ROLE AND SCOPE OF MIDWIFERY PRACTICE INDEPENDENT NURSE MIDWIFERY PRACTITIONER - Obstetric & Gynaecological Nursing

1. ROLE AND SCOPE OF
MIDWIFERY PRACTICE
INDEPENDENT NURSE
MIDWIFERY
PRACTITIONER
SUBMITTED BY: -
TANU SHEKHAWAT
MSc. (N) 1st year
COLLEGE OFNURSING
AIIMS JODHPUR

2. INTRODUCTION
Midwifery is an approach to care of women and their newborn
infants whereby midwives:
 optimise the normal biological, psychological, social and
cultural processes of childbirth and early life of the newborn;
work in partnership with women, respecting the individual
circumstances and views of each woman;

3.  Promote women's personal capabilities to care for themselves
and their families;
 Collaborate with midwives and other health professionals as
necessary to provide holistic care that meets each woman's
individual needs.
CONT..

4. Midwife as: “a person who has successfully completed a midwifery education
programme that is duly recognized in the country where it is located and that is
based on the International Confederation of Midwives (ICM) Essential
Competencies for basic midwifery practice and the framework of the ICM
Global Standards for Midwifery Education; has acquired the requisite
qualifications to be registered and/or legally licensed to practice midwifery and
use the title ‘midwife’ and who demonstrates competency in the practice of
midwifery. (ICM)
DEFINITION OF A MIDWIFE

5. NURSE PRACTITIONER MIDWIFE
An NPM is one who has successfully completed the 18 months' Nurse Practitioner in
Midwifery training program designed by the Indian Nursing Council (INC) based on
the ICM essential competencies for basic midwifery practice and recognized in India by
the Ministry of Health and Family Welfare, Government of India, and who will be
registered and licensed to practice midwifery in high caseload facilities across the
country under the title ‘Nurse Practitioner Midwife', upon demonstrating competency in
the practice of midwifery.

6. WOMAN, BABY AND
FAMILY-CENTREDNESS
CORE VALUES
The core values provide a foundation to develop midwives who are committed to promoting a
positive childbirth experience for all women and were derived from core government (WHO
and ICM documents )
COMPASSION
MORAL
COURAGE
TEAM
WORK
ETHICAL
PRACTICE
EQUITY
& RIGHTS
RESPECT
CORE
VALUES

7. • The State of the World’s Midwifery Report 2014, which examined the midwifery workforce
data across 73 low- and middle-income countries, calls for urgent investment in high-quality
midwifery care.
• A Cochrane Review on “Midwife-led continuity models vs other models of care for
childbearing women” (2016) provides evidence that midwife-led continuity of care can
result in a 24% reduction in pre-term birth, a significant reduction in episiotomy,
instrumental birth or use of pain relief while increasing psychological support for women
WHY DOES INDIA NEED MIDWIFERY?

8. • A post basic course, known as the Nurse Practitioner in Midwifery (NPM) course,
was instituted by the Indian Nursing Council (INC).
• In 2000-2003, with support from the ‘India – Australia Training and Capacity
Building Project’, a curriculum for the NPM was prepared, with the aim to provide
nurses with advance knowledge, skills and attitudes which -allow them to become
safe and competent NPMs.
• Duration of the course was 18 months (including 6 months internship)
HISTORY OF MIDWIFERY IN INDIA

9. • This initiative was pilot tested in the State of West Bengal. Two batches of training
were conducted and 12 candidates who passed out of this course were posted as
NPMs and were offered a remuneration equivalent to that of Assistant Nursing
Superintendent.
• The “Inter-Institutional Collaboration between Institutions in India and Sweden for
Improving Midwifery and Emergency Obstetric Care (EmOC) Services in India”
project 2007-13 was carried out by collaboration between State governments, IIM-
A, SOMI, TNAI, ANS, WRAI supported by the Swedish International Development
Agency (SIDA), the Karolinska Institute, and the Swedish Midwifery Association.
Cont.

10.  Access to a midwife 24 hours a day, 7 days a week
 Two midwives available alternatively and provide women centered antenatal,
postnatal midwifery care.
 Antenatal care in privacy
 Continuity of care through out labour
 Post natal care up to 6 weeks
 Knowledgeable breast feeding support
MIDWIFERY PRACTICE PACKAGE FOR
INDEPENDENT PRACTICE

11. CHALLENGES IN ESTABLISHMENT
MIDWIFERY PROGRAMME IN INDIA
Role Clarity of
NPM and their
Integration into the
Existing Heath
System:
Career
Progression
of
NPMs
Lack of Legal
and
Regulatory
Framework
Training
of
Midwives

