Exploring global recognition of quality midwifery education: Vision or fiction?

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Discussions

Exploring global recognition of quality midwifery education: Vision or fiction? Ans Luybena,b,* , Mary Bargerc , Melissa Averyd, Kuldip Kaur Bharje, Rhona O’Connellf , Valerie Flemingg , Joyce Thompsonh , Della Sherratti a

Department of Health Services Research, University of Liverpool, Waterhouse Blds, Block B, 1-5 Brownlow Street, Liverpool L69 3GL, England, UK Centre for Midwifery, Maternal and Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth House, 19, Christchurch Road, Bournemouth, BU1 3LH, England, UK c School of Nursing, University of San Diego, San Diego, CA, USA d School of Nursing, University of Minnesota, Minneapolis, MN, USA e School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, England, UK f School of Nursing and Midwifery, University College Cork, Cork, Ireland g Institute of Midwifery, School of Health Professions, Zürich University of Applied Sciences ZHAW, Zürich, Switzerland h Independent Consultant, Michigan, USA i Independent Consultant, Bristol, England, UK b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 13 October 2016 Received in revised form 9 January 2017 Accepted 3 March 2017 Available online xxx

Background: Midwifery education is the foundation for preparing competent midwives to provide a high standard of safe, evidence-based care for women and their newborns. Global competencies and standards for midwifery education have been defined as benchmarks for establishing quality midwifery education and practice worldwide. However, wide variations in type and nature of midwifery education programs exist. Aim: To explore and discuss the opportunities and challenges of a global quality assurance process as a strategy to promote quality midwifery education. Discussion: Accreditation and recognition as two examples of quality assurance processes in education are discussed. A global recognition process, with its opportunities and challenges, is explored from the perspective of four illustrative case studies from Ireland, Kosovo, Latin America and Bangladesh. The discussion highlights that the establishment of a global recognition process may assist in promoting quality of midwifery education programs world-wide, but cannot take the place of formal national accreditation. In addition, a recognition process will not be feasible for many institutions without additional resources, such as financial support or competent evaluators. In order to achieve quality midwifery education through a global recognition process the authors present 5 Essential Challenges for Quality Midwifery Education. Conclusion: Quality midwifery education is vital for establishing a competent workforce, and improving maternal and newborn health. Defining a global recognition process could be instrumental in moving toward this goal, but dealing with the identified challenges will be essential. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Keywords: Maternal and newborn health Scaling up health care workforce Midwifery education Recognition process

Statement of significance * Corresponding author at: Department of Health Services Research, University of Liverpool, Waterhouse Blds, Block B, 1-5 Brownlow Street, Liverpool L69 3GL, England, UK. E-mail addresses: [email protected], [email protected] (A. Luyben), [email protected] (M. Barger), [email protected] (M. Avery), [email protected] (K.K. Bharj), [email protected] (R. O’Connell), fl[email protected] (V. Fleming), [email protected] (J. Thompson), [email protected] (D. Sherratt).

Problem There is an urgent need for an increase in both the number and the quality of midwives to meet the increasing global demands to reduce maternal and neonatal mortality and morbidity rates worldwide.

http://dx.doi.org/10.1016/j.wombi.2017.03.001 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

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What is already known Wide variations exist in the type and nature of midwifery education programs. Evidence-based competencies and global standards for midwifery education have been developed to be used as benchmarks for establishing quality midwifery education and practice but are only advisory. What this paper adds This paper discusses accreditation versus recognition as quality assurance processes to improve midwifery education quality. A global recognition process is suggested as an appropriate strategy. The real challenges and opportunities for such a strategy are explored with illustrative cases from very different country contexts. Specific challenges to consider in developing a global recognition program are presented.

