midwifery
journal homepage: www.elsevier.com/locate/midw

Knowledge and use of the ICM global standards for midwifery

education
Mary K. Barger a,∗, Barbara Hackley b, Kuldip K. Bharj c, Ans Luyben d, Joyce B. Thompson e
a
University of San Diego Hahn School of Nursing and Health Science, 5998 Alcala Park, San Diego, CA, 92110, USA
b
Jefferson University, USA
c
University of Leeds, Leeds, UK
d
Bournemouth University, Bournemouth, UK
e
Independent Consultant

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To explore how the International Confederation of Midwives Global Standards for Midwifery Ed-
Received 3 May 2019 ucation are currently used and their influence, if any, on the development of education programs globally.
Revised 28 August 2019
Secondarily, to identify current challenges to midwifery education.
Accepted 31 August 2019
Design: Cross-sectional exploratory descriptive qualitative study using focus groups and one-on-one inter-
views to collect data about knowledge of and use of the Education Standards and participants perceived
Keywords: current challenges to midwifery education. Interviews conducted in English, Spanish, and French.
Midwifery Setting and Participants: Midwife educators, education directors, or regulators attending one of four na-
Education tional/international conferences or one-on-one interviews in person or via internet. Thematic analysis
Educational standards
was employed using the Framework approach for data analysis.
Findings: There were 11 focus groups and 19 individual interviews involving 145 midwives from 61
countries. There was a general awareness of the Education Standards amongst the participants although
knowledge about the specifics of the document was lacking. The Standards were mainly used as a refer-
ence and greater use was made when developing new educational programs. The Standards identified as
most difficult to meet included: organization and administration of the program, ensuring that teachers
were formally prepared as teachers, meeting targets for teacher to student ratios and that 50% of edu-
cational time took place in the clinical setting. Universally endorsed challenges to midwifery education
were: 1) inability to accommodate the increase in curricular content without compromising prior con-
tent or lengthening programs; 2) insufficient resources including lack of classroom and clinical teachers;
3) medicalization of childbirth and health system changes limiting student exposure to the midwifery
care model; 4) role conflict and competition for clinical experience with other health professionals.
Key Conclusions: The Education Standards need to be more widely disseminated and implemented.
Stronger collaborations with clinical settings and government systems are required to solve the current
challenges to midwifery education.
Implication of Practice: Well-educated midwives can provide the majority of maternal and neonatal care,
however it will require an investment in strengthening midwifery programs globally for this goal to be
achieved.
© 2019 Published by Elsevier Ltd.

Introduction decrease the rates of maternal mortality and morbidity (United

Nations, 2015; World Health Organization (WHO), 2015; WHO,
A skilled professional midwifery workforce has been promoted 2019). Where midwives are educated and regulated to interna-
as a way to improve maternal and child health worldwide and tional standards, it is estimated that they can provide 87% of the
essential sexual and reproductive health services for women and
neonates (United Nations Population Fund, 2014; Renfrew et al.,
∗
Corresponding author. 2014), “could avert over 80% of all maternal deaths, stillbirths and
E-mail addresses: mbarger@sandiego.edu (M.K. Barger), neonatal deaths” (Homer et al., 2014), as well as provide safe high-
Barbara.hackley@jefferson.edu (B. Hackley), K.K.Bharj@leeds.ac.uk (K.K. Bharj),
quality, culturally appropriate care to women and neonates. How-
aluyben@bournemouth.ac.uk (A. Luyben).
ever, it is the quality of midwifery education that makes it possi-
Social media: (M.K. Barger), (K.K. Bharj), (A. Luyben)

https://doi.org/10.1016/j.midw.2019.102534
0266-6138/© 2019 Published by Elsevier Ltd.
2 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534
Table 1
ICM Global Standards for Midwifery Education and Essential Competencies for Basic Midwifery Practice content outline with a few highlights.