12.  The NPM is a registered nurse-midwife with an additional 18 months of post basic
training in midwifery.
 Generally, ‘in service’ candidates who are GNMs/BSc level staff nurses with 2 years of
experience in maternity care are eligible for 18 months NPM training.
 The education and training of NPMs must be carried out at accredited NPM Training
Institutes recognized by INC. Training must be skill based and should be in accordance to
the ‘Essential Competencies for Midwifery Practice (2018 Update)’ defined by
International Confederation of Midwives for a total duration of 18 months
WHO WOULD BE A NURSE PRACTITIONER
IN MIDWIFERY IN INDIA

13. ROLE OF MIDWIFERY PRACTICE
Caregiver Coordinator Leader
Communicato
r
Manager Educator Counsellor
Family
Planner
Adviser
Record
Keeper Supervisor

14. • CAREGIVER: provide high quality antenatal and postnatal care to maximize the
women's health during and after pregnancy, detect problems early and manage or
refer for any complications.
• COORDINATOR: coordinate care for all women. Coordinator ensures holistic,
voluntary and social services for pregnant women when appropriate so that every
woman's birth experience regardless of risk factor.
• LEADER: to plan, provide and review a women's care, from the initial antenatal
assessment through to the postnatal period. Midwife's leading role results in
significantly less intervention during birth.
CONT..

15.  COMMUNICATOR: As a communicator, the midwives understand that
effectiveness of communication. It helps to develop trust relationships with
pregnant women and family members.
 MANAGER: Manager is a great role for midwife. Midwives manage all the
circumstances where appropriate and can recognize and refer women to
obstetricians and other specialists in a timely when necessary.
 EDUCATOR: As an educator, midwives provide high quality, culturally sensitive
health education in order to promote healthy. helpful family life and positive
parenting.
CONT..

16.  COUNSELLOR: Midwives provide information and counsel to pregnant women
on prenatal self-care including nutrition, hygiene, breastfeeding and danger sings
in pregnancy and childbirth.
 FAMILY PLANNER: They also counsel people as a family planner. They
provide all information about all kinds of family planning methods and help
couples to make decision.
 A:DVISER Midwives give advice on development of birth plan and promote the
concept of birth preparedness. They also give advice during complicated situations
so that it will help them to take decisions.

CONT..

17.  Record Keeper: Record keeping is an integral part of midwifery practice. It
helps making continuity of care easier and enables identifying problems in
earlier stage.
 Supervisor: Supervising and assisting mothers during antenatal period,
monitoring the condition of the fetus and using their knowledge to identify
early sings complication.
CONT..

18. ICM ESSENTIAL COMPETENCY
The ICM (2019) competencies standards for midwifery practice and Council's
practice are grouped under four main categories. They are:
(1) general competencies that apply to all aspects of midwifery practice and specific
competencies that are specific to
(2) pre-pregnancy and antenatal
(3) labour and birth
(4) ongoing care of woman and newborn.

19. SCOPE OF PRACTICE
The Scope of Practice of a Midwife is combined with the ICM definition (ICM 2019)
and sets out the boundaries of a midwife's practice as adapted for NPM in India and is
as follows:

20. A. PRE-PREGNANCY CARE
(SEXUAL AND REPRODUCTIVE HEALTH)
• Provide Family planning counselling and services
• Provide Pre-conception care and counselling
• Perform measures in prevention and screening for Sexually Transmitted
Infections and advice treatment based on the syndromic management
approach

21. • Determine health status of pregnant women
• Detect and confirm pregnancy, estimate gestational age from history, physical
examination and advice on laboratory test from the recommended list of investigations
• Monitor the progression of pregnancy
• Assess fetal and maternal wellbeing
• Promote and support healthy behaviors that improve women's wellbeing including
ANC exercises.
• Detect, manage, and refer women with complicated pregnancies
B. ANTENATAL CARE

22. • Provide counselling to the women and their family on the following:
o Preparation of birth preparedness and complication readiness plan
o Antenatal education and anticipatory guidance related to pregnancy, birth,
breastfeeding, parenthood, postpartum family planning and change in the
family.
o Self-care in normal pregnancy at every contact
o Pregnancy options and care to women with unintended or mistimed pregnancy
o Safe abortion services and post abortion care to women
o Post-partum & Post- abortal Family Planning Methods
CONT..

23. • Confirm onset of labour
• Provide supportive respectful care to all women in normal labour at term and in
immediate postnatal period
• Identify complications during labour, childbirth and the immediate postpartum period,
and provide immediate management3 and referral when indicated
• Assist physiological birthing processes leading to a safe birth and active management of
the third stage of labour for the prevention of postpartum haemorrhage
C. CARE DURING LABOUR AND BIRTH
(INTRAPARTUM CARE)

24. • Provide immediate essential newborn care (warmth, early initiation of breastfeeding,
delayed cord clamping, Vitamin K, eye and cord care)
• Perform neonatal resuscitation when indicated
• Identify newborn complications, perform immediate management and when
indicated, initiate a timely referral
• Perform and repair episiotomy for evidence based indications with the woman’s
consent
• Repair perineal, vaginal and vulval lacerations (excluding 3rd /4th degree or
complicated tears)
CONT..

