Indian Nursing Council {Nurse Practitioner in Midwifery (NPM) Program}, Regulations, 2020

Indian Nursing Council Act, 1947

Published vide Notification No. F.No. 11-1/2019-INC, dated 6.1.2021

Last Updated 18th January, 2021 [act3794]

F.No. 11-1/2019-INC. - In exercise of the powers conferred by sub-section (1) of Section 16 of Indian Nursing Council Act, 1947 (XLVIII of 1947) as amended from time to time, the Indian Nursing Council hereby makes the following regulations namely:-

1. Short Title and Commencement. - i. These Regulations may be called Indian Nursing Council {Nurse Practitioner in Midwifery (NPM) Program}, Regulations, 2020.

ii. These Regulations shall come into force on the date of notification of the same in the Official Gazette of India.

2. Definitions. - In these Regulations, unless the context otherwise requires,

i. 'the Council' means the Indian Nursing Council constituted under the Act;

ii. 'SNRC' means the State Nurse and Midwives Registration Council, by whichever name constituted, by the respective State Governments;

iii. 'RN & RM' means a Registered Nurse and Registered Midwife (RN & RM) and denotes a nurse who has completed successfully, recognised Bachelor of Nursing (B.Sc. Nursing) or Diploma in General Nursing and Midwifery (GNM) course, as prescribed by the Council and is registered in a SNRC as Registered Nurse and Registered Midwife;

1. Introduction and Background - 1.1 Introduction In 2015, India became one of the 193 countries to commit to the Sustainable Development Goals (SDGs), which aim to transform the world by 2030 to a more prosperous, more equal, and more secure planet for all. Needless to say, India's responsibility is immense as these ambitious goals cannot be achieved without accelerating progress in one sixth of the world that resides in our country.

Health is central to commitments made by the Government of India. For us to be able to ensure healthy lives and promote well being for all at all ages, it is critical to focus on improving our core health indicators, which include maternal and infant mortality.

When a pregnant woman enters the health system, she puts her faith in the system to receive high quality services for herself and her newborn. Responding to this faith India has strengthened maternal and child health services in our country under the National Health Mission. India has made tremendous progress over the last few decades in increasing institutional deliveries through the National Health Mission and schemes like the Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram, and this has greatly reduced the maternal and infant mortality. India's maternal mortality ratio has declined from 254 per lakh live births in 2004-06 to 130 per lakh live births in 2014-16 (Sample Registration System. India has shown impressive gains in reduction of Maternal Mortality evident from the fact that the compound annual rate of decline of MMR has increased significantly from 5.8% during (2007-09 to 2011-13) to 8.01% (2011-13 to 2014-16). Similar achievements are also visible in reduction of under-five and infant mortality rates.

Investments on maternal and child health remain a key focus area under the National Health Mission. Operationalizing First Referral Units, new Maternal and Child Health Wings, Obstetric High Dependency Units and Intensive Care Units, capacity building initiatives such as Dakshata trainings, quality antenatal care strengthening programmes such as the Pradhan Mantri Surakshit Matritva Abhiyan etc. continue to be a key priority.

In addition to above, the Government of India has recently launched the LaQshya - Labor Room and Maternity Operation Theatre Quality Improvement Initiative. Substantial global evidence exists that addressing the time around and immediately after childbirth is critical for saving the lives of mothers and newborns. Studies conducted by White Ribbon Alliance have also highlighted the need to focus on respectful maternity care. The LaQshya programme has thus been launched to provide quality intrapartum and immediate postpartum care and promote respectful maternity care.

Despite the tremendous progress, nearly 32,000 pregnant women each year still lose their lives during pregnancy, childbirth and the postnatal period each year. In addition, 5,90,000 newborns die every year in the first month of life. Additional efforts are needed in India to increase Universal Health Coverage (UHC) and to achieve Sustainable Development Goals (SDGs) for maternal and newborn and child health. The National Health Policy 2017 aims at the reduction of maternal mortality ration to 100/lakh live births by 2020.