Education standards (2013)
I. Organization and administration:, control of budget, director is a midwife
II. Midwifery Faculty: majority are licensed as midwives, formally teacher
preparation
III. Student Body: policies for admission, progression, and graduation
IV. Curriculum: length, content to include Basic Competencies
V. Resources, facilities, and services: access to and sufficiency of clinical sites
ble to reach these goals, and that quality is inherent in the ICM
Global Standards for Midwifery Education (ICM 2013) that speak to
the preparation of competency-based teachers (Standard II) within
a competency-based curriculum (Standard IV). However, it is evi-
dent that wide inconsistencies exist in the nature and content of
midwifery education programs globally (Castro Lopes et al., 2016;
Fullerton et al., 2003; Fullerton and Thompson, 2013) although the
variation may be narrowing in low- and middle resource coun-
tries (Castro Lopes et al., 2016). One strategy to ensure education
meets an international standard is to promote global accreditation
of midwifery education as advocated by the WHO for midwifery
(WHO, 2019).
In order to achieve its mission of promoting autonomous mid-
wifery globally, the International Confederation of Midwives (ICM)
situates its work within a framework of three pillars that are es-
sential for a strong profession: education, regulation, and asso-
ciation. The ICM has developed key documents to support these
activities, which receive periodic review and updating. One tool
aimed at improving the consistency and quality of midwifery edu-
cation is the ICM Global Standards for Midwifery Education (here-
after the Education Standards) (ICM, 2013). The Education Stan-
dards along with Companion Guidelines were first approved for
use by the ICM Board in 2010, endorsed by the ICM Council in
2011 (Thompson et al., 2011), and then subsequently reviewed and
amended in 2013 (International Confederation of Midwives (ICM),
2013). The Education Standards were developed using criterion ref-
erences from the existing literature and a Delphi process partici-
pated in by midwife educators from 88 countries was used to edit
standards and provide consensus (Thompson et al., 2011). These
Education Standards cover six areas (organization, faculty, students,
curriculum, resources, and evaluation) and incorporate the ICM Es-
sential Competencies for Basic Midwifery Practice (ICM, 2019) into
the standard related to midwifery curriculum content (see Table 1).
The documents are readily accessible on the ICM website in ICM’s
three official language: English, French, and Spanish. ICM has pro-
moted the Education Standards at international conferences and
professional meetings attended by midwives and policy makers. In
addition, the Education Standards have served as a basis for ICM
sponsored global workshops aimed at building competency-based
educational skills among midwifery educators. These ICM Educa-
tion Standards are further reflected in the 5th of the Seven-Step
action plan to strengthen quality midwifery education developed
by a joint task force from UNFPA, UNICEF, WHO, and ICM, pub-
lished by WHO in 2019 (Framework for Action: Strengthening qual-
ity midwifery education for Universal Health Coverage 2030).
As part of the ICM strategic planning, an update of the Global
Standards for Midwifery Education was considered and discussed
with the ICM Education Standing Committee and liaised with con-
sultants in Spring 2016. During these discussions multiple ques-
tions were raised concerning their worldwide dissemination and
implementation. The conclusion was a lack of knowledge about
their current usage. Therefore, the purpose of this qualitative study
was to explore how the Education Standards are currently used
and their influence, if any, on the development of education pro-
grams globally.
Basic competencies (2019)
1. General competencies: autonomy and responsibility as a health professional
2. Competencies to pre-pregnancy and antenatal care: health assessment &
promotion, detection of complications
3. Competencies specific to labour and birth: facilities physiological processes
4. Competencies specific to ongoing care of women and newborns:
breastfeeding family planning, detect complications
Methodology
This cross-sectional exploratory qualitative descriptive study re-
ceived Institutional Review Board approval from the University of
San Diego. To be eligible to participate in this study, individuals
needed to be older than 18 years and were required to be a prac-
ticing midwife, midwifery educator, or midwifery regulator. Con-
venience sampling was used. The focus groups occurred at mid-
wifery conferences and the ICM Triennial Congress in Toronto and
individual interviews took place at conferences or via internet with
midwives from ICM regions not well represented within the focus
groups.
Three members of the research team (MB, KB, JT), who are in-
timately familiar with the Education Standards, developed the in-
terview guide. These researchers are members of the ICM Educa-
tion Standing Committee and have been in dialogue with interna-
tional midwifery colleagues about these standards. In addition, the
study’s consultant (JT) used the Standards extensively in projects
aimed at improving competency-based midwifery education and
practice, primarily in Latin America and the Caribbean sub-regions.