1. Introduction Competent midwives make a difference to the lives of women and newborns.21,35,39 An extensive body of evidence shows that midwifery practice has contributed to significant reductions in maternal and infant mortality, and midwives are viewed to be essential in achieving high quality maternal and neonatal care in all settings in all countries.39 Midwives played a key role towards the achievement of the Millennium Development Goals, and their involvement will be essential in achieving targets for further reductions in maternal and neonatal morbidity in the next decade, as defined in the Sustainable Development Goals (SDGs).40 Midwifery education is the foundation for equipping midwives with appropriate competencies to provide a high standard of safe, evidence-based care for women.42 With the aim of strengthening midwifery and scaling up its workforce, the International Confederation of Midwives (ICM) defined evidenced-based Essential Competencies and Global Standards for Midwifery Education17,37,24–26 to be used as benchmarks for establishing quality midwifery education and practice worldwide. Once these Standards were established, the logical next step asked by international organizations committed to promoting maternal and child health was, “How can we promote the acceptance and use of these international standards in all countries, and make them a global reality?” 1.1. The need for quality midwifery education Among the 140 million births annually,39 303,000 women die during pregnancy, childbirth or the postnatal period, and 2.7 million newborns die in the first month of life. In pursuit of Millennium Development Goal 5, the maternal mortality ratio (MMR) fell by nearly 44% although the magnitude of the reduction differed substantially among regions.46 The recent Lancet Series on Midwifery highlighted the contribution of midwifery to these improvements in MMR and neonatal mortality ratio (NMR).23,36,35,21,22 Subsequently, the authors provided a framework for the development of a competent midwifery workforce sufficiently large to meet the estimates in the State of the Worlds’ Midwifery reports.38,39 Based on the framework, the authors contended that midwifery services should be a core part of maternal and newborn health services, and emphasized the need for an increase in both the number and the quality of midwives to meet the increasing global demands. Quality midwifery education was viewed as essential to meet this goal.

Midwifery education should result in a competent midwifery workforce that meets the needs of women and their families world-wide.35,21,5 However, only four of the 73 countries that account for over 90% of the global burden of both maternal and neonatal deaths have enough competent midwives to meet the needs of the population.39 In six sections of standards for organization and administration of an educational program, the Global Standards for Midwifery Education (hereafter ICM Standards)37,25 outline quality criteria for processes that should be in place for midwifery faculty, admission of and responsibilities to students, the content of curriculum, and adequate required resources, facilities, and other services. The Essential Competencies for Basic Midwifery Practice17,25 define the outcome of the program, while competency-based education was identified as a key foundation for the provision of quality midwifery education. Concurrent with the development of these standards, the WHO defined Global Standards for the Initial Education of Professional Nurses and Midwives44 and Midwifery Educator Core Competencies45 which reinforced the efforts in this field. Together, these policy documents provide a framework for guiding the development and establishment of quality midwifery education programs worldwide. Against the background of this framework, Harris and Bharj19 carried out a survey to obtain an overview of the current status of midwifery education programs world-wide. Wide variations in type and nature of education programs were identified, including the duration of midwifery programs (for example from six months to four years), range of routes into initial midwifery education (for example direct entry or following a health professional qualification), and the ratio of theory versus placement learning component (for example a ratio of 40:60 or 60:40). The consequences of inconsistent application of the ICM Standards are that newly qualified midwives may not have the knowledge, skills and attitudes/behaviours needed to provide the scope and quality of care required. In addition, national midwifery practice culture appeared to largely influence programs. For example, if working in a birthing unit is considered the most important focus of midwifery, prenatal and family planning services may be given less attention in an education curriculum. In order to reduce these inequalities, some international organizations suggested taking further steps, and called for exploring a global quality assurance process for midwifery education.6 1.2. Strategies to assure quality education Systematic methods for evaluating education processes and the student’s competencies articulated by the educational process are recognized methods for improving both educational and care standards. These kinds of quality assurance processes generally have two forms: accreditation or recognition of programs. Accreditation is understood as a formalized process by which an institution or program of study is evaluated on whether it meets minimal standards for preparing students with designated competencies by the time of graduation. An accreditation body is an organization delegated to make decisions on behalf of the education sector, about the status, legitimacy, or appropriateness of an institution or program. In some countries, accreditation is a governmental function, which opens the process to political influence. In other countries, it is carried out by non-governmental agencies, which themselves may need to be accredited as accrediting organizations by the government. In general, the accreditation body has an authoritative mandate, with independence both from governments and from providers who have a vested interest in the outcome.27 The accreditation process requires a high level of transparency, with pre-identified general