The survival of women and newborns is closely correlated with the care and attention received during pregnancy and, most importantly, at the time of delivery. Delayed management of cases, due to lack of access to skilled care, is one of the major reasons for the deaths, particularly in the rural areas. Skilled and respectful care during childbirth is important because millions of women and newborns develop serious and hard to predict complications before, during or immediately after delivery.

Evidence shows that quality midwifery care, provided by midwives educated to international standards, reduces maternal and newborn mortality and stillbirth rates by 83% and with 56 improved maternal and newborn health outcomes. It is also evident that 87% services can be delivered by midwives educated to international standards. There also has been an increasing body of evidence globally that Midwife Led Care Units (MLCUs) can address maternal and neonatal mortality and morbidity by promoting quality and continuity of care through provision of women-centric care and promoting natural births. Where a model of Midwife Led Continuity of Care (MLCC) is introduced, this reduces preterm birth by 24%. Beyond survival, quality midwifery care improves breastfeeding rates and psychosocial outcomes, and reduces the use of unnecessary interventions, in particular caesarean sections and increases access to family planning (Lancet Series, 2014; UNFPA, 2014 & WHO 2017).

The International Confederation of Midwives outline the Midwifery philosophy and model of care1. Midwifery has a unique body of knowledge, skills and professional attitudes drawn from disciplines shared by other health professions such as science and sociology, but practised by midwives within a professional framework of autonomy, partnership, ethics and accountability. 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; 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. Midwifery care is provided by an autonomous midwife.

1.2 The 'Midwifery Services Initiative' of India Considering the need for trained human resources to provide quality care to 30 million pregnancies every year in India and at the same time recognizing the challenges earlier, Government of India has proposed an alternative model of service provision for strengthening reproductive, maternal and neonatal health services by nurse practitioners in midwifery through Midwife Led Care Units (MLCUs). Quality maternity care provided by midwives through the MLCUs is vital to this transformation. The recognition that quality of care will not only save lives but will also provide a positive experience of childbirth means that the change required must be transformative. This will require making fundamental change to the way services are delivered, and the culture of care provided to women. The 'Guidelines on Midwifery Services in India' set transformative change must be at the heart of midwifery education.

The 'Midwifery Services Initiative' aims to create a new cadre of midwives titled "Nurse Practitioner in Midwifery" (NPM) who are skilled in accordance with ICM competencies, knowledgeable and capable of providing compassionate women centered, reproductive, maternal and newborn health services (RMNCH) and to develop an enabling environment for integration of this cadre into the public health system in order to achieve the SDGs for maternal and newborn health (MoHFW, 2018).

1.3 Preparing Nurse Practitioners in Midwifery (NPM) for the future of India Quality education is essential to prepare international-standard midwives complying with the ICM competencies with the knowledge and skills to provide the full scope of midwifery care that women and newborns need. Evidence indicates that the optimum duration of training required to acquire needed midwifery skills and competencies is 18 months. The existing one year Nurse Practitioner in Midwifery post basic diploma program of the Council is redesigned and upgraded to an 18 month intensive residency program to develop more NPMs for providing respectful, highest standards of quality and evidence based care at the institution and community levels with specific emphasis on providing safe and competent midwifery care. The essential components for quality midwifery based on the Quality Maternal and Newborn Care (QMNC) framework is integrated in the curriculum.

The Nurse Practitioner in Midwifery (NPM) will be responsible for promotion of health of women throughout their life cycle, with special focus on women during their childbearing years and their newborns. She will be responsible for providing respectful maternity care during preconception, pregnancy, childbirth, and post-natal period including the care of newborn. She will be responsible and accountable for her practice. The NPMs will practice independently and collaboratively with the doctors in the hospital and within the existing peripheral health system consisting of skilled birth attendants, auxiliary nurse midwives, nurses, doctors and specialists. She can be posted in a facility where no obstetricians are available and provide midwifery care based on predetermined midwifery care protocols alongside treatment protocols and drugs permitted for use by NPMs.

Responding to this urgent need, the NPM curriculum is designed in line with ICM competencies for midwives that emphasizes humanizing transformation. The curriculum which aims to strengthen the technical knowledge, clinical skills and attitude of the NPMs in midwifery. The training aims to prepare competent NPMs, who can provide quality and compassionate care to the mother, neonate and family, demonstrating international standards of midwifery practice. The program will also equip the NPMs to utilize the principles of effective communication, counseling, leadership, supervision and management and enable them to understand and utilize the research end evidence relevant to midwifery practice.