The team brought this expertise to the development of the study’s
interview guide. The questions from the semi- structured ? inter-
view guide relevant to the study questions were:
1) Were participants aware of the ICM Education Standards?
2) If they were not aware of them, why? If aware, which aspects
were helpful and which were a challenge to meet?
3) Did they use the standards to inform the development of edu-
cation programs in their home countries?
4) What were the greatest challenges facing midwifery education
at present?
Consent was obtained the same way for both the individual
interviews and for the focus groups. The study was explained to
participants and they were given a copy of the consent form. The
consent form was available in English, Spanish, and French. Any
questions participants had about the process were answered be-
fore proceeding. Participants were told that they could leave at any
time or choose to not answer any questions. If they agreed to con-
tinue and participate, their consent was implied. Participants com-
pleted a brief survey about the country where they practiced, the
number of years they had been in midwifery clinical practice and
as an educator, if applicable, and the type of midwifery program
they graduated from, as well as their current position. The inter-
viewer then asked questions from the interview guide. The inter-
views and focus groups were recorded and if recording was not
possible due to noise, the interviewer took detailed notes. Inter-
views were conducted in English, Spanish, or French. All interviews
were transcribed and if they needed translation, were translated
into English. All notes were typed up. If someone inadvertently
used a name during a focus group, the name was not included in
the transcript to preserve anonymity.
Thematic analysis was carried out using the principles of
Framework Analysis (Ritchie and Lewis, 2003) were used to an-
alyze the data. Briefly, this approach involves five key stages: fa-
miliarization with the transcripts, developing a thematic frame-
 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534 3

Table 2 Table 3
Description of the sources and numbers of study interviews. Demographic characteristics of study participants.

Source Number of participants Total sample = 145

Characteristic N (%) or mean [range]
American College of Nurse-Midwives Meeting 5
Normal Birth Conference 4 Years as a midwife 19.9 [2–45]
Southern Europe Midwife Conference 11 Years teaching midwifery 13.9 [1–35]
ICM Triennial Congress 106 ICM Region
- Africa (12) • Africa 27 (18.6)
- Africa (11) • Eastern Mediterranean 6 (4.1)
- America, North (24) • Europe 32 (22.1)
- America, South (11) • Southeast Pacific 16 (11.0)
- Asia (28) • Western Pacific 24 (16.8)
- Europe, North (9) • America 40 (27.6)
- Europe, Central (12) Current Position
- Europe, South (8) • Midwife lecturer 74 (51.0)
Individual interviews 19 • Midwife clinical teacher 57 (39.3)
Total 145 • Midwife Education director 21 (14.5)
• Midwife researcher 42 (29.0)
• Clinical midwife/supervisor 66 (45.5)
• Regulator or other leadership role 46 (31.7)
work, indexing of themes, charting of themes, and finally mapping Type of midwifery program as an educator (n = 136)
and interpretation. All principle researchers familiarized them- • Pre-service/ direct-entry 56 (41.2)
selves with the transcripts. They then met to decide on a the- • Post-nursing or other health profession education 35 (25.7)
• Both program types 45 (33.1)
matic framework. Then two researchers were assigned to each of
the three major areas and independently indexed the meaning or Note: Participants could select more than one current position category.
latent content of that area and any emerging themes and high-
lighted notable findings. Saturation was achieved when the anal-
than 10%) could recall their knowledge of the Education Standards.
ysis repeatedly generated the same themes and no new themes
Many who participated in the four focus groups confused the Edu-
emerged. Once the investigators completed their independent anal-
cation Standards with the Essential Competencies for Basic Midwifery
ysis of the transcripts, they met to discuss their findings and re-
Practice (ICM 2013. Rev) when responding to this question, despite
solve any differences in findings by consensus and chart the rela-
the fact it was emphasized we were asking about the Educational
tionships of any identified themes. The research group then inter-
Standards and not the Core Competencies. For example, one par-
preted the findings. Finally, the findings were sent to lead inter-
ticipant stated,
viewers of the focus groups as a validity check to the interpreta-
tions. Specific quotes or comments in general are attributed to the “Let me give you an example, the ICM Competencies for Midwives
country of the respondent but if the participant did not identify – they sent it to us and we looked at it and everyone, those who
their country, it is attributed to the name of the focus group. work at the hospital and work at the school, look at the compe-
tencies, to make sure everyone is learning it.” (Participant, Africa).
