Midwifery Qualification in Selected Countries: A Rapid Review

Background: While the global maternal mortality ratio (MMR) shows a decreasing trend, there is room for improvement. Midwifery education has been under scrutiny to ensure that graduates acquire knowledge and skills relevant to the local context. Objective: To review the basic professional midwifery qualification and pre-practice requirements in countries with lower MMR compared with Malaysia. Methods: A rapid review of country-specific Ministry of Health and Midwifery Association websites and Advanced Google using standardised key words. English-language documents reporting the qualifications of midwives or other requirements to practise midwifery from countries with a lower MMR than Malaysia were included. Results: Sixty-three documents from 35 countries were included. The minimum qualification required to become a midwife was a bachelor’s degree. Most countries require registration or licensing to practise, and 35.5% have implemented preregistration national midwifery examinations. In addition, 13 countries require midwives to have nursing backgrounds. Conclusion: In countries achieving better maternal outcomes than Malaysia, midwifes often have a degree or higher qualification. As such, there is a need to reinvestigate and revise the midwifery qualification requirements in Malaysia.


Introduction
Globally, there has been improvement in the number of maternal deaths over a span of 25 years, due to better healthcare access and improvements in quality of care [1]. Similarly, Malaysia has recorded an overall decrease in the maternal mortality rate (MMR) per 100,000 live births, which fell by 24% between 2000 and 2017, but this trend has plateaued from 2006 onwards [2]. The latest World Bank statistics in 2017 reported Malaysia's MMR at 29 per 100,000 live births [3]. Although this number is below the global target set in the Sustainable Development Goal Target 3.1, Malaysia is aiming to further lower its MMR to the single digit range, as maternal deaths are often preventable and reflect the quality of maternal care [2,4]. Areas such as effective coordination and communication among providers for pregnant women, early identification, diagnosis and treatment of women with "high risk" status could influence maternal mortality rates [5][6][7]. Without sufficient coverage, access and support from maternity care providers especially midwives, this possesses great barriers in preventing avoidable maternal deaths [8].
One of the established strategies is to improve access to skilled midwifery practitioners and provide adequate health facilities, especially as it could significantly reduce maternal mortality and morbidity [9]. For example, Uganda has recently upgraded its midwifery education to a Bachelor's degree, and enabled midwives to employ higher-level skills compared to their certificate-trained counterparts [10]. To strengthen health systems' responses to maternal and child health, WHO recommends workforce management with regulated care providers as well as education and core competencies that meet global The search identified 4204 records, with 124 derived from handsearching of websites and 4080 from Advanced Google (Figure 1). A total of 153 records were further identified and screened for eligibility, and 64 documents were included in this rapid review. The study flow is shown in Figure 1.
Japan has numerous pathways to becoming a midwife, but this pathway was considered to be the minimum qualification required. b Primary care midwife considered here. c Although the United States offers numerous midwife qualifications, only Certified Nurse-Midwives (CNM) were considered here because CNMs are the most widely recognised, and are licensed to practise in most areas in the United States. d The General Nurse (Diploma in Nursing and Midwifery) qualification considered here. e The rural health nurse qualification is considered to be equivalent to a certificate. f The technical midwife qualification is considered to be equivalent to a certificate.

Other Requirements to Practise as a Recognised Midwife
Requirements other than midwifery education were not available for four countries. Of the 31 countries with available information, 28 (90.3%) required registration and/or licensing in midwifery. Eleven (35.5%) implemented a preregistration national midwifery examination [33,35,39,40, For countries with multiple pathways into midwifery, only the registration requirements for graduates of "purely midwifery" courses or a lower qualification that includes midwifery training were considered except in the United States, due to the different legislations governing midwifery in each * Other than midwifery education. ** Assumed to be supervised. *** Practising certificate considered to be a midwifery licence. a Qualification from the training school for nurses is considered to be equivalent to a diploma, whereas the qualification from the training school for midwives is considered to be a post-nursing qualification. Japan has numerous pathways to becoming a midwife, but this pathway was considered to be the minimum qualification required.

