Midwifery 27 (2011) 409–416

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

The International Confederation of Midwives: Global Standards for

Midwifery Education (2010) with Companion Guidelines
Joyce B. Thompson, DrPH, CNM, FACNM (Emeritus Professor)a,n, Judith T. Fullerton, PhD, CNM, FACNM
(Professor (Retired))b, Angela J. Sawyer, RN, CNM, FWACN (Assistant Clinical Professor (Retired))c
a
10852 Enzian Road, Delton, MI 49046, USA
b
7717 Canyon Point Lane, San Diego, CA 92126, USA
c
The Phoenix Center, Jacob Town, Paynesville, Monrovia, Liberia, West Africa

a r t i c l e i n f o abstract

Article history: Objective: a 2-year study was conducted to develop Global Standards for Midwifery Education in
Received 11 February 2011 keeping with core documents of the International Confederation of Midwives. Elements of the
Received in revised form standards were based on evidence available in the published and unpublished literature. Companion
28 March 2011
Guidelines to assist in implementing the standards were also developed.
Accepted 3 April 2011
Design: a modified Delphi survey process was conducted in two rounds following item validation by a
panel of midwifery education experts.
Keywords: Setting: a global survey conducted in 88 countries.
Midwifery education Participants: midwifery educators and clinicians associated with midwifery education located in any of
Midwifery competencies
the ICM member association countries. Additional participants included an Expert Midwifery Resource
Accreditation standards
Group, other Key Stakeholders, midwifery regulators and policy makers. A total of 241 individuals from
46 ICM member association countries and ten non-member countries responded to one or both of the
survey rounds.
Measurements: survey respondents expressed an opinion on whether to retain or to delete any of the
proposed components of the standards. Version one had 109 proposed components and version two
had 111 items for consideration.
Findings: a majority consensus of .80 was required to accept an item without further deliberation. The
Education Standards Task Force (expert panel) made final decisions in the four instances where this
level of consensus was not reached, retaining all four items. The panel also amended the wording of
selected items or added new items based on feedback received from survey respondents. The final
document contains 10 Preface items, 35 glossary terms, and 37 discrete standards with 27 sub-sections.
& 2011 Elsevier Ltd. All rights reserved.

Introduction
The 2005 World Health Report, Make every mother and child count
(WHO, 2005), focused on the strategies needed to improve the health
and well-being of childbearing women and children, especially in
resource poor nations. It addressed Millennium Development Goals
(MDGs) four (child health) and five (maternal health) (UN, 2000)
directly and reinforced what had been known for over a century,
especially in Western Europe, which is that skilled care during
pregnancy, labour and birth and the postnatal period facilitates/
contributes to positive outcomes for both mother and infant. The
report went on to state, ‘The prototype for a skilled attendant is the
n
Corresponding author.
E-mail addresses: joycethompsonllc@gmail.com (J.B. Thompson),
jfullerton@san.rr.com (J.T. Fullerton), number1juaka@yahoo.co.uk (A.J. Sawyer).
licensed midwife.’ The 2006 World Health Report, Working Together
for Health (WHO, 2006), noted that an additional 334,000 new
midwives were needed immediately to assist countries in meeting
MDG 5. The need for competent, caring midwives is very urgent to
help women and childbearing families achieve optimal health and
well-being in every corner of the world. Identifying, implementing
and scaling-up best practices in the preparation of such midwives are
a priority, if progress is to be made toward achievement of the MDGs
(UNFPA et al., 2010).
The education of midwives across the globe varies widely and
individuals using the title ‘midwife’ do not always have the
competencies needed to provide quality care for childbearing
women and newborns (Fauveau et al., 2008). The title ‘midwife’
has a long-honoured tradition. However, how that term is defined
by women, families, practitioners, governments, donors and non-
governmental organisations (NGOs) varies as widely as do the
education programs designed to prepare midwives. For example,

0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2011.04.001
410 J.B. Thompson et al. / Midwifery 27 (2011) 409–416
the authors have evaluated programs where governments have
tried to prepare ‘community midwives’ in short periods of time
using training approaches that have minimal educational content
and clinical practice requirements, and have no mechanisms for
ongoing mentoring. Other countries in the authors’ experience
have university programs that purport to prepare ‘midwives’ but
the political climate (e.g. medical students given preference for
clinical experiences or doctors not allowing midwives to attend
births) is such that these students have very limited opportunities
to work with women in clinical settings—in other words, they
have little or no supervised practical experience as a student.