2. Philosophy and Vision

2.1 Philosophy The Council believes that strengthening midwifery education to International Standards is a key step to improving quality of women centered respectful care and reducing maternal and newborn mortality and morbidity. The Council believes that registered nurses need to be given additional training to work as nurse practitioner in midwifery in clinical and community settings to provide Midwifery Led Continuum of Care (MLCC) bringing about transformation in terms of humanization and autonomous role in the midwifery services provided by the NPMs as per the aspirations of Government of India (GoI).

The Council believes that competency-based training integrating ICM competencies would enable the Nurse Practitioners in Midwifery (NPM) to demonstrate knowledge, skills and behaviors based on sound evidence-based knowledge, focusing on the concept of 'women-centered and respectful care' that is central to midwifery practice. The NPMs will be able to combine their knowledge, skills with interpersonal, social and cultural competencies and work as part of inter-professional team.

The philosophy of the midwifery training is underpinned by the internationally accepted definitions of a midwife, incorporating the globally understood key elements of midwifery care. The ICM defines a midwife as: 'a person who has successfully completed a midwifery education program that is duly recognized in the country where it is located and that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who 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'. This philosophy is adapted by the Council's philosophy in preparing NPMs through the proposed curriculum.

The Council also believes that a variety of innovative educational strategies can be used in the theoretical and clinical settings to provide best theoretical and clinical learning experiences. The teaching learning approaches will integrate adult learning principles, competency-based education, collaborative learning, experiential learning, mastery learning and self-directed learning. The Council also believes that effective collaborative and interdisciplinary learning can be facilitated by involving medical and other faculty from related disciplines such as Obstetrics and Gynecology, Pediatrics and Public Health. It is hoped to facilitate developing policies towards creation of cadre positions for appropriate placement of these NPMs to function in Midwife Led Care Units (MLCUs) with appropriate career progression opportunities.

2.2 Vision The program is envisioned to provide high quality education, which meets international standards and prepares NPMs to work autonomously to their full scope of practice in respectful partnerships with women and in collaboration with the obstetrician, pediatrician and the other health care team members when indicated, to provide compassionate, quality, evidence-based, woman-centered and family-focused care during pregnancy, labour and postnatal period. The program prepares NPMs to champion positive childbirth experience, optimal transition to parenthood and safe reproductive health care.

The nurse practitioners in midwifery from this program will meet educational and practice standards of the Council with focus on the ICM Essential Competencies for Midwifery Practice. They will uphold recognized standards of midwifery practice, embrace, support the qualities and values of the midwifery practice, and be motivated, flexible and evidence-informed practitioners. They will be prepared to grow and advance through learning and continuing experience.

The NPMs are equipped to work within midwifery led care and continuity of care models in India, both with in the newly formed midwife-led care units within public health facilities and/or integrated into primary health care within the community.

3. Aim & Objectives

3.1 Aim The aim of Nurse Practitioner in Midwifery program is to prepare a cadre of NPMs who are confident and skilled in accordance to competencies prescribed by the ICM and the Council for providing high quality respectful, dignified, compassionate and evidence based midwifery care to woman, newborn and family and working autonomously with their full scope of practice, as per regulations of the Council/MoH&FW.

3.2 Objectives The program will prepare the NPMs to

3.2.1 Facilitate a positive childbirth experience for women and their families, placing women at the center of care inclusive of psychosocial, spiritual and cultural background across community settings and within institutions contributing to natural childbirth providing humanized care to improve quality of care

3.2.2 Work in partnership with women, families and the other health care team to plan and provide the necessary support, care and advice during pregnancy, labour and the postpartum period up to six weeks

3.2.3 Advocate for ethical, compassionate respectful and culturally sensitive care in pregnancy, labour and childbirth, and post-partum, including promoting the woman's autonomy and rights to informed decision making

3.2.4 Contribute to reduction of over medicalization of maternity care and reduce impacts of socio-economic inequalities including hard to reach and tribal areas