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and specific criteria for program review, use of an external review process, and use of both self-evaluation and validation site visits for program information. The requirements for accreditation of specific health education programs vary by country. In some countries, such as the United States (U.S.), healthcare providers cannot take the compulsory licensing and certification examinations if they have not graduated from an accredited educational program. Therefore, accreditation becomes a de facto requirement to practice.27 Rarely does accreditation cross international borders. This means that graduates of accredited programs may vary widely in their competencies, and migration of providers among countries can be limited. Exceptions to this, however, are (for example) the European Union12 , and the Association of Veterinary Medicine Association Council on Education, which accredits veterinary medical programs for any program that applies, in multiple countries.3 Since the exact same standards are used, they have been able to negotiate practice reciprocity for graduates of European accredited program to practice in Canada or the U.S. Recognition programs and their processes are not as welldefined. In practice, however, it can be difficult to distinguish the processes of high-quality recognition programs from the processes of high-quality accreditation. The real difference between accreditation and recognition exists in the consequences of the process. Accrediting bodies set a minimum standard, and if programs consistently fall below that standard, they will not be allowed to continue to function. By contrast, recognition bodies typically have no enforcement or penalising power. They tend to express standards that are considered to be above the minimum necessary for continuing practice. Their influence is informal, meaning that programs that are recognized may be able to advertise this fact to stakeholders. The value of recognition programs, such as the Baby Friendly Hospital Initiative (BFHI), appears to be their potential for stimulating quality development within individual hospitals and birth centers. Those recognized institutions are able to demonstrate a commitment to greater excellence and standards and the recognition program can gain a foothold in communities of providers, and become more widely adopted. Potentially, they can

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provide a way for programs and providers who have the desire and the ability to ‘do a little more’ to be rewarded for their efforts, which could motivate even more of the group to the higher standards. However, programs must be able to see a practical benefit within the existing system of payments and other reinforcements. In this current article therefore, based on the arguments above, the authors preferred to use the term recognition, rather than accreditation, while discussing a global quality assurance program for midwifery education. In a recent study, members of the ICM Education Standing Committee globally surveyed midwifery educators to determine if there was a perceived need for a program that recognizes individual midwifery education programs that meet the ICM Standards, including the full set of Essential Competencies.4 An additional aim was to identify potential barriers to completing such a program. Four questions with three additional clarification questions were asked of midwifery educators worldwide through several electronic Listservs. Educators from 52 countries and three ICM regions (Americas, Asia-Pacific, and Europe) responded. The survey was available in French, Spanish and English. Overall, 79% of respondents were favorable about a global recognition process, preferring onsite verification. However, 80% identified the need for additional resources, such as time allowed to prepare a self- assessment report, financial support, electronic capacity and expert consultation. In addition, in the next section the need and feasibility of such a global recognition process are explored from the perspective of four case studies. They illustrate the situation of midwifery education programs in four different global areas chosen for their diverse economic and cultural contexts. Furthermore, the case studies represent different stages of program development, with opportunities and challenges, and also highlight the diverse needs for a potential accreditation or recognition process. 2. Four illustrative case studies Case studies are presented from Ireland, Kosovo, Latin America and Bangladesh (Fig. 1). Except for the Irish case, all present

Fig. 1. The regions respectively countries that the exemplar case studies on midwifery education address and report on.

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projects aimed at assuring a quality midwifery education program. International governments and organizations, such as the United Nations Populations Fund (UNFPA), facilitated the projects, with the intention to improve the midwifery workforce in that region. International midwifery consultants (three authors of this article; VF, JT, DS) facilitated, supported or led the projects, and collaborated with the teams at the place of implementation. They were asked to describe the project outline, and consider the need, the feasibility and the added value of a professional recognition process in this particular situation. Their stories are presented in boxes one to four with commentary below. In the first case study (Box 1), Ireland presents an example of midwifery education common in many high-resource countries. For more than a century, midwifery education and practice have been strongly regulated by a governmental professional board based on Irish national policies. Like all members of the European Union (EU), since the 1980s Irish midwifery education programs also must meet the requirements of the EU Directives (EU 2013/55/EC) for their profession. These requirements are incorporated into the national standards for accreditation of midwifery education programs. The advantage of meeting EU Directives is to ensure cross-border mobility of midwives throughout the EU. ICM core documents, such as the Standards, inform both Irish and EU standards for midwifery; therefore there is no need for additional accreditation. However, Irish midwifery education programs may be interested in a recognition process. Such a process could emphasize the importance of a midwifery education program in this particular country context, against an increasingly dominant nursing and medical landscape, both in Ireland and the EU, improving midwifery’s autonomy and visibility. Therefore, particular midwifery programs in Ireland would likely not only be able to gather necessary resources for completing a recognition