Their practice base is primarily theoretical (Fullerton et al., 2010).
The authors have consulted in countries that have such a paucity
of human resources that when midwifery students go to the
clinical areas, there is no one to teach, supervise or evaluate them
as they provide care to childbearing women. Many of these
individuals complete midwifery programmes without having
had opportunity to acquire the competencies needed to save lives
or confirm that they are ready to practice independently.
The world continues to experience an annual global loss of over
340,000 childbearing women and eight million newborns (Hogan
et al., 2010), in part because of the lack of fully qualified profes-
sional midwives. Fully qualified midwives are those who have
been educated and trained to competency in the ICM Essential
Competencies for Basic Midwifery Practice (2010), are legally
recognised as autonomous health professionals, and have main-
tained their competency in practice over time. One of the primary
reasons for developing Global Standards for Midwifery Education
is to create an educational environment in which graduates
of a midwifery programme have opportunity to acquire the
competencies needed to become fully qualified. In other words,
the programme meets defined benchmarks for quality midwifery
education (ACME, 2009; ANMC, 2009; Billings and Halstead, 2009;
International Association of Medical Colleges, 2010).
The International Confederation of Midwives (ICM) is a global
federation of midwifery associations (MAs). The organisation has
had official NGO recognition by the United Nations since 1956.
The ICM envisioned for many years that it had a role in develop-
ing Global Standards for Midwifery Education and midwifery
practice. The first step in carrying out this vision was the
development of the ICM Essential Competencies for Basic Midwifery
Practice (EC) that would provide the content for any midwifery
education programme and framework for the regulatory system.
The EC were first adopted in 2002 after a five year process
through which the competency statements were developed and
in-country field testing by which the statements were affirmed
(Fullerton et al., 2003). The competencies were updated during
2009–2010 (Fullerton et al., in press). A part of this updating
process included a review of literature on competence and
competency and deriving consensus on definition of these terms
(Fullerton et al., 2011).
The World Health Organisation (WHO) also recognised the
importance of having global standards for pre-service education
of midwives and nurses in keeping with several World Health
Assembly resolutions related to strengthening midwifery and
nursing. WHO, under the direction of the Nursing & Midwifery
Human Resources for Health department, established a Task Force
on Global Standards in Nursing and Midwifery Education in 2006
in collaboration with the international nursing honour society,
Sigma Theta Tau International. There were multiple consultations
with educators and other stakeholders along with two face-to-
face meetings (Bangkok, 2006; Glasgow, 2007) to develop the
standards. These efforts resulted in the publication of Global
Standards for the Initial Education of Professional Nurses and Mid-
wives (WHO, 2009). These standards call for a minimum of a
university baccalaureate degree as the standard educational
pathway to the midwifery profession. The WHO standards docu-
ment was reviewed in detail by the ICM Education Standards Task
Force, in collaboration with WHO consultants who were part of
the ICM standards development activity.
Similar efforts to develop or to update midwifery education
standards have been carried out in many other countries and
regions (ECSACON, 2001; European Union Law, 2005; Glover,
2005; ANMC, 2009; CAM, 2010). For example during 2007, the
South-East Asia Regional Office (SEARO) of WHO convened
representatives of midwifery and nursing education institutions
to improve the quality of midwifery and nursing education in that
region, strongly recommending standards as a mechanism for
quality assurance (SEARO, 2008). Their cycle of quality improve-
ment began with accreditation/education standards as a frame-
work for quality assurance derived from audit and other
assessment activities.