Results
On the other hand, some participants provided specific exam-
ples of using the standards, e.g. those from Caribbean, Paraguay,
Focus groups took place during 2017 at four international meet-
Mexico, Philippines, and Nepal.
ings: the American College of Nurse-Midwives in the US, the
Southern European Midwifery Conference in Spain, the Normal
Use of the ICM education standards
Birth Conference in Australia, and the ICM Congress in Toronto
(see Table 2). The focus group in Toronto primarily consisted of
There were a few specific examples of countries or specific ed-
ICM Council members and Council guest observers. Focus groups
ucational programs using the Education Standards especially when
at the other conferences were primarily midwife educators. The to-
developing new midwifery education programs or during major
tal number of focus groups were 11 which ranged in size from 4
program revisions. For example, one participant stated the ICM
to 28. In addition, 19 one-on-one interviews were conducted either
standards:
face-to-face or via web-based platforms by project team members.
The total number of participants in this study was 145, repre- “helped us a lot in developing the course for our four year degree
senting 61 different countries. More than 60% of participants held program … it is a tool for us to be the guide in developing our
more than one position (See Table 3). The vast majority of partic- own normal course midwifery education.” (Participant, Asia)
ipants had experience teaching midwifery with just over half of
However, the majority of the participants indicated that they
them currently teaching in the classroom and just under half in
used the ICM Education Standards, at least indirectly. In general,
the clinical setting. The average time for participants’ engagement
midwives representing high resource countries e.g., Japan, Aus-
in midwifery teaching was about 14 years. Nearly one-third of par-
tralia, New Zealand, North America (exclusive of Caribbean), some
ticipants indicated that they held a position in either regulation or
South American countries, Great Britain, and other European Union
leadership. Both pre-service and post-nursing or health profession
countries indicated that they tend to use Education Standards as a
education program types were well represented by the sample.
background reference for their national education or accreditation
Three major areas addressed by the interview guide were: (1)
standards. They further explained that their home countries have
awareness of the Education Standards; (2) use of the Standards;
other educational standards or an accreditation process that either
and (3) current challenges to midwifery education. Several themes
incorporate, or exceed, the ICM Education Standards. A participant
for the last area emerged from the focus group and interviews.
from the Central European focus group stated:
Awareness of the ICM education standards “I think when you use them in consultation responses to pol-
icy, you reference them because you’re looking for evidence of
Most of the participants in the focus groups indicated they were something that is sort of credible on a global level. So I would
aware of the ICM Education Standards. Very few participants (less imagine that there’s quite a few documents that would have
4 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534
reference to them but really directly use them and disseminate
them as policy, no”.
However, one participant from the same focus group indicated,
“So, the competencies I think are more relevant to us. International
education standards are not something we need” (Participant, Cen-
tral Europe). Several participants from both focus groups and in-
dividual interviews stated the Education Standards could not be
adopted in their entirety but needed to be adapted for the local
situation. They did not provide more specifics nor their reasoning
for this statement.
Participants reported that, whilst within their country they
were aware of the Education Standards, their use was not consis-
tent. For example, among three different educators from the same
country but different institutions, one stated that the Standards
were used ‘completely’, another identified using them to a limited
degree, and the third participant reported that their institution did
not use the Standards as their university had their own require-
ments.
A minority of participants stated the ICM Standards were not
used in their countries and at least one cited the use of the WHO
Global Standards for the Initial Education of Professional Nurses and
Midwives (World Health Organization, 2009) as the reference doc-
ument for their country.