3.2.5 Educate women individually or in groups to have knowledge about family planning, a healthier pregnancy including diet, nutrition, mother baby bonding, breastfeeding support, family integrity and optimal start to life to enhance health and disease prevention

3.2.6 To assume responsibility for her own decisions and actions as an autonomous primary maternity care practitioner and lifelong learner

3.2.7 Recognize abnormalities and complications and implement appropriate management and care, including managing emergency care and timely referral

3.2.8 Draw on research informed/evidence-based knowledge to be an effective problem solver and to think critically and reflect on practice

3.2.9 Work within the legal and professional boundaries by understanding their role within the broader health care profession and engage inter-professionally; with doctors, nurses, and other health care providers as part of a maternity care team

4. Curriculum - Conceptual Model Midwifery Education recognizes that learning and continuing competency are lifelong pursuits thus this curriculum aims to facilitate a passion for learning through well-designed teaching and learning strategies aligned to evidence informed and contemporary midwifery knowledge and practice.

The conceptual model has been designed to reflect a holistic approach to midwifery education. Conceptually, it sets seven core values at the center of the curriculum, highlighting qualities that are central to provide a positive childbirth experience. Key approaches that inform contemporary midwifery practice are integrated throughout the curriculum, alongside maternity and newborn care priorities. The ICM Essential Competencies for Midwifery Practice and the Council educational and practice standards direct the course aims, objectives and content. The course delivery will incorporate evidence informed teaching and learning principles.

The values, integrated concepts, maternity care priorities, midwifery competencies, teaching and learning principles are informed by the Guidelines on Midwifery Services in India, Strengthening Quality Midwifery Education Framework for Action, The Framework for Quality Maternal and Newborn Care and Lancet Series on Midwifery, Council's Educational and practice standards, ICM Essential Competencies for Midwifery Practice and ICM Global Standards for Midwifery Education.

The curriculum conceptual model that informs the overall program design and course development is illustrated in Figure 1 below.

Figure 1. Curriculum Conceptual Model

4.1 Curriculum Principles

4.1.1 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. These values include: (i) compassion, (ii) respect, (iii) woman, baby and family-centredness, (iv) equity and rights, (v) collaboration and team work, (vi) ethical practice, (vii) moral courage.

4.1.2 Integrated concepts Within the curriculum there are seven concepts which represent key approaches that inform contemporary midwifery practice. These concepts include: (i) social inequities and midwives as primary health practitioners, (ii) evidence-based midwifery practice, (iii) cultural competence, (iv) quality maternity and newborn care, (v) continuity of midwifery care, (vi) midwifery as a relationship between a woman, baby, family and a midwife, (vii) optimizing physiological birth, (viii) community knowledge.

4.1.3 Maternity care priorities The program provides a strong focus on identified maternity care needs and priorities which are addressed across the curriculum. They are: (i) improving maternity and newborn care for vulnerable and hard to reach women, (ii) reducing maternal and newborn maternity and morbidity, (iii) effective management of emergency care, (iv) human rights and gender-based violence, (v) strengthening midwifery-led care, (vi) humanizing and promoting natural childbirth.

4.1.4 ICM Essential competency standards for midwifery practice and Council's practice standards The ICM (2019) competencies 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. These competencies provide framework for the courses within the program. The Council practice standards guide midwifery practice and provide regulations.

4.1.5 Continued Professional Development The quality of midwifery practice is achieved when the practice is led by autonomous role of NPMs. Continued professional development is essential for advancing and building the future of midwifery practice in India.

5. Scope of Practice The Scope of Practice of a Midwife is combined with the ICM definition and sets out the boundaries of a midwife's practice as adapted for NPM in India and is as follows:

• The NPM is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the newborn and the infant.

• This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

• The NPM/midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women's health, sexual or reproductive health and childcare.

• NPM may practise autonomously in any setting including the home, community, hospitals, clinics or health units mostly in MLCUs that is envisaged by GoI.

• The NPM will be able to perform full scope of practice as per education and training and Council's/ MoHFW regulations and guidelines.