The ICM determined that it would be important to comple-
ment the WHO standards document by development of standards
that addressed the variety of educational pathways through
which midwives were prepared for practice in many global
settings, rather than focus solely on university degree pro-
grammes. This work was differentiated from the WHO standards
by its focus on competency-based education. It was differentiated
from other standards for midwifery and nursing education with
its focus on midwifery only in keeping with core ICM documents,
including the International Code of Ethics for Midwives (ICM, 2008),
the Philosophy and Model of Care (ICM, 2005b) and the Essential
Competencies for Basic Midwifery Practice (ICM, 2002, 2010a), and
the key elements of quality education programmes that were
available in the published and unpublished literature. The ICM
also determined the need to develop a set of guidelines to explain
what was meant by the standard as well as suggestions to users
as to how to measure whether a standard had been met.
This article describes the two-year study that was carried out
to develop Global Standards for Midwifery Education. It incorpo-
rates a brief discussion of the process that was undertaken
concurrently to develop Companion Guidelines.
Methods
Establishment of the Education Standards Task Force
The ICM initiated the formal process of developing Global
Standards for Midwifery Education in January 2009 by appointing
two Co-Chairs (JT, AS) to lead a Task Force (TF) to carry out this
work. The Task Force worked in collaboration with the Chair (JF)
of the Task Force that was working in a parallel timeline to update
the Essential Competencies for Basic Midwifery Practice. A study
designate at ICM Headquarters and other ICM staff provided
logistical support for the project.
Ten Task Force members were selected by the Co-Chairs and
ICM Board based primarily on their expertise in midwifery
education and current practice. These members represented mid-
wives from all ICM regions and from ICM’s three official language
groups (English, French, and Spanish), the ICM Board and the ICM
Education Standing Committee. Primary responsibilities of Task
Force members included review of documents on midwifery
education and standards in their area of the world, assisting with
refinement of the content of the survey instrument, providing
feedback concerning the linguistic and cultural sensitivity of
survey items, and serving as the expert panel for making final
decisions on content and wording of the ED standards. A WHO
member was added to the Task Force in the early stages of
the project to help ensure consistency of documents between
the two organisations. The TF communicated via electronic
 J.B. Thompson et al. / Midwifery 27 (2011) 409–416 411

communication, teleconferences and two face-to-face meetings
throughout the two year project timeline.
Instrument development and validation for the Education Standards
A first draft of midwifery education standards was developed
through a search of bibliographic sources and organisational
literature related to education standards and accreditation pro-
cesses. ICM core documents and policy and position statements
(Appendix A) underpinned the draft standards. Midwifery educa-
tion standards already developed by countries or regional orga-
nisations were additional valuable resources (ECSACON, 2001;
NMC, 2004; PAHO, 2006; ACME, 2008; SEARO, 2008). Members of
the Task Force from Chile, Tunisia, and Pakistan added their
country’s standards for midwifery education to the review and
drafting process. A select group of midwives, including members
of the ICM board, the ICM Standing Committees on Education and
Research, and the ICM Regulatory Task Force, provided feedback
on the draft instrument.
A comparison of existing health professional education stan-
dards revealed common areas addressed in such standards that
were used as a beginning point in drafting the ICM standards. The
framework for the education standards was organised into six
discrete sections: (1) Organisation and Administration, (2) Mid-
wifery Faculty, (3) Student Body, (4) Curriculum, (5) Resources,
Facilities and Services, and (6) Assessment Strategies. The Task
Force agreed, based on the review of literature and feedback from
a variety of individuals, to address the items shown in Fig. 1 as the
minimum elements of the Global Standards for Midwifery Educa-
tion. This first working draft contained 109 items distributed as
follows: 32 glossary terms, 11 Preface statements including
minimum length of education programmes, 35 discrete standards,
and 31 sub-parts to the standards.
Development of the demographic tool
A demographic tool was also developed for the purpose of the
study in collaboration with the Essential Competencies survey
Team Leader. This common demographic tool allowed the infor-
mation gathered about respondents in both surveys to be cross-
referenced. The demographic tool included coding for designation
of respondents from ‘high’, ‘medium’, or ‘low’ resource country.