When referring to particular standards in terms of their help-
fulness and those that were a challenge to meet, in general an-
swers were non-specific and vague. The participants were unable
to provide specific examples. The majority of participants were fa-
miliar with two standards and these were: (a) the recommended
length of educational programs and (b) the curriculum should in-
clude ICM’s Essential Competencies to the extent permitted by law.
However, some standards were noted as being ‘hard’ to meet. “Edu-
cational administration” was cited as an example of a standard that
was difficult to meet. This presumably refers to Standard 1 (Organi-
zation and Administration) which includes items such as: financial
and public support for the program, having control over the bud-
get, and a self-governing midwifery faculty. Other issues identified
as challenging to meet were the requirement the program director
be a midwife, student to teacher ratios, formal preparation of mid-
wives as teachers, and the criterion that 50% of curriculum hours
to be allocated to practice.
Perceived current challenges to midwifery education
This area generated much discussion. Many groups regardless of
geography or economic status of the country were facing similar
challenges in midwifery education, namely the impact of transi-
tion into longer duration programs, having sufficient academic and
clinical resources to adequately educate midwifery students, role
conflicts with nursing, and context of care.
Program length
Midwifery programs worldwide have different expectations
about what constitutes basic midwifery education for entry-level
practice. While it was impossible to outline these expectations by
country from the conversations captured in the focus groups, it
was clear many countries are moving toward increasing the aca-
demic level of midwifery education programs which requires that
the length of the programs is increased (Central and Southern Eu-
rope, Asia). The general move to a university degree, Baccalaureate
or Master level studies, presents a challenge to balance the need
for significant increase in the curricula content (both content re-
lated to the higher degree and the expanding role of the midwife)
with that of keeping the length of the programs reasonable. As one
participant stated,
“I think there’s a lot of pressure to put more and more in the cur-
riculum … It’s a real challenge to get everything you want to put
into the program within the timeframe.” (Participant, Central Eu-
rope)
Insufficient resources
A shortage of qualified midwifery educators, both for the class-
room and the clinical setting, was uniformly endorsed as a prob-
lem. This issue was most acute in settings that are moving to
higher academic levels of study where the expectation is for the
classroom teacher to hold a degree higher than one awarded to
students. One participated reported:
“The other problem is there’s not enough midwifery educa-
tors…Bachelor teaching bachelor. But we don’t have much Master
training in midwifery.” (Participant, Asia).
In the clinical setting, a general shortage of midwives world-
wide was noted. In lower income countries this may be due to
insufficient funds to hire sufficient clinical providers; in wealth-
ier countries, it may be active strategies for cost constraint by
consolidation of health systems. Both scenarios result in increased
midwifery workloads which makes it difficult to supervise stu-
dent learning. For example, a participant from Northern Europe as-
serted: “We don’t have enough clinical supervisors at hospitals, so we
can’t increase the number of students.”
A shortage of practice sites emerged as a second resource is-
sue. The limitation of practice sites seems to centre on two chal-
lenges. First, participants cited competition for caring for pregnant
women from other health profession students in the setting, pri-
marily medical and nursing students. This was well summarized
by one participant
“Students are not getting enough exposure to conduct deliveries
because they’re not getting supervision support from the other per-
son because of medical students. The number of [other types of]
students is increasing so our [students] are not getting enough to
do their practice.” (Participant, Turkey)
Secondly the consolidation and re-configuration of maternity
services is resulting in fewer sites and this also determines the
number of students who could be recruited to midwifery pro-
grams.
Financial support for midwifery education programs emerged
as a third resource limitation. This challenge was particularly noted
by participants who lived in countries where midwifery is situ-
ated in departments of nursing or medicine (United States, Canada,
France, Spain). Additionally financial support for students is an in-
creasing concern where midwifery is moving to the university set-
ting, since students at vocational training levels typically receive
more financial support during their formation than those as the
university level.
Context of care – lack of midwifery model of care
This theme was also almost universally endorsed by partici-
pants. Participants emphasized that the medicalization of child-
birth, such as high caesarean rates, was making it difficult for stu-
dents to acquire fundamental midwifery skills. This was particu-
larly affirmed by those from developed and high income countries
whereas those from lower resourced areas of Africa, Caribbean, and
parts of Asia did not echo similar views. Changes in health care
practices, for example, early postpartum discharge, were seen as
limiting time for student clinical practice with women and their
families. In a few countries (Japan, Chile, and France), decreasing
birth rates also were seen as an issue limiting both student expe-
rience and the perceived need for midwives.