6. Competencies The Council adapted the International Confederation of Midwives (ICM) competencies for training of nurse practitioners in midwifery for India and the framework is given below:

Figure 2. ICM Essential Competencies for Midwifery Practice (2019)

The competencies are organized under 4 categories/domains.

Competency Category 1: General Competencies NPMs demonstrate professional accountability as an autonomous practitioner in the delivery of midwifery care as per ICM standards adopted by the Council that are consistent with moral, altruistic and humanistic principles in midwifery practice.

Competencies:

1a. Assume responsibility for own decisions and actions as an autonomous practitioner

1b. Assume responsibility for self-care including personal safety and self-development as a midwife

1c. Appropriately delegate aspects of care and provide supervision

1d. Utilize research to inform practice

1e. Uphold the fundamental human rights of individuals when providing midwifery care

1f. Adhere to jurisdictional laws ethical, regulatory requirements, codes of conduct for midwifery practice

1g. Facilitate women to make individual choices about care

1h. Demonstrate effective interpersonal communication with women and families, health care teams, and community groups

1i. Facilitate normal birth processes in institutional and community settings, including women's homes

1j. Assess the health status, screen for health risks, and promote general health and well-being of women and infants

1k. Prevent and treat common health problems related to reproduction and early life

1l. Recognize conditions outside midwifery scope of practice and refer appropriately

1m. Care for women who experience physical and sexual violence and abuse

Competency Category 2: Pre-Pregnancy and Antenatal Care NPMs Perform health assessment of woman and fetus, promote their health and well-being, detect complications during pregnancy, and provide care to women with unexpected pregnancy.

Competencies:

2a. Provide pre-pregnancy and antenatal care

2b. Determine health status of women

2c. Assess the fetal wellbeing

2d. Monitor the progression of pregnancy

2e. Promote and support health behaviors that improve their wellbeing

2f. Provide anticipatory guidance related to pregnancy, birth, breastfeeding, parenthood, and change in the family

2g. Detect, manage, and refer women with complicated pregnancies

2h. Assist the woman and her family to plan for an appropriate place of birth

2i. Provide care to women with unintended or mistimed pregnancy

Competency Category 3: Care During Labour and Childbirth The NPMs continue to monitor and provide care to woman during labour that facilitates physiological processes and a safe birth, immediate care to newborn infant and detect complications in mother and infant.

Competencies:

3a. Promote physiologic labour and birth

3b. Manage a safe spontaneous vaginal birth and prevent complications

3c. Provide care of the newborn immediately after birth

Competency Category 4: Ongoing Care of Women and Newborns The NPMs continue to perform health assessment of mother and infant, provide health education and support for breast feeding, detect complications, and initiate family planning services.

Competencies:

4a. Provide postnatal care for the healthy woman

4b. Provide care to healthy newborn infant

4c. Promote and support breast feeding

4d. Detect and treat or refer postnatal complications in woman

4e. Detect and manage health problems in newborn infant

4f. Provide family planning services

7. Program Details

7.1 Program Description The NPM program is an 18-month residency program, which includes 12 months of residency education and training followed by 6 months of intensive practicum/internship. The program mainly focuses on Competency based education and training facilitated by mastery and experiential learning centered around transformational and relationship-based teaching and learning integrating Council's/global educational and midwifery practice standards. The change in paradigm shift to women-centered and respectful midwife led midwifery services is emphasized throughout the program recognizing their scope of practice.

The curriculum comprises of theory and practicum (lab and clinical), offered in four course modules namely (i) Foundations to midwifery, (ii) Normal Pregnancy, birth, postpartum and care of newborn, (iii) Complex care of woman and care of compromised newborn. Besides the foundational training, the curriculum encompasses hands on skill training and orientation to the treatment protocols/national midwifery guidelines and drugs permitted for use by NPMs relevant to midwifery practice.