The Human Development index (UNDP, 2010) and World Bank
(2010) criteria were used for classification.
Development of a glossary
The Task Force identified the need to define key terms used in
the standards document in view of the multiple versions of
English spoken world-wide and how well each word would

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Fig. 1. Summary of standards content.

412 J.B. Thompson et al. / Midwifery 27 (2011) 409–416
translate into French and Spanish. Therefore a glossary of terms
was developed over the course of the project. Study respondents
provided their feedback about wording of each glossary term as
one component of the survey process.
Development of Companion Guidelines
The development process for the Guidelines was initiated
immediately following Task Force approval of the final working
version of standards. The first iteration of the Guidelines was
drafted by Task Force members. The document contained expla-
natory information that was consistent with what other organisa-
tions concerned with health professional education and
accreditation had done (International Association of Medical
Colleges, 2010; ACME, 2009; MEAC, 2010) to assist programs to
verify their compliance with standards. This development process
occurred over a 5-month period in 2010. Feedback from all
reviewers was collated and a second version prepared for a
second external review by members of the Expert Panels. Task
Force members also crafted a detailed list of the documentation
(i.e. ‘the evidence’) that Education Programmes could use to help
them determine whether they had met a given standard.
Translation and confirmation
The English survey tools were translated into French and
Spanish by ICM’s professional translation service in order to
generate linguistically and grammatically accurate versions of
the study tools. The Spanish and French translations were then
reviewed by native speakers who were members of the Task Force
in order to accommodate the use of colloquial (more familiar)
terminology. The study documents were prepared as dual lan-
guage instruments (English–French and English–Spanish) to
enhance understanding and context.
Human Subjects approval
Approval for conduct of a global survey was obtained from
Western Michigan University (USA) Human Subjects Institutional
Review Board. The approval indicated that the survey approach
was in accord with internationally accepted principles of ethical
research (Dresser, 1998, CIOMS, 2002). Voluntary completion and
return of the survey was deemed equivalent to informed consent
for participation in the research. This survey protocol also con-
formed to the principles for conduct of international research as
set forth in the ICM Guidelines for Ethical Research Collaboration
across International and Culturally Diverse Communities (ICM,
2005a; Kennedy et al., 2006).
Survey and sampling process for the Education Standards
Surveys were conducted in two discrete time periods between
August 2009 and June 2010. A modified Delphi survey process
was used in both rounds (Hsu and Sandford, 2007; Yousuf, 2007;
Sinha et al., 2011).
The surveys were distributed electronically from ICM Head-
quarters to the leaders of all ICM member associations (n ¼88 in
early 2010). These individuals were asked to forward the study
materials to midwifery educators in their respective countries.
Survey respondents were asked to indicate their opinions about
whether an item should be retained (retain) or omitted (delete)
from the Education Standards documents. Respondents were also
given the opportunity to comment or suggest alternate wording
on each item. The Task Force Chair worked with the ICM Board
members and TF members to target recruitment of volunteers
from medium and low resource countries. The anticipated sample
size for both rounds was a minimum of one response from each of
ICM’s 88 member association countries.
Survey and sampling process for the Guidelines
The draft Guidelines were sent for comment to the ICM Board,
ICM Standing Committees, ICM Regulation Task Force, and two
independent review groups, one comprised of midwives (educa-
tors and regulators), and the other comprised of education
experts from a variety of health professions with experience
teaching midwifery students. Members of the review groups were
identified through a nomination process via ICM Board and Task
Force members and confirmed by ICM leaders and Co-chairs of
the Task Force once the individuals agreed to serve.
Data entry and analysis for Education Standards
Demographic and survey data entry tools were developed using
SPSS as the data entry platform. Programming included automatic
data checks designed to reduce data entry errors. Data for the
Education Standards project were entered by a staff assistant.
Random data verifications were conducted throughout the period
of data entry (September–October 2009; June–July 2010).
Data were analysed in SPSS version 18, and then exported to
Excel for presentation and preparation of tables. The N and
proportion of responses to ‘retain’ or ‘delete’ were computed for
each survey item. These data were summarised and sent to
members of the Task Force for review and discussion. All
qualitative comments that had been submitted during the survey
were reviewed and considered.