25. D.ONGOINGCAREOFWOMENANDNEWBORNS
(POSTPARTUMCARE)
• Provide postnatal care which focuses on continuing health assessment of women and
infant.
• Support maternal and infant bonding and healthy child-rearing
• Counsel on postpartum family planning services
• Provide anticipatory guidance to the woman and her family on prompt recognition of
danger signs in both the mother and baby and seek immediate care

26. SUMMARY
The role of an independent nurse midwifery practitioner encompasses a wide
range of responsibilities within maternal and reproductive health. These
professionals are trained to provide holistic care to women throughout
pregnancy, childbirth, and postpartum periods. They offer a combination of
medical expertise and emotional support, emphasizing the importance of a
personalized and patient-centered approach.

27. CONCLUSION
In conclusion, independent nurse midwifery practitioners play a crucial role in
promoting positive maternal and neonatal outcomes. Their scope of practice
involves not only clinical skills but also strong interpersonal abilities. By
facilitating a supportive and empowering environment, they contribute
significantly to the well-being of expectant mothers and their families,
embodying the essence of comprehensive and compassionate midwifery care.

28. RELATED ARTICLE
Advancing Quality And Safety Of Perinatal Services In India:
Opportunities For Effective Midwifery Integration
● AUTHOR: Saraswathi Vedam, Reena Titoria, Paulomi Niles, Kathrin
Stoll, Vishwajeet Kumar, Dinesh Baswal, Kaveri Mayra, Inderjeet Kaur,
and Pandora Hardtman
● Published online 2022 Apr 16
● DOI: 10.1093/heapol/czac032

29. ABSTRACT
India has made significant progress in improving maternal and child health. However, there are persistent disparities in
maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-
based violence are common and reduce women’s sense of safety. Recently, the Government of India committed to
establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the
current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and
improve resource allocation, ultimately improving maternal–newborn outcomes. To synthesize the evidence on
effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory
documents describing models of practice, organization of health services and lessons learned from other countries. We
also interviewed key informants in India who described the current state of the healthcare system, opportunities, and
anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical
framework, we triangulated the findings from the desk review with interview data to identify levers for change and
recommendations. Findings from the desk review highlight those benefits of midwifery on outcomes and experience
link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to
successful integration. Interviews with key informants affirm the importance of meeting global standards for practice,
education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of
respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre.
Domains needing attention include building professional identity; creating a robust, sustainable education system;
addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and
professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice
environments will be key to successful integration of midwives in India.

30. CONT..
KEYWORDS: Health services, integration, national health service, policy
implementation, pregnancy, nurse practitioners, mothers, maternity
services, community health
KEY MESSAGES:
 There are a number of opportunities and threats to integration of
midwives in India, including regulatory and educational structures; role,
scope and models of practice; inter-professional and public acceptance
and enabling practice environments.
 Gender issues and marginalization impact the delivery and organization
of health care in India—for both maternity service users and health
professionals—and could destabilize the new midwifery cadre.

31. CONT..
● Expansion of training in human rights, respectful maternity care and inter-
professional communication for midwives, educators and other health
professionals who work alongside midwives will be essential to effective
integration.
● A set of recommendations are presented to ensure that the well-being and
sustainability of a new midwifery workforce are secured, along with
considerations for equity in roles, compensation and leadership.

32. BIBLIOGRAPHY
● Annamma J. A Comprehensive Textbook of Midwifery & Gynaecological
Nursing.5th edition. New Delhi: Jaypee Brothers Medical Publisher (P)
Ltd; 2015.
● Kaur S. Textbook of Midwifery and Gynaecological Nursing for GNM
Nursing Students.2nd edition. New Delhi: CBS Publishers & Distributors
Pvt Ltd, India;2022.
● Scope Of Practice For Midwifery Educator & Nurse Practitioner Midwife
Ministry of Health & Family Welfare Government of India [Internet].
2021 [cited 2023 Nov 26].Available
From:https://www.indiannursingcouncil.org/uploads/pdf/16261595601759
27057460ed39c8888fe.pdf

33. CONT..
● Guidelines on MIDWIFERY SERVICES IN INDIA 2018 [Internet]. Available
from:https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/
MH/Guidelines/Guidelines_on_Midwifery_Services_in_India.pdf
● World Health Organisation. Midwifery education and care [Internet]. World
Health Organization. 2022. Available from:
https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-
ageing/maternal-health/midwifery
● Vedam S, Titoria R, Niles P, et al. Advancing quality and safety of perinatal
services in India: opportunities for effective midwifery integration. Health
Policy Plan. 2022;37(8):1042-1063. doi:10.1093/heapol/czac032.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9469892/

34. THANK
YOU