Higher-Educated Midwives Add Value to the Practice
Direct-entry midwifery degrees were found to be the minimum qualification in the majority of countries included. In comparison, most midwifery practitioners in Malaysia are community nurses [92] with certificate-level qualification, followed by nurses with basic qualification at certificate, diploma or degree level with a post-nursing advanced diploma in midwifery or public health [18]. The risk-approach system used in Malaysia [19] delineates case management by nurses of different qualification levels, where only low-risk cases are managed by community nurses and mild to moderate risk cases are managed by nurses.
Community nurses in Malaysia mainly serve rural clinics. While community mobilisation improves access to care, variable quality of care remains a challenge [93]. As such, WHO has called for midwives to be educated and trained to fulfil international standards, in an effort to strengthen midwifery education [94]. In Australia, recognising the need for multiskilled practitioners in the rural community, a four-year double degree programme combining nursing and midwifery was introduced in 2008 [95]. Iceland, with an MMR of three per 100,000 population in 2015 [3], have nurse-midwives, where only the best nursing students are able to qualify for a seat in midwifery training [96]. Therefore, revising the minimum qualification holds the potential for improving midwifery care standards. Additionally, further education of current community nurses can be enhanced to elevate them to the level of nurse-midwives. This would enable practise of the full scope of midwifery care as spelled out in the Framework for Action Strengthening Quality Midwifery Education for Universal Health Coverage 2030 [94].
A higher-qualified nursing workforce is valued for their variety of skills from critical thinking to effective health promotion across both inpatient and outpatient settings [97]. Undergraduate nurses were found to perform better in areas of professional practice compared to their lower-educated counterparts [98]. Various studies found that increasing the proportion of degree-qualified nurses among hospital staff resulted in lower in-patient mortality rates [99][100][101][102]. In the United States, there has been a shift to encourage nurses to obtain a bachelor's degree to achieve the Institute of Medicine's recommendation for more degree-level nurses, owing to evidence of better patient outcomes with degree-level nurses [103]. Although the available literature evaluating the impact of nurses' qualification levels is hospital-focused, it can be postulated that having degree-level midwives in primary care will result in better patient outcomes. Moreover, the Chair of the Nursing and Midwifery Council in the United Kingdom highlighted the need to have degree-level education to meet increasing work demands [104].
A participant-assessed study of undergraduates and diplomates of nursing or midwifery found that undergraduates performed better in areas of cognitive ability and reflective practice ability [105]. Shin [106] evaluated critical thinking abilities of Korean senior nursing students and found that those enrolled in undergraduate programmes scored better than those in associate degree programmes. In solving complex problems, the ability to think critically is vital in enabling midwives to arrive at the best clinical decisions in a timely manner [107]. Current evidence linking critical thinking and clinical decision-making abilities in nursing is disputable, due to the uncertain validity of methods used in measuring critical thinking, but overall such evidence seems to be credible [108]. You et al. [109] highlighted that having better-qualified nurses is essential with the expansion of nurses' roles in the community and the increasing complexity-level of care. In public healthcare systems that are often challenged by finite resources, employing undergraduate nurses who are trained to be critical thinkers and problem solvers under an evidence-based curriculum is valuable, as they are able to adapt and adjust their practice accordingly [110].
Undergraduate nurses are also more likely to be educators, participate in research and incorporate best evidence into practice [111]. Evidence-based practice (EBP), "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" [112] (p.71) positively impacts patient outcomes in nursing and midwifery, reduces healthcare costs and empowers nurses and midwives, resulting in the WHO Regional Office in Europe urging its Member States to encourage and develop EBP culture in nursing and midwifery [113]. An integrative review found that although EBP in midwifery is valued, implementation is still lacking [114]. Similarly, Lai et al. [115] found that nursing and allied health practitioners in several Malaysian hospitals reported less favourable attitudes towards EBP, which could possibly be due to the low confidence attributed to their diploma qualification level. This supports the need to upgrade the qualifications of all Malaysian midwives to degree level, with emphasis on evidence-based practice as a strategy to potentially improve all maternal outcomes as they often face clinical decision-making junctures in practice.
Higher education is an empowering tool for day-to-day practice in midwifery, as midwives are at the forefront of primary care and need to be not only prepared in providing consistent advice in antenatal care, but also equipped to skilfully promote family planning, a core strategy that reduces risk of maternal death [116]. Effective counselling on preconception care by nurses or midwives has the potential to assist a woman in preparing herself physically and mentally to sustain a pregnancy [117]. Women who receive preconception counselling are more inclined to improve their health behaviour [118] and lifestyle [119] before becoming pregnant. In recognition of the extensive duties expected of a competent midwife, having better-qualified midwives will facilitate quality improvement in maternal care.
The duration of study for most direct-entry midwifery qualifications is three or four years in the included countries, while the duration of post-nursing or postgraduate studies ranges between seven months to two years. In Malaysia, graduates with community nurse certificates were simultaneously trained in midwifery and basic nursing over the short span of two-and-a-half years [120]. While community nurses are only expected to provide care for low-risk pregnancies, they are required to identify signs of escalating pregnancy risk and recognise the need for referral, while failure to do so can put both mother and child in imminent danger. Hence, with increasingly complex maternal cases, it is important for community nurses to acquire adequate knowledge and skillsets to meet expanding demands. Since effective midwifery is projected to improve outcomes, [21,116] the situation in Malaysia raises questions on whether the curriculum of local midwifery programmes is comprehensive enough to produce graduates who are as competent as the midwives with longer training durations in countries with lower MMR.