process, and may also then have the capacity to assist in recognition processes in other countries. The second case study (Box 2) presents a project in Kosovo, a small landlocked country in Eastern Europe, aiming to develop a direct-entry midwifery education program. This project aim was to establish a competent midwifery workforce, in order to assist in reducing the high maternal and infant mortality rates in Kosovo at that time. This case study illustrates the development of a midwifery education program based on international standards, such the EU Directives, World Health Organization (WHO) recommendations, and the ICM Standards. The case also highlights the use of consultants to establish the program: a team of experienced educators supervised the program development on location over more than three years. Similar to other European countries, in Kosovo, a governmental accreditation agency as well as the university itself ensure the quality of midwifery education. A need for additional accreditation does not exist, whereas the benefit of taking part in a global recognition process is unclear. If Kosovo midwives would opt for such as process, additional international resources would be required. This case highlights the possibility that building quality midwifery education also creates a risk of losing this competent workforce to other countries and thus, not improving women’s and newborns’ health locally in the country. The third case study (Box 3) highlights the strengthening of midwifery education in the Latin American and Caribbean (LAC) region; not only by developing high-quality new midwifery education programs, but also by improving the quality of existing programs. The project is based on a collaborative partnership between ICM and UNFPA-LAC, and involved a consultant approach. Furthermore, the project is built on principles of multiplication of information and experiences through direct stakeholders and political involvement and participation, as advocated for in the K4

Box 1. Case study 1: strengthening midwifery education in Ireland Throughout the 20th century, Irish midwives struggled for recognition due to the risk of being subsumed under nursing.20 The strength of European midwifery was an important support to the profession in Ireland, in particular the support of the European Midwives Association (EMA) and the ICM. Since the 1998 report by the Commission on Nursing,11 midwives are now recognized as a distinct profession from nursing, enacted under the Nurses and Midwives Act 2011. Midwives have been registered, ever since the introduction of statutory regulation of midwives in 1918. Initially with the Central Midwives Board, from the 1950’s with An Bord Altranais (the Nursing Board) and now the Nursing and Midwifery Board of Ireland (NMBI). Regulation of midwives in the European Union (EU) is addressed under the EU Directives on Midwifery. These directives aim to ensure cross-border mobility of health care professionals throughout the EU. Currently midwives educated and registered in Ireland can seek registration in non EU countries such as Canada, Australia and New Zealand. In 1998, midwifery education programs were transferred to the Higher Education Sector and in 2006, direct entry midwifery education was reinstated as a four year Bachelor of Science (BSc) Midwifery. Educators were required to achieve Master of Science (MSc) level education and since this time have obtained their Doctor of Philosophy (PhD) which is now the standard for employment in the university sector. Within the university setting, midwifery education programs run alongside nursing programs with some areas of shared learning. The move to higher level education has benefited the profession with an increasing number of midwives obtaining an MSc or PhD in midwifery and engaging with research and issues related to practice development. The recently published Maternity Strategy10 has challenged the current provision of maternity care services identifying a need for more community midwifery services, including homebirth services. For the first time, women are identified as the centre of the service care model with women’s choice as core strategy for meeting this vision. Midwives will be required to take the lead in the implementation of the strategy. The NMBI has responsibility for the approval of midwifery education programs and their associated maternity care institutions. To be accredited by the NMBI, each program must submit curriculum documentation including a self-assessment of compliance with program standards. Annual reports are submitted and site visits are made every five years. The NMBI produces standards for the approval of education programs leading to registration.31 Midwifery values are based on Practice Standards for Midwives32 and Scope of Midwifery Practice.33 As Ireland is a full member of the EU, midwifery programs meet EU requirements for Midwifery Education.12 The ICM core documents such as the definition of the midwife and the essential competencies inform these documents.