Findings
Round one: response rate, instrument revision, and amendments to
the sampling strategy
A total of 123 usable surveys were received for the first
external round. Each survey could be completed by up to six
individuals, hence the difference in survey numbers and individual
responses. There were 150 individual respondents from 35 coun-
tries distributed among each of ICM’s four global regions (Africa,
Americas, Asia-Pacific, and Europe). A total of 26 (17%) of the 123
surveys were from Low Resource Countries (LRC) and medium
resource (i.e. economically challenged) countries (ECC). An addi-
tional three surveys were unknown (country data not provided).
The remaining surveys were from high resource countries (HRC),
mainly USA, Canada and the UK. There were 123 midwives (82%)
and 10 nurses (7%) responding, with 17 unknown (11%). There
were four French and 18 Spanish responses in Round one.
A criterion of .80 (i.e. 80% agreement among respondents) was
arbitrarily set as the cut-off score for the decision to ‘retain’ or to
‘delete’ items on the Education Standards instrument. A content
validity index value of .78 for three or more reviewers is
considered good evidence of item relevance and reviewer con-
sensus (Polit et al., 2007). The vast majority of the survey items
were affirmed as content valid. A total of six items fell below that
cut-off score in Round one.
Qualitative and quantitative findings from the Round one
survey were carefully reviewed by the TF Co-Chairs and by
members of the TF to determine how survey items should be
refined in content or wording, and whether new items should be
developed. Qualitative responses received from LRC and ECC were
given particular attention, as it was anticipated that these
countries would more likely be challenged in the attempt to
become compliant with the standards.
 J.B. Thompson et al. / Midwifery 27 (2011) 409–416
The ED survey tool was modified for the 2nd external round
based on responses to Round one and decisions by the TF
members. The revised ED standards survey included 32 glossary
terms, the same 11 items from the draft Preface, 36 discrete
standards (a new item on workforce considerations: I.6) and the
32 sub-parts (including new III.3.d on requirements for comple-
tion of the programme). The revised ED standards survey tool
contained a total of 111 items. The revised instrument was
subjected to the same translation and translation verification
procedures that were conducted for the first version of the tool.
Strategies to increase the response rate for the next survey
round from LRC and ECC areas of the world were selected in
collaboration with the ICM Board and Task Force members from
these countries. These strategies included targeted recruitment of
individuals via e-mail, or at meetings and conferences.
Round two: sample and response rate for Education Standards
The minimum target sample for Round two was established to
be 51% of MA countries (n ¼88 in early 2010), including three
countries in each of the nine regional areas represented by Board
members. The survey sample for Round two was expanded to
include other key stakeholders and multidisciplinary experts
along with targeted midwifery educators from French and Spanish-
speaking countries and educators from LRC and ECC countries.
A total of 63 surveys were received in the second survey
round. Survey respondents represented 91 individuals in 33
countries. Seventeen (52%) of those surveys were from LRC and
ECC; four unknown country responses were received and the
remaining responses were from HRC. The target of 51% of ICM
member countries was not achieved; however, the fact that 52%
of the responses that were received were from LRC and ECC
member countries was a favourable bias.
The combined response rate to the two survey rounds was 46
(unduplicated) of 88 countries (overall 52% response rate).
Responses were also received from an additional two HRC, six
LLC and two ECC countries that did not have midwifery associa-
tion membership in ICM for a total of 56 unduplicated countries.
Round two had 22 French responses and four Spanish responses.
Responses to the Guidelines
Fourteen individuals responded with useful comments and
suggestions. The final edit of the Companion Guidelines was done
by the Task Force. However, to augment the information received
from this small number of respondents a supplementary process
for solicitation of informal feedback on the Companion Guidelines
was implemented by the ICM Education Standing Committee in
early 2011. Volunteers from a number of education programmes
in 21 countries around the globe provided their opinion about the
guidelines that had been proposed for each element of the
standards. The reviewers were asked to indicate their opinion
about whether the proposed guideline should be accepted as
written, or to offer suggestions for rewording any portion of the
statement in order to improve its clarity and usefulness. The Task
Force Co-Chairs collaborated with the ICM Education Standing
Committee to craft the final version of the Companion Guidelines,
which was accomplished in spring 2011.