The program is designed so that learning is scaffolded across the program to enable the progressive development of the knowledge, skills and values essential for the students to practice with professional competence as qualified midwives recognizing that the students are registered nurses with some prior midwifery experience. The first two series of courses provide the opportunity to develop contemporary midwifery knowledge, skills and values with a focus on promoting normal pregnancy, birth and puerperium, including healthy fetal and neonatal development. The third set of courses focuses on the deviation from normal including complex care of the woman and newborn as well as the midwife's role in primary health care. These courses focus on readying the student for their role as an autonomous midwife practitioner working in and advocating the new model of midwifery-led care in India. As described in the curriculum conceptual model, students have opportunity for consolidated learning. The integrated concepts are incorporated into content and learning activities that increase in complexity throughout the program. Alongside this, maternity care priorities are addressed with varying emphasis depending on course objectives. Similarly, the core values and ICM Essential Competencies are also interwoven into course content, learning activities and practice experience throughout the program.

7.2 Program Structure

Courses/Modules	Theory (Hours)	Practicum (Hours)
Courses/Modules	Theory (Hours)	Skills Lab (Hours)	Clinical (Hours)
Module I: Foundations to Midwifery	90	20	180
1. Indian Healthcare System & Maternal and Neonatal Health (MNH) scenario in India 2. Professionalism and professional midwifery practice 3. Woman centered continuity of midwifery care & respectful maternity and newborn care 4. Humanization of childbirth and the impact of communication 5. Legal issues relevant to midwifery practice 6. Ethics in midwifery 7. Education and counseling in midwifery 8. Community engagement and research informed practice
Module II: Normal pregnancy, birth, puerperium and care of newborn	100	40	980
1. Basic Sciences applied to midwifery: Maternal, Fetal and Newborn Physiology, Pharmacology & diagnostics and Infection Control 2. Normal Pregnancy, Birth and Puerperium 3. Care of the Newborn
Module III: Complex Care of woman and care of compromised newborn	40	35	570
1. Perinatal psychological health 2. Complex care of the woman 3. Care of the compromised newborn 4. Healthy families and communities
Total Hours : 2055 hours	230	95	1730
Internship : 1035 hours	1035 Hours

7.3 Guidelines for Starting the Nurse Practitioner in Midwifery Program

7.3.1 The program may be offered at

1. The Government (State/Center/Autonomous) nursing teaching institution offering degree programs in nursing having parent/affiliated Government Hospital facilities of maternity, and neonatal units along with primary, secondary and tertiary health care facilities.

Other Non-Govt. nursing teaching institution offering degree programs in nursing having parent hospital facilities of maternity and neonatal units along with primary, secondary and tertiary health care facilities.

2. The eligible institution shall get recognition from the concerned SNRC for starting the Nurse Practitioner in Midwifery program for the particular academic year, which is a mandatory requirement.

3. The Council will conduct inspection for two consecutive years for continuation of the permission to conduct the program.

7.3. 2 Staffing

1. NMP Faculty: M.Sc. Nursing with OBG/Pediatrics/Community health nursing speciality or B.Sc. (Nursing) with NPM educator training

2. Medical Preceptors: Medical faculty from Obstetrics and Gynecology, Pediatrics and Public Health with 3 years post PG experience/consultant

3. Guest faculty: NHM/MoH&FW officials/Experts from other fields

Teacher student ratio - 1:10

Preceptor student ratio - 1:10

No. of seats - Maximum 30 per batch

7.3.3 Physical facilities

1. Classroom - 1

2. Skills/simulation lab- 1 with necessary equipment and supplies

3. Library - Current nursing textbooks including midwifery, maternal, neonatal & journal (National and International publications), relevant GoI guidelines/modules

4. Teaching Aids -

■ LCD projector

■ Screen for projection

■ Computer

■ Laptop

■ Tablet for IT applications (For ex. Safe Delivery App, e-Partograph and other apps)

■ Connectors to project tab screens to external screen

■ 4 Mbps internet leased line

5. Office facilities for midwifery educators

7.3.4 Clinical facilities - Minimum Bed strength and other Clinical Facilities:

■ 100-200 bedded Parent Hospital having minimum 50 maternity beds or 50 bedded maternity hospital with an established MLCU

■ Labour room as per the LaQshya guidelines of Government of India

■ Minimum 6 labour tables/beds

■ Maternal and neonatal units

■ Case load of minimum 6000 deliveries per year

■ Maternity OT and Obstetric HDU/ICU

■ Separate Kangaroo Mother Care Unit

■ 8-10 level II neonatal beds

■ Affiliated Heath Sub-centre, Community Health Centre and Primary Health Centre

■ Referral links to tertiary care hospital

■ Affiliation to Tertiary Hospital - Medical College Hospital

■ Affiliation with level III neonatal beds

7.4. Admission Requirements

7.4.1 Eligibility for admission The candidate seeking admission to this program should have the following qualifications:

■ Be a RN & RM with Diploma in General Nursing and Midwifery or B.Sc. (Nursing) qualification.