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Box 2. Case study 2: developing a midwifery education program in Kosovo Kosovo (Eastern Europe) was part of the Republic of Yugoslavia until the early 1990s. In 1999, increasing oppressive Serbian dominance resulted in war. The subsequent United Nations brokered peace agreement resulted in Kosovo obtaining status as an independent nation, which allowed for many health developments, including making maternal and child health (MCH) a high priority. Kosovo faced many health challenges, including a 3.4% infant mortality rate.8 Unfortunately, Kosovo’s education system failed to prepare students for modern midwifery practice, vital for improving MCH. Kosovo’s Chief Nurse identified the crucial need for midwives to be educated in a system that met EU standards9,30 The European Agency for Reconstruction awarded a contract to Glasgow Caledonian University (GCU) (UK) to help establish the required midwifery education program. The Bachelor’s program led by GCU was hosted by the University of Pristina. After much negotiation with the Ministries of Education and Health, the program commenced in 2003 with 20 midwifery students. It adhered to EU legislation13,14 which requires a minimum of 2300 theory hours and 2300 practice hours in programs leading to the qualification of midwife (World Health Organisation (Europe))43 Although recommendations for essential competencies for midwives were incorporated into the curriculum, it also reflected Kosovo’s specific culture, including its history, societal needs, and health structure. GCU evaluation processes for the program were used, since the University of Pristina had not established its own procedures at that point. The three- year- program was modular, with some modules in the first 18 months shared with nursing students. Year three was heavily weighted towards clinical practice. There sometimes appeared to be a lack of understanding by students of the importance of the clinical practice hours, as they were repeatedly absent from clinical assignments, requiring an extension of their program time to meet EU criteria. Despite some of these initial difficulties, students were successful in demonstrating their theoretical and clinical competence, which was assessed using examinations comprising case studies and clinical oral examinations based on scenarios,15 as well as a demonstration of the International Confederation of Midwives’ Essential Competencies (2003). This program fulfilled its aims and has become a regular offering at University of Pristina. Two obstacles to the employment of the graduates existed. First, the historical tradition that all graduates must complete a period of unpaid internship in clinical practice,34 and was a requirement to consolidate medical secondary school training, was insisted on. Secondly, due to cutbacks by the Ministry of Health, there were a lack of positions for new graduate midwives. Thus, nine of the initial graduates chose to move elsewhere in Europe, where their qualifications were immediately recognized, depriving Kosovo of their much needed skills. The major obstacle that has not yet been overcome is the lack of suitably qualified midwives for teaching in the program, as the government has failed to provide sufficient opportunities for graduate studies. The future of the program is not clear, as many private universities are opening in Kosovo and initiating new programs in all health- related disciplines, leading to closure of programs in public universities. In some disciplines, notably nursing and midwifery, Kosovo’s accreditation agency has scrutinized programs before opening, to ensure that they meet EU requirements; but an increasing number of students and limited available clinical placements make meeting these requirements difficult.

Box 3. Case study 3: consultant approach to strengthen midwifery education in Latin America and the Caribbean A collaborative partnership of UNFPA-LAC and ICM began in 2011 with the goal of strengthening midwifery in Latin America and the Caribbean within the framework of ICM’s three pillars of Education, Regulation, and Association. As the UNFPA Technical Adviser for Midwifery, I worked with midwifery colleagues throughout the region (Spanish and English). The focus of strengthening midwifery education began with an analysis of the status of education in 18 countries using a variety of tools, including the Midwifery Rapid Assessment tool from the WHO/PAHO Midwifery Toolkit, the State of the World’s Midwifery Report 2011 (later 2014), and a short survey based on the ICM Resource Packet #4 on Competency-Based Education. Results of the survey in the Caribbean indicated that many midwife educators were not aware of the ICM global standards and competencies, and did not understand the concept of competency-based education (CBE), though they were eager to learn16 . These results informed the decision to start strengthening midwifery preservice education by upgrading current educators in CBE teaching, learning and evaluation strategies so that current students could benefit. In 2013, a CBE Trainer of Trainers (TOT) was held in Trinidad for 19 midwife educators from seven countries and in 2014 a similar CBE-TOT was held in Lima, Peru for 19 midwives from five counties. The required follow-up observed Continuing Education Workshops have resulted in 26 Midwifery CBE Master Trainers who continue to provide such workshops throughout the region, exposing more than 200 other midwife educators to CBE strategies. Additional CBE-TOT workshops are planned for Brazil and Mexico in 2016. The midwifery rapid assessments revealed a variety of pre-service midwifery programs in the region ranging from hospital to university-based, direct entry to post nursing, and of varying lengths and content. Efforts to evaluate and update curricula by midwifery educators from Chile, Peru, and the United States of America (USA) began in 2013, using the ICM Education Standards Gap Analysis (modified) and the ICM Curriculum Concordance Map and are ongoing given the time-intensive consultant costs and the year-long time frame needed for each review on site. For example, it took on average several days to do a desk review of midwifery curriculum, then several days in country to observe the actual teaching of midwifery content, etcetera. Funds for midwifery educationalists were limited, and often delayed the process — hence the year-long time period to cover just a few midwifery programs. To date, pre-service midwifery education programs in Ecuador, Guatemala, and Haiti have had a curriculum review based on ICM competencies and standards. Chile has translated all the ICM instruments into Spanish and applied them to their long-standing program with positive results that identified specific competencies that were missing. An additional five education programs in Latin America and four in Mexico will apply the ICM tools to their programs during 2016, analyzed in collaboration with the UNFPA-LAC Chilean Technical Midwife Adviser.