Demographic characteristics of respondent sample (education
surveys)
Over 80% of respondents to Round one were midwives.
Respondents to Round two included 74 midwives (81%), two
nurses (2%), two clinicians (2%), and 13 others (14%). Selected
demographic data are shown in Tables 1 and 2.
413
Table 1
Demographic profile of midwives who provided responses to Round two (item
affirmation round) of Education Standards Survey (n¼ 74).
Characteristic Mean Range
Years since entry into the profession 23.33 years 1–42
(1965–2007)
No. of years in the primary practice role of
Midwifery clinician 14.08 1–41
Classroom teacher of midwifery students 8.90 0–41
Clinical teacher of midwifery students 10 0–41
Qualitative and quantitative findings of the Education Standards
survey
The primary intended outcome of a Delphi survey is the
generation of data that reflects agreement at a given level. This
80% level of consensus was achieved during the second external
round with the exception of four items discussed below. A
secondary analysis of quantitative (survey) results and of quali-
tative comments received from respondents to the Round two
survey were reviewed by the TF Co-Chair to determine if the
country resource level made a difference in responses to these
four items. Particular attention was paid to responses from low
and middle resource country sites as these are the countries that
are more likely to need the guidance contained in the standards.
The four items that did not reach the .80 level of consensus for
retention were related to the specific time period for midwifery
education (length of programme) and midwifery experience
required of midwife teachers and midwife preceptors. The sec-
ondary analysis revealed several important distinctions.
The low and middle resource country groups supported the
proposed minimum length of direct entry programmes (three years)
at the .91 and .87 levels, respectively, whereas the HRC group had
only a .61 level of support and wanted a minimum of 4–5 years
within a baccalaureate degree programme. A similar pattern of
support from LRC (1.00) and ECC (.73) groups was noted for the
proposed 18-month minimum programme length post-nursing
although less than half (.46) of the HRC group supported this length.
The high resource country group comments favoured a minimum of
two years for a master’s degree programme suggesting that using a
university degree framework influenced the HRC responses for a
longer time frame post-nursing.
The proposed two years of clinical experience prior to teaching
midwifery in either the classroom or clinical setting demon-
strated a different pattern of responses by country resource level.
The LRC group had very high support (1.00, .91) and the HRC
group was also supportive at the .82 and .75 levels respectively.
However, the ECC group response on these items was at .60 and
.53, respectively, with comments preferring a minimum of 3–5
years experience. Given the global workforce shortages, this
higher level of clinical practice prior to teaching was deemed
impractical.
Task Force members considered this information as part of
their deliberation about disposition of these four items. After
careful review of these distinctions by country resource level, the
TF members made the final decision to retain each of the items
without amendment.
Discussion
Limitations of the study
The sample size projected for this study was ideally at
least one response from each ICM Member Association country.
414 J.B. Thompson et al. / Midwifery 27 (2011) 409–416
Table 2
Selected characteristics of midwifery education programmes (Round two; n¼35).*
Direct entry
Number countries 24/35 (69%)
Entry qualification secondary school minimum 22 of 24 direct entry programmes
n
Some countries have more than one type of midwifery education programme so the total number of programmes is more than the countries responding. Four
demographic forms were missing.
That ideal was not reached. Therefore, in consultation with the
ICM Board, the sample size was reconsidered. The revised target
was to have a simple majority of 51% of the then 88 MA countries
respond. This criterion was met when the unduplicated responses
from both survey rounds were calculated. It was also agreed that
a minimum of three countries be represented from each of the
nine regional areas represented by ICM board members. The only
region that did not meet this minimum was South and Central
Asia. It was a known fact from midwifery consultants in Laos and
other countries of the region that many of these countries either
had no midwifery education programme or active midwifery
association. For those with a midwifery association, communica-
tion channels were unreliable as often there was no central office.