■ Possess a minimum of two-years of recent clinical experience in the maternity care with passion toward midwifery.

■ In-service candidates are also eligible for admission and will be receiving their regular salary. Being a residency program, the other students undergoing the program will be given salary equivalent to their counterparts in the respective organization.

■ Age 45 years or younger at the time of admission.

Note: The candidate in order to practice midwifery during the period of training, has to obtain temporary/ transfer registration (RN & RM) in the respective state where the candidate is enrolled in the NPM program.

7.4.2 Selection process Selection Criteria and Process Overview for Recruitment of NPM is outlined below:

■ The Entrance exam will be conducted in two parts with certain percentage weightage for each component.

The overall score for entrance examination is 100 marks (60 for written test & OSCE and 40 for interview).

• Part 1 - Written Test and OSCE:

- Written Test (40%): Multiple Choice Questions and two short essay (2 hours duration) covering the areas of antenatal, intrapartum, postnatal, complication management and neonatal care. Short essays will be screened for technical proficiency as well as fluency in written English. Some weightage should be given for proficiency in written English.

- OSCE - Objectively Structured Clinical Examination (20%)

• Part 2 - Interview (40%)

Successful candidates who clear the written test and OSCE will be screened for the following at the interview:

(1) Motivational Screening (20%)

Based on the information provided in the personal statement of the candidate:

(a) Passion for woman's health-to provide respectful care for a positive birthing experience.

(b) Willingness to undergo the 18-month residential course at the designated SMTI

(c) Willingness to serve as individual practitioners of midwifery care-low-risk pregnancies and normal births as posted after the training

(2) Aptitude Assessment (20%) will be a part of interview process to ascertain spoken English language proficiency and communication, technical knowledge, leadership and advocacy for client's rights, and team spirit.

7.5. Organization of the Program

7.5.1 Distribution of the program in weeks (78 weeks):

First 12 months: 52 weeks

■ Annual Leave + Casual Leave + Sick Leave + Public holidays = 4 weeks

■ Exam preparation and examination = 2 weeks

■ Theory and practicum (Skill Lab & Clinical) = 46 weeks

Next 6 months: 26 weeks of internship

■ Annual Leave + Casual Leave + Sick Leave + Public holidays = 2 weeks

■ Exam (competency assessment) = 1 week

■ Internship experience = 23 weeks

7.5.2 Implementation of the Curriculum

First 12 months (46 weeks)

Total: 2055 hours

7.5.3 Distribution of the Courses for teaching (52 weeks = 2055 hours)

DETAILS

Block classes

3 weeks × 40 hours per week = 120 hours (Full theory block classes - Theory 90 hours + Skill lab 30 hours)

Clinical residency

43 weeks × 45 hours per week = 1935 hours (Theory - 140 hours + Skills lab - 65 hours + Clinical - 1730 hours)

• 140 hours of theory and 65 hours of skills lab to be integrated during clinical experience. Theory can be covered in the form of faculty lecture, clinical rounds, clinical presentations, drug presentations etc. First 35 weeks: 6 hours per week × 35 weeks = 210 hours (Theory - 140 + Skill lab - 65 hours and Next 8 weeks: 2-3 hours per week may be used for revision.