 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534
Role conflict
Participants in focus groups discussed the confusion about the
scope of practice of midwives educated through newer (higher)
degrees and those educated in historic midwifery pathways or
in combined nursing and midwifery program designs (Indonesia,
Malawi, North America, South America, Western Europe). For ex-
ample, participants from Indonesia, the US, and Canada cited that
role confusion between midwifery and nursing made it difficult
for midwives to practice since either midwives were seen as hav-
ing a more limited skill set than nurses or regulations for practice
did not recognize midwifery as a separate profession. Other par-
ticipants from Malawi and South America were uncertain how the
midwifery role differed if midwives were educated at the techni-
cal/vocational, university, or Masters level. Some participants called
for a standardized midwifery curriculum worldwide, as a resolu-
tion to this challenge.
Discussion
The main finding of this study was that while midwives glob-
ally were aware of the ICM Educational Standards their depth of
knowledge was variable. Participants appeared to be much more
knowledgeable about ICM’s Essential Competencies than the Ed-
ucation Standards. For example, there were only two areas cov-
ered by the Standards that the participants could recall in detail:
(1) recommended program length and (2) the curriculum should
cover the content of the ICM Essential Midwifery Competencies. On
the other hand, participants cited different competencies required
such as breech or vacuum assisted birth, family planning, repro-
ductive loss including post-abortion care. Among those participants
who had greater understanding of the Education Standards, they
reported that the criteria about the organization and administra-
tion of the program and teacher preparation (both classroom and
clinical) and teacher/student ratios were difficult to meet. Indeed,
the responses of participants indicate that the Education Standards
are hard to implement because there is a shortage of adequately
prepared classroom and clinical teachers and increasing difficulties
in obtaining sufficient clinical experience for students to effectively
achieve fundamental competencies at the time of their graduation.
Therefore, midwives may not have the necessary competence to
provide safe, evidence based care.
These findings echo those of Castro Lopes et al. (2016) whose
survey of 73 low- middle-income countries on midwifery profes-
sional factors identified major educational challenges included a
shortage of prepared midwifery teachers, limited opportunities for
students to acquire needed skills, and a lack of equipment. This
is confirmed by the finding reported by the WHO that only 6.6%
of midwifery educators in low-middle income countries have for-
mal preparation in education (WHO, 2013). Concern over qualified
educators, especially those with a degree higher than the one be-
ing awarded, also has been documented in high income countries
(Albarran and Rosser, 2014).
The need for increased skills among midwifery educators es-
pecially among low-middle income countries is further supported
by a recent systematic review of the literature (West et al.,
2016). West et al. (2016) identified a need to update edu-
cators’ knowledge and skills in teaching and clinical practice.
WHO has promoted the importance of strengthening midwifery
educator skills through the publication of midwifery teacher
core competencies (WHO, 2013). An emphasis has been placed
on promoting competency-based education (CBE) teaching skills
(Thompson et al., 2017). Changing to a CBE teaching approach re-
quires leadership support and mentoring. Single one-time work-
shops have not been highly successful when educators return
to their countries where they find it easier to fall back on
5
the familiar straight lecture approach rather than take the time
to develop new learner centred activities (West et al., 2016).
Thompson et al. (2017) have developed a detailed approach to de-
velop an educator from a CBE learner to a CBE Master Educator
which requires support from administration for the needed de-
velopment time. Institutional policies which require frequent ro-
tation of heads of programs may inhibit the expertise to pro-
vide this needed support and supervision required to institu-
tionalize this newer teaching approach (Nyoni and Botma, 2018).
Thompson et al. (2017) also encountered difficulty finding mid-
wifery classroom educators who were also clinically active, the
ideal candidates for their master training workshops. Many partic-
ipants in this qualitative study identified the difficulty of balancing
the demands of both academia and practice.