Though such countries would be unlikely to be in a position to
offer substantive comment on the education standards, it would
have been preferable to hear from them.
The use of electronic communication for this study may have
favoured those countries with easy access to and familiarity with
electronic post. In many low resource countries, gaining access to
computers may have presented a challenge, further limiting the
number of responses from LRC. However, with targeted recruit-
ment of volunteers from LRC and ECC areas during Round two,
there was a marked increase in the number and percent of
respondents from these geographic settings.
Another limitation of this study was the confusion caused by
use of the same demographic tool for this and the concurrent ICM
study to update the essential competencies. Several respondents
thought they had received the same survey twice, and thus chose
not to respond to the second request for participation in an ICM
study effort. The ED survey was first in the field, so the impact of
this confusion was less on the ED study than on the essential
competencies update.
Length of direct entry programme
The length of programmes that prepare single-qualified mid-
wives (direct entry following minimum of secondary education)
varies across the world (Dower et al., 1999; ECSACON, 2001;
European Union Law, 2005; Glover, 2005; CAM, 2010; ACME,
2011). Some of the TF members were direct entry midwives and
teachers who represented the range of direct entry programmes
of 3–5 years in length. For example, the five year university
programme conducted by the University of Chile exceeds all the
basic ICM competencies and provides an additional one year of
supervised practicum following completion of all midwifery
content. As previously noted, LRC and ECC country respondents
were very supportive of the three-year minimum standard for a
direct entry programme in contrast to HRC respondents who
wanted the longer time frame. Generally speaking, comments
from HRC respondents referred to the requirement of university
degrees, such as is now the situation for direct entry in the United
States and Australia (Glover, 2005; ACNM, 2009), including both
baccalaureate and masters degrees, with inclusion of required
content about research and administration. None of the com-
ments received from the HRC group related solely to the time it
would take to meet the basic or essential competencies for
Integrated Post-nursing
5/35 (14%) 16/35 (46%)
Five of five integrated programmes 13 of 16 post-nursing programmes
midwifery practice defined by the ICM. The TF included expert
midwifery educators with experience in competency-based cur-
ricula. TF members used their own informed opinions and a
variety of sources (Chapman, 1999; Dower et al., 1999; Jones
et al., 2002; Fullerton et al., 2003; Mansfield, 2004) to determine
the time in years, given sufficient human resources and practical
learning opportunities, it would take to meet the ICM core
competencies within a competency-based curriculum of study.
This time period was used as a proxy for the minimum length of
time needed for students to acquire competency in the knowl-
edge, skills and behaviours required at entry into practice.
There were a total of 56 unduplicated countries responding to
both rounds of the survey, separated into LLC (15), ECC (12) and
HRC (29). Given that LRC and ECC groups supported this time
frame at the combined .85 level of consensus (23/27), the TF
agreed to set a minimum of three years as the standard length for
direct entry programmes. This time frame was considered to be
both practically and economically viable for low and medium
resource countries. Should other programmes choose to exceed
this time period and add additional, non-midwifery content and
practice to the curriculum, they would be supported in doing this.
Length of post-nursing or other health professional programme
The length of time needed to educate and train an individual in
the ICM core competencies, given prior professional preparation
as a nurse or other cadre of health-care practitioner, was deter-
mined in a manner similar to the time frame for direct entry.
Again the HRC respondents talked about needing more than the
proposed 18 months within the context of completing a graduate
degree in a university such as is now mandatory for graduates of
ACME accredited programmes in the US (ACNM, 2009). Some of
the TF panel of expert midwifery educators had experience in
preparing nurses as midwives, and considered their own pro-
grams when distinguishing between midwifery content that was
included in post-nursing preparation of midwives and other non-
midwifery content such as nursing theory or research methods.
Given that LRC and ECC groups supported this time frame at the
combined .81 level of consensus (22/27), the TF agreed to set 18
months as the standard for the minimum time needed to achieve
proficiency in midwifery competencies.