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Health Pre-Service Education Toolkit.29 The ICM Standards and the related principles of CBE18 were used as a basis for developing and improving midwifery education programs, including teacher and preceptor teaching abilities. In many countries, accreditation of all education programs lies with governmental bodies. Based on the intense midwifery education activities in the LAC region, midwives in these regions have expressed desire for some form of ICM acknowledgement that they meet their Standards. Currently all available resources in these countries are needed simply to carry out the program on a daily basis, while improving educational quality. Therefore, the costs of a recognition program in these settings would be prohibitive without external funds, and some might say, would be inappropriate at this time, given existing educational resource needs. The fourth case study (Box 4) on midwifery education in Bangladesh expands on the Kosovo and the LAC region case studies. While initially reporting on the development of a quality midwifery education program, this particular case demonstrates that international standards, including the ICM core documents, have provided Bangladesh with a useful platform for developing a midwifery education program. The case focuses on improving a specific element to ensure this quality: the lack of competent midwifery educators, and the efforts undertaken to improve this situation. It also highlights the challenges in achieving such international standards, primarily due to lack of in-country expertise, including among individuals in the regulatory body.

An external global recognition process, especially one based on internationally agreed standards and involving an interactive process, would undoubtedly help in providing unbiased expert quality improvement feedback to the country and the institution. However, in Bangladesh, formal accreditation also lies within the purview of a regulatory authority. It is unclear to what extent this authority would be willing to support institutions to obtain international recognition or that donors would be willing to fund such a program. Funds to continue the clinical mentorship program have still not been approved, despite acknowledgement of its benefits. These cases describe midwifery education programs in four different areas of the world. Despite the different contexts in which midwifery education is situated, similarities and differences in the development of quality midwifery education are evident. On further reflection, we viewed these case studies as an illustration of the exploration of the need, feasibility and added value of a global recognition process, which we discuss in the following section. 3. The need for global recognition The authors of this paper set out to explore issues around the idea of global recognition of midwifery education programs as a further step in ensuring their quality, as defined in Standards set by ICM17,37,24,25 in collaboration with its international partners, such as WHO and UNFPA. Harris and Bharj19 confirmed wide variation in midwifery programs in program length, theory to clinical practice ratio, as well as the emphasis of content. While the ICM Standards

Box 4. Case study 4: strengthening midwifery education in Bangladesh applying clinical mentorship: benefits of external consultants In spite of the impressive progress in all the socioeconomic and health indicators in Bangladesh, including a 40% decline in maternal mortality over the last decade, there remain serious short-falls in maternal health outcomes and access to services, particularly for poor women and in hard to reach areas. In 2012, responding to the government’s “Strategy to scale-up the midwifery workforce in Bangladesh” and call for public-private partnerships to meet the national need for competent regulated professional midwives especially for deployment in more rural and hard to serve areas, the James P. Grant School of Public Health (JPGSPH) at Building Resources Across Communities (BRAC) University, with assistance from local non-government organizations (NGOs), ICM and the United Kingdom Department For International Development (UK DFID), began to develop and implement a new three-year Diploma in Midwifery (Dip M). The new program was specifically customized for a health workforce providing care and support at the community level. As with all midwifery education programs in Bangladesh, the program is guided by the regulatory standards established by the Bangladesh Nursing Council. On successful completion of the program, students may then apply to sit the BNC midwifery licensing examination. As in other parts of South and South-East Asia, midwifery as a recognized profession is at an early stage of development in Bangladesh. In preparation for a cadre of fully qualified professional midwives in Bangladesh, in 2012 a scope of midwifery practice was defined by the Bangladesh Nursing CouncilThis scope of practice is built upon the ICM Definition of a Midwife (2011)47 and the World Health Organization South- East Asia Regional Office (WHO SEARO) Standards of Midwifery Practice for Safe Motherhood (1999)48. One of the many challenges facing implementation of the Dip M was the lack of competent midwife teachers. To address this challenge, yet quickly achieve a large number of qualified midwives for the community, JPGSP adopted a “hub and spoke” model. Six outlying spokes/centers, each managed by a different local NGO experienced in community health programs, were enlisted. Nationally recruited Dip M teachers, regardless of their base and experience, underwent a specific ‘Training for Trainer’s’ program plus a short practice internship in the nearest medical college. In addition, during semester breaks, technical updating seminars were provided with inputs from the Bangladesh Society of Obstetrician and Gynaecologists. However, despite these inputs, in 2015 a review of all centers by the new Director of Midwifery Education (DME), herself an experienced midwife educator from USA, identified serious gaps in midwifery knowledge and practice. To rapidly address these gaps, UK DFID agreed to the recruitment of six expatriate clinical midwife mentors (five from UK and one from US) to work as mentors to a group of teachers in each centre to try address some of the gaps in clinical knowledge and practice. Each mentor worked in-country for a short period of time, one in each centre. All mentors arrived in country at the same time and spent two days at the centre (Hub), working with the DME. All mentors tried to adopt a similar agenda; this was aided by staying in close communication using mobile technology (WhatsApp). All mentors acted as role models, applying interactive teaching and learning methodologies, and demonstrating respectful midwifery care. Whereas the clinical mentorship program was deemed successful by all, mentors felt there remained significant technical weaknesses in the capacity of the all centers, including the Hub, to bring the Dip M up to international standards.