Producing Work-Ready, Quality-Assured Midwives
A national midwifery examination and subsequent registration or licensing ensures all prospective midwives meet the same competency standards prior to practising. Malaysian midwifery students are required to pass the national midwifery examination mandated by the Midwifery Board of Malaysia (Lembaga Bidan Malaysia) to qualify for registration [121]. We found that 11 out of 31 countries with available information implemented a preregistration national midwifery examination, whereas nearly all the countries required midwives to obtain midwifery registration and/or licensing in order to practise legally.
Midwifery registration or licensing is a certification, a formal mechanism enforced to regulate quality and competency. Certification, defined as "a process by which an authorised body, either a governmental or nongovernmental organisation, evaluates and recognises either an individual or an organisation as meeting predetermined requirements or criteria", has long been accepted as a quality improvement strategy in various healthcare professions [122] (p. 3). In the Malaysian context, midwives are governed by the Midwifery Act, which requires every person practising midwifery to be registered [121]. A literature review on how nurses perceive specialty certification reported that certified nurses were more satisfied with their job, felt more empowered in their practice and had a greater sense of collaboration with other healthcare professionals. These nurses found that certification facilitated professional growth, and had proof that their abilities were on par with those of the practice standard [123]. Certified nurses also reported being better able to intervene and prevent adverse outcomes due to an increased ability to recognise changes in patient status [124]. In another study, it was found that surgical wards with more certified specialty nurses had a lower rate of central-line-associated bloodstream infections [125]. Certification was thought to enhance nurses' autonomy in practice and clinical expertise, consequently improving patient outcomes [123]. Additionally, certification allows the patient to trust in the abilities of the healthcare professional in managing their health [126]. Hence, certification by a regulatory body validates the professional autonomy of a midwife, consequently generating confidence among their clients.
"Learning through doing" [127] is crucial in preparing graduates for a practical profession like midwifery. This is reflected in the recommendation by the International Confederation of Midwives, where it is stated in the Global Standards for Midwifery Education that, "the midwifery curriculum should include both theory and practise elements with a minimum of 40% theory and a minimum of 50% practise" [12] (p. 6). Our search did not reveal the actual extent of practical skills and experience required of midwifery students upon completion of their studies. However, concerns pertaining to the sufficiency of clinical preparation of midwifery graduates have been voiced [128,129]. Graduates have described the transition from student to qualified, professional midwife as challenging [130], stressful, an unexpected reality [131] and overwhelming [132], due to a perceived lack of knowledge and experience.
Two countries (Singapore and Latvia) reported the requirement of supervised inservice training for new midwives in our study. In Malaysia, new nurses and midwives are supported via an unofficial mentor-mentee programme where the mechanics are not set, and may differ in execution [17,133]. In contrast, New Zealand runs a compulsory midwifery transition programme known as the "Midwifery First Year of Practice" (MYFP) programme aimed to support new midwives in building confidence as independent practitioners, using a mentor-mentee approach with continuous professional development [134]. The programme has also been found to boost retention regardless of age, race, level of education or place of work [135]. A study of midwifery students in Turkey found that internships and night shift practical training were perceived to be beneficial in preparing students for professional practice [136]. Similarly, a study of Irish midwifery students who undergo a paid 36-week internship in final year found students were able to apply knowledge into real-world practice which in turn builds confidence [127]. In Norway, a comparison between midwives who had a one-year internship as part of their two-year course and midwives who did not, found that the latter felt less prepared for practice than the former [128]. Evidently, be it internships or transition programmes, supervised clinical training prepares midwifery students in becoming self-efficacious practitioners.