Prior years experience for midwife teacher and preceptors
The length of midwifery practice prior to taking on the role of
midwifery teacher for theoretical content or clinical teaching
revealed a different variance among countries at various resource
levels. The number of years in full time clinical practice was used
in this survey as a measureable proxy for gaining and maintaining
competency in practice (Fullerton et al., 2011). ECC respondents
were in disagreement with LLC and HRC respondents, primarily
because they wanted more than three years (range
3–5) of midwifery practice before taking on either of these roles.
This amount of time was deemed impractical by the Task Force
from an economic and resource perspective. Review of the LRC
responses noted 100% agreement with the time frame with
 J.B. Thompson et al. / Midwifery 27 (2011) 409–416
comments related to shortages of midwife teachers, a high
volume of patients needing midwifery care in such countries,
and not wanting to raise the number of years of experience
required. When the LRC and HRC responses were combined, there
was 87% consensus that exceeded the cut-off point of 80% for
retaining the item. Thus the TF decided to set the proposed two
years as a minimum standard with explanation of the need for full
scope practice and evidence of competency written into the
Companion Guidelines.
In summary, it was high resource countries that were at
variance with the LRC and ECC related to the length of a
midwifery programme by type whereas the ECC were at variance
with the LRC and HRC in length of clinical experience for
midwifery teachers and preceptors. The Task Force decision to
retain all four items as standard was final.
Conclusion
The Global Standards for Midwifery Education 2010 (ICM, 2010b)
were approved by the ICM Board in December 2010. The package
of documents include a Glossary of terms included in the
standards, a Preface, and the Standards themselves for a total of
109 items. There are 35 glossary terms, 10 key items included in
the Preface, and 37 discrete standards organised in six content
areas, with 27 sub-parts. The Guidelines are a living document
and continue to be field tested in a variety of countries and at
relevant global meetings. These documents are available on the
ICM website at: www.internationalmidwives.org.
The ICM has two additional resources available to countries
who wish to use these Education Standards. The first are the
ICM/UNFPA regional and country midwife advisers who are
working to raise awareness and strengthen midwifery skills and
services in low resource countries in Sub-Saharan Africa, Asia, and
Latin America. In collaboration with UNFPA this team is available
to review and assist countries and regions with the development
and/or strengthening of midwifery education, regulation, and
building midwifery association capacity to advocate for healthy
women and infants. The second ICM resource available to all
countries is the ICM Education Standing Committee, an expert
international group of experienced midwifery educators who can
be asked to provide clarification about the Education Standards
and their use or suggest individuals in a particular region or
country who might be available to consult with a given education
programme. Both resources can be contacted through ICM head-
quarters in The Hague.
Acknowledgement
We are grateful for the assistance of ICM Staff Members,
Agneta Bridges, MSc, RM, Nester Moyo, MScN, SCNM, and
Dympna Byrne, BA, PGD; and the members of the Task Force:
Hilda Bonilla G., MPH, BMidw., Ellen Mbweza Chirwa, PhD,
MRNM, Kyllike Christensson, PhD, RN, RM, Atf Gherissi, PhD,
CM, Mary Higgins, MComm, RM, Rafat Jan, PhD, RN, RM, Karyn J.
Kaufman, DrPH, Ans G. Luyben, PhD, RM, Bente Silversten, MSN,
RN, Nester T. Moyo, MScN, SCNM, Sally K. Tracy, DMid, MA,
RM, RCON.
Appendix A. ICM position statements used in development of
education standards
 Basic and On-going Education for Midwives (2008).
 Collaboration and Partnership for Healthy Women (2008).
415
 Ethical Recruitment of Midwives (2008).
 Heritage and Culture in Childbearing (2005).
 Keeping Birth Normal (2008).
 Legislation Governing Midwifery Practice (2008).
 Midwifery Care for Women with Complicated Births (2008).
 Professional Accountability of the Midwife (2008).
 Qualifications and Competencies of Midwifery Teachers
(2008).
 Role of the Midwife in Research (2008).
ICM Position Statements available from: www.international
midwives.org.
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