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are advisory at this time, some international organizations have suggested that there is a need to increase the commitment to the ICM Standards, and called for exploring a global assurance of midwifery educational quality.6 Indeed, one global survey provides evidence that midwifery educators endorse the need for such a program.4 Accreditation and recognition are different types of programs, the former more formal than the other. Any universal quality assurance program would require not only the investment of both monetary and human resources in developing an effective process and structure, but also the provision of additional resources for programs to be able to participate. The four illustrative cases provide glimpses into the stages of development of midwifery programs in different regional contexts, and highlight both the potential need and value of global recognition in these settings, as well as opportunities and challenges for midwifery programs participating in such a process. Against this background, we consider the question “Is global recognition of quality midwifery education necessary or beneficial?” The establishment of a global recognition process might assist in assuring and validating the quality of midwifery education programs world-wide. Through universal quality assessment, the ICM Standards would become more than just an advisory guideline, and have the potential to bring about meaningful change. In all four case studies, the ICM Standards were used as essential information to develop, improve or update midwifery education programs. The hard work of educators in the LAC region to meet these Standards over several years led to their wish for some formal global acknowledgement that their midwifery education programs indeed met these standards. The LAC region case study also presents a good example of a successful collaboration with some governmental bodies, which resulted in a request to review new curricula with the Standards as a reference. In contrast, the Kosovo case study shows governmental intention to establish a high-quality midwifery education program that would meet international standards, but a lack of a long-term commitment to maintain the standards. On the other hand, the acceptance and implementation of the EU Directives,12 Europeanwide since 1985, demonstrates that government and professional associations can partner in an effective way to assure quality and competence in midwifery education and practice. Other examples of recognition programs include the MAGNET Recognition Program on a hospital’s quality of nursing,2 and the Baby-Friendly Hospital Initiative,28 which has become a universal quality standard in maternity care. In this light, endorsement of educators of a recognition process for midwifery education is therefore understandable. Reasons for desiring endorsement might differ by region; however, we believe that such initiatives facilitate the identification of quality midwifery education, and strengthen the midwifery profession by increasing its visibility locally and worldwide. A global professional recognition process, however, cannot replace formal national accreditation of an education program, in the traditional culture of education. Formal accreditation is typically based on professional standards as well as local legal standards. The results of an accreditation process have legal consequences. The accreditation body reviews midwifery program information in order to make decisions about the status, legitimacy or appropriateness of an institution or program. Such decisions might imply that further financial support will be available, but might also lead to closure of a program. A global recognition process may be fully supported by a professional midwifery association, but the association may not have the political power to influence the larger educational and/or health infrastructure to make the required changes recommended as a result of the recognition process. And thus lead to improvement of the quality