Limitations
Although strengthening midwifery education has the potential to reduce maternal mortality, there are other associated factors that must be considered in order to improve maternal outcomes.
The database search did not yield any relevant documents that related midwifery qualifications to maternal outcomes. As such, a grey literature search was carried out. Although every effort was taken to retrieve the latest country-specific documents, there may be a delay in availability of document updates online, and thus the documents may not reflect the current country practice. Some countries may label a qualification as a "diploma", but it may be equivalent to a degree or higher. Additionally, the prerequisites and duration of study for the qualification should be considered. Not all the included countries in this review had complete information, nor were we able to retrieve information from all the countries identified as having a lower MMR than Malaysia.
While some countries offered multiple pathways into midwifery, this study only looked at the minimum levels of qualification required to practise as a midwife. The proportion of midwives corresponding to different qualification levels in each country was not considered. Also, we only included government-recognised midwifery qualifications.
Authors or relevant midwifery organisations in other countries were not contacted for further information in this review. When required, permission was sought to use information from the included documents.
This study provides a comparison between Malaysia and countries with lower MMR than Malaysia. It would also be helpful to make comparisons with countries with higher MMR in the future to gain a comprehensive comparative understanding of global midwifery education.

Conclusions
Most countries achieving better maternal mortality outcomes than Malaysia had degree-level midwives. Revision of the qualification requirements of midwives has significant potential for improving maternal care quality and hence reducing MMR. In order to produce midwives who can stand independently at the forefront of increasingly complex maternal health demands, areas for improvement in their education must continue to be identified and addressed to ensure their continuing competency and professional development meets international standards. Funding: This investigation was carried out by the Malaysian Alliance for Embedding Rapid Reviews in Health Systems Decision Making (MAera). MAera received financial support from the Alliance for Health Policy and Systems Research for platform establishment from 2018-2020 (WHO Reference 2018/860628-1). For this project, funding was utilised for the employment of research assistants and hospitality during meetings with stakeholders. The funders had no involvement in any part of running the project or publication of outputs from the project. The Alliance is able to conduct its work thanks to the commitment and support from a variety of funders. These include their long-term core contributors from national governments and international institutions, as well as designated funding for specific projects within our current priorities. For the full list of Alliance donors, please visit: https://www.who.int/alliance-hpsr/partners/en/ (accessed on 26 January 2021).

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki, was registered under the National Medical Research Register (NMRR-18-3421-45549) and was exempted from ethical review by the Medical Research & Ethics Committee (MREC) as it did not involve human or animal subjects (reference letter KKM/NIHSEC/P19-1528 (4)).

Data Availability Statement:
The data presented in this study are openly available in Open Science Framework at https://osf.io/gzn3a (accessed on 5 August 2021).