The concern over adequate student supervision in the clinical
setting and appropriate opportunities of clinical experiences for
midwifery students to acquire essential midwifery competencies
is not new. Bharj and Embo’s (2018) summary of two workshops
at ICM Congresses identify similar issues expressed by midwifery
participants from a broad geographic spectrum of educational pro-
grams. The participants of these workshops recognized the wide
variation in education and educational resources and opportunities
globally. The lack of prepared clinical supervisors and the chal-
lenges of having to balance heavy caseloads with clinical teach-
ing results in poorer evaluation of student progress, more lim-
ited student clinical opportunities with more experience shifted
to ‘specialty’ care (Bharj and Embo, 2018). McKellar and Gra-
ham (2017) reported similar issues in Scotland where heavy clin-
ical workloads of midwives detracted from the ability to provide
clinical supervision to students. They identified midwives in the
clinical setting needed skills, particularly how to encourage stu-
dents to self-reflect on their practice.
Finally to consider is the issue whether the Education Standards
are too aspirational, at least for some countries. Several partici-
pants in this study advocated that the Education Standards should
be ‘adapted’ for local use. This is questionable given the stan-
dards were developed using evidence and endorsed globally, with
Guidelines offering suggested ways to meet each standard. There-
fore, the Standards can be viewed as providing guidance on how
current educational processes might be developed or revised to
meet them. From this perspective, the Standards are an important
step in the global call to action to incorporate an evidenced-based
competency-based curriculum in midwifery education as essential
to strengthening the midwifery workforce to meet the world’s ma-
ternal and child health needs (Renfrew et al., 2014; WHO, 2016,
2019).
In fact, in one global survey nearly 80% of educators endorsed
the need for a recognition program documenting that a midwifery
education program meets the Education Standards (Barger et al.,
2017). The development of such a program could be complex
(Luyben et al., 2017). A pilot project by the ICM showed both the
difficulties of carrying out such an accreditation process and the
potential benefit of the self-evaluation process as a valuable tool
for assessing a programme and identifying areas for improvement
(Nove et al., 2018).
Limitations
This study has some important limitations. As a qualitative
study, it is only the expressed opinions of the participants and is
made up of a convenience sample of midwives. The largest focus
groups were comprised of ICM Council Delegates who have some
leadership or professional recognition to be appointed to this po-
sition and therefore, more than likely have a higher than average
knowledge of ICM core documents including the Education Stan-
dards. Thus, the findings are likely to be skewed toward more fa-
6 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534
miliarity which may mean the Education Standards are less known
and used than the findings of this study may indicate. Additionally,
individual participants could have very different knowledge and
experiences with ICM Education Standards as seen above where
three participant from the same country but from different in-
stitutions demonstrated variable understanding of the Standards
ranging from no awareness of the Standards, to some awareness,
to being familiar and working with the Standards within an edu-
cational program. Therefore, any conclusion about the use of the
Education Standards within a country or a region would be inap-
propriate. However, the findings of this study are consistent with
what other have reported related to the variability in midwifery
education programs and resources and the challenges in keeping
improvement in standards, once achieved, sustainable.
Conclusion and recommendations
In this study the use of the ICM Global Standards for Midwifery
Education, and their influence on the development of education
programs were globally explored with midwifery educators, reg-
ulators, and leaders. The findings indicate it is too early to update
and change these Standards. While there is an awareness of the
Education Standards, there appears to be lack of knowledge about
specific Standards and many inconsistencies between the desired
standards and the real life situation of midwifery education. The
Education Standards were perceived by the participants as a help-
ful framework of reference in developing new midwifery education
programs. Limitations however were experienced when aiming for
sustainability of quality midwifery education based on these Stan-
dards. Many educators mentioned experiencing challenges in pro-
viding high quality midwifery education, such as having insuffi-
cient human resources, both in school and in practice, and limited
opportunities for skill acquisition in practice.
Therefore, the main global focus for the near future should
be threefold; improving and increasing dissemination of the Stan-
dards and Guidelines, supporting their implementation, and once
the Standards are achieved, sustainability of quality midwifery ed-
ucation programs. The experiences of the participants in the cur-
rent study highlight the need to develop and implement mecha-
nisms that support this threefold focus, which involves
• Make formal education in teaching more readily available.