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of midwifery education and consequently the competency of the midwifery workforce. An external global recognition process based on international standards, involving an interactive process with site visitation, might provide unbiased expert feedback to the country and the institution for quality improvement. It is unclear to what extent resources might be available to support local institutions in obtaining international recognition in locations where such resources would be needed. Another layer to this question is that in countries with the highest maternal and newborn mortality, many other nongovernmental organizations are developing projects to educate, or rather “train”, midwives. In the face of great need, there is strong incentive to opt for shorter-term solutions, such as shorter, truncated education programs producing individuals with some, but not all, of the ICM agreed upon competencies.1 Although it is recognized that this may be a needed intermediary step, the evidence for the use of midwives to improve the health of women and children is predicated on movement toward adoption of the articulated midwifery competencies and educational standards. Both the Bangladesh and the LAC region case study highlight the use of smaller, intermediate steps. However, the LAC region case demonstrates how smaller steps can be embedded in a master plan in order to bring about the desired quality of midwifery education. Effective collaboration and a long-term commitment of governmental bodies is critical, as illustrated in the Kosovo case study. Finally, the results of the survey4 documenting a desire for a recognition process and the case studies indicate that such a process will not be feasible for many institutions, particularly in low- and middle-resource countries, without additional resources. Resources include financial assistance, staff or faculty time to devote to the actual process, and improved electronic capacity to transmit and receive documents during the process. Survey respondents also described the critical importance of experienced evaluators; competent, knowledgeable educators who possess ethical principles, such as being unbiased and having high integrity. The Irish case study illustrates the availability of such experts in that region, but it is uncertain how these needed resources will be found for global program participation. 4. Towards quality midwifery education: five essential challenges In the authors’ opinion, the favorable attitudes of midwifery educators towards developing a global recognition process for assuring quality midwifery education programs are noteworthy, but not sufficient. Their responses express their desire to create good midwifery education programs, to belong to a professional group that looks after the provision of quality education and clinical care, to support their autonomy within the educational system, and to enhance the profession’s visibility on a local and regional level. How could a recognition process become reality? How can we assure that such a program would lead to quality midwifery education? In order to achieve this vision of quality midwifery education through a global recognition process, the authors identified Five Essential Challenges for Quality Midwifery Education; a Ensuring that a global recognition process will be a valuable, but voluntary process. In this paper, the added value of a potential global recognition process is highlighted. In contrast, many consequences for a particular institution in its specific context cannot yet be foreseen. Therefore, participation in a global recognition process must be voluntary. Legal issues and human rights must be accounted for.7

Please cite this article in press as: A. Luyben, et al., Exploring global recognition of quality midwifery education: Vision or fiction?, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.03.001

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Multiple levels of recognition based on specific country needs, such as with and without a site visit, should be considered. b Identifying and educating midwives to be experienced evaluators possessing ethical principles of high objectivity and integrity. A key element of the recognition process is the availability of experienced, credible, international, culturally appropriate evaluators. The Irish case study showed the availability of such persons in that region, while other case studies highlighted a lack of experts in other regions. Experts must also be unbiased and meet cultural and ethical standards of expertise and authenticity in midwifery. c Establishing effective, sustainable collaborations between professional and governmental institutions on national and international levels. Effective collaborations between midwifery associations and governmental institutions are necessary to achieve quality midwifery education, leading to a competent midwifery workforce that can improve maternal and newborn health. The Kosovo case study in particular highlights the vital role of a collaboration for securing the input of both school and practice settings. Such collaborations require equal partnerships, in which “communities of practice”41 might be brought together in order to improve the quality of midwifery education, and consequently, midwifery practice. d Securing sustainable political and financial investment and support for recognising and improving quality midwifery education at national and international levels. Another vital element is political and financial investment in making the recognition process work in establishing robust, quality midwifery education programs. Building infrastructure and capacity for midwifery education must be elevated on the global agenda, including increased resources for midwifery education in all education and practice settings. While a pervasive lack of infrastructure and adequately educated teachers in low resource countries have been reported,39,5 political and financial investments are imperative to fully realize the potential of quality midwifery education. e Strengthening and supporting sustainable midwifery leadership in education at national as well as international levels. Midwifery leadership, meeting standards of knowledge, integrity and authenticity, is essential in the transformation of the system at all levels. Supporting leadership in midwifery education must include strengthening midwives to become leaders in national or global organizations, and midwives as active partners in projects that involve the organization of care for mothers and their families. 5. Conclusion Quality midwifery education is vital for establishing a competent workforce, and improving maternal and newborn health.5 Defining a global recognition process could be an instrument to continue to move forward. Consideration of the pros and cons of such a process including our proposed specific challenges to be considered by midwifery clinicians, educators and regulators is a necessary step. Fulfilling midwifery’s role in the achievement of the SDGs for the worlds’ women and their families requires such a conversation, consequently followed by careful and deliberative next steps.

Acknowledgments The authors would like to thank people and organizations that contributed to making quality midwifery education a global reality, while contributing to the projects that are presented in this article. A special thanks goes to Frances Ganges and Margriet Pluymakers from the International Confederation of Midwives’ Headquarters in The Hague. VF and her team thank the European Agency for Reconstruction for s1.5 million to develop midwifery and nursing in Kosovo. JT would like to acknowledge UNFPA-LAC Regional Director for SSR, Dr. Alma Virginia Camacho, for support of midwifery activities in the region. DS thanks the UK Department for Intentional Development (DFID) for supporting the development of midwifery education in Bangladesh and to all the other agencies who are assisting. She specifically would like to acknowledge Dr Pandora Hardtman, Clinical Technical Director of Midwifery Developing Midwives Project Bangladesh Rural Advancement Committee (BRAC) and Department for International Development (DFID) in Dhaka, Bangladesh.

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