Lack of qualified teachers in both the classroom and clinical set-
tings appears to be a universal problem. Efforts to develop and
provide formal teacher preparation should be a priority of pol-
icy makers and academic institutions. Use of newer, innovative
teaching strategies, such as online learning, and use of readily
accessible videos might be potential venues for such expansion.
• Develop and support midwifery leadership in education
Participants highlighted “Organization and Administration” as
a Standard that was hard to meet. This feedback highlights a
lack of autonomy and self-governance of the midwifery edu-
cation programs. To successfully implement quality midwifery
education, midwifery leadership is needed. Leadership needs to
occur both at the programme level and the educational insti-
tution’s administrative level. Lack of such leadership and self-
governance on national and local levels will further inhibit the
implementation of quality midwifery education, or its sustain-
ability, once achieved.
• Strengthen collaborations between schools, practice settings, and
government systems
Close collaboration among the educators, clinical setting, reg-
ulators and policy makers of the midwifery profession at each
level might lead to improved communication about, and aware-
ness of, essential professional issues, such as the Education
Standards, and the need for joint action on national and lo-
cal levels. This assumption is supported by feedback from
midwifery educators who had worked on establishing new
programs and their positive experiences with the Standards,
whereas vague or inconsistent awareness was experienced by
others not in this position. Additionally, the participants in
this study particularly highlighted the lack of human resources,
both in schools as well as in practice. Also noted was the lack
of capacity for clinical teaching in practice settings influenced
by cost-saving measures resulting in high clinical workloads.
Without an environment where learners are able to develop
and practice skills so they can demonstrate competency, mid-
wifery education will not be successful in graduating compe-
tent midwives. Effective collaboration among all involved part-
ners therefore is essential in order to use and implement the
Standards successfully.
• Focus policy efforts on developing the exercise of full scope of prac-
tice for midwives
Last but not least, a successful implementation of the Standards
and the sustainability of quality midwifery education is highly
influenced by current maternity care practice and the role and
possibilities of midwives. The current study highlights three im-
portant themes. Firstly, a need to increase midwifery models of
care in practice, coupled with a reduction of medical interven-
tions. Secondly, a need to clearly define the role of a midwife
in practice, with reference to other maternity care professionals.
Thirdly, define expanding roles for midwives in practice, so that
increased (academic) knowledge will contribute to the quality
of care for future mothers, their children and families. Exercis-
ing full scope of practice by midwives is therefore imperative
to make quality midwifery education a reality and to equip stu-
dent midwives with the skills they need for their future mid-
wifery work in practice.
The ICM Global Standards for Midwifery Education provide a
robust framework for implementing quality midwifery education
that can provide for a skilled professional midwifery workforce.
Globally sustainable political, financial and professional investment
and support is needed to improve their dissemination and imple-
mentation, while tackling and overcoming challenges in the cur-
rent context of midwifery education. Only with this support, will
improvement in the health of women and their families be real-
ized.
Ethical approval
This study received Institutional Research Board approval from
the University of San Diego.
Funding
The research was funded by a contract with the International
Confederation of Midwives.
CRediT authorship contribution statement
Mary K. Barger: Conceptualization, Funding acquisition, Project
administration, Data curation, Investigation, Formal analysis, Writ-
ing - original draft. Barbara Hackley: Methodology, Investiga-
tion, Formal analysis, Writing - review & editing. Kuldip K. Bharj:
Methodology, Investigation, Formal analysis, Writing - review &
editing. Ans Luyben: Conceptualization, Data curation, Investiga-
tion, Writing - review & editing. Joyce B. Thompson: Conceptual-
ization, Data curation, Investigation, Writing - review & editing.
 M.K. Barger, B. Hackley and K.K. Bharj et al. / Midwifery 79 (2019) 102534
Acknowledgements
We wish to acknowledge the following midwives who assisted
with the focus groups: Dr. Melissa Avery, Dr. Lea Beckmann, Dr.
Rita Borg-Xuereb, Dr. Judith Fullerton, Dr. Caroline Homer, Prof. He-
len McDonald.
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