• A small individual/group research project to be conducted during clinical postings applying the steps of research process and written report to be submitted

Total = 230 hours (theory) + 95 hours (skills lab) + 1730 hours (clinical practice) = 2055 hours

7.6. COURSE OF INSTRUCTION

S.No.	Courses/Modules	Theory	Practicum {Skill Lab (SL) + Clinical Lab (CL)}	Areas of Clinical Postings
I	Module I: Foundations to Midwifery	90	20 SL + 180 CL	Integrated clinical practice at all maternity areas of the hospital
1	Indian Healthcare system & Maternal and Neonatal Health (MNH) scenario	10	20 CL
2	Professionalism and professional midwifery practice	18
3	Woman centered continuity of midwifery care & Respectful Maternity and Newborn Care	6	8 SL + 40 CL
4	Humanization of childbirth and the impact of communication	10	8 SL + 20 CL
5	Legal issues relevant to midwifery practice	6
6	Ethics in Midwifery	4
7	Education and counseling in midwifery	6	2 SL + 20 CL
8	Community engagement and Research ? Community responsibility & leadership and research informed practice	30	2 SL + 80 CL
II.	Module II: Normal pregnancy, birth, puerperium and care of newborn	100	40 SL + 980 CL
1.	Basic sciences applied to midwifery: Maternal, Fetal and Newborn Physiology, Pharmacology & diagnostics and Infection Control	40	12 SL + 210 CL	Integrated clinical practice
2.	Normal Pregnancy, Birth and Puerperium	50	22 SL + 680 CL	Antenatal OPD/ward Labour room/casualty Postnatal ward/OPD
3.	Care of the newborn	10	6 SL + 90 CL	SNCU/NICU/postnatal ward
III.	Module III: Complex care of woman and care of compromised newborn	40	35 SL + 570 CL
1.	Perinatal psychological health	4	60 CL	ANC ward/Labour room/ PNC ward
2.	Complex care of the woman	25	20 SL + 330 CL	Antenatal OPD/ward/ Obstetric HDU/ICU/Labour room/casualty/maternity OT/Obstetric HDU/ICU Postnatal ward/OPD/ Obstetric HDU/ICU
3.	Care of the compromised newborn	8	10 SL + 130 CL	NICU/Postnatal ward/OPD
4.	Healthy families and communities	3	5 SL + 50 CL	ANC OPD/Postnatal OPD/ ward/FP ward
	Total = 2055 hours	230 hours	95 SL + 1730 CL hours

7.7. Clinical Practice

7.7.1 Clinical Residency experience: A minimum of 45 hours per week is prescribed, however, it is flexible with different shifts and OFF followed by on call duty every week or fortnight.

7.7.2 Clinical postings: The students will be posted to the under mentioned clinical area during their training period

First 12 Months

S.No.	Clinical Area	Week/s
1	Antenatal (AN) OPD	6
2 3	Antenatal (AN) Ward	4 12
2 3	Labour Room	4 12
4	Postnatal (PN) Ward & OPD	4+1
5.	NICU (SNCU)	2
6	OBS Casualty	1
7	OBS OT	1
8 9 10 11	OBS ICU	2 1 4 4
	Family planning ward
	PHC/CHC
	MLCU
	TOTAL	42

Next 6 Months of Internship

S.No.	Clinical Area	Week/s
1	AN OPD & Ward	3
2	PN OPD & Ward	3
3	Labour Room	6
4	NICU (SNCU)	2
5.	OBS Casualty & ICU	3
6	OBS OT	1
7	PHC/CHC	3
8	Miscellaneous	1
	TOTAL	22

8. Teaching and Learning Teaching learning within the NPM curriculum draws on Experiential Learning theories. Experiential learning recognizes that learning is an active process that occurs as students interact with authentic activities, experiences and social encounters. The educational process is underpinned by respect, with educators modelling the respectful care and communication that these graduates will engage in with women. The student is intentionally situated at the center of learning and becomes directly involved in the process of constructing knowledge. As such, experiential learning relies on experience, as the source material and thoughtful reflection to facilitate learning. Providing 'real world' context to activities and experiences aligns students learning to the types of practice and complexities they might encounter as midwifery graduates. Motivation and engagement increase as students work with real-life situations that require decision-making that reflect the nature of maternity care environments and promote autonomous roles that need to be assumed upon completion of the program and called to lead midwifery care in MLCUs.

Experiential learning is also committed to minimizing the theory-practice gap that has been recognized as a challenge in contemporary tertiary health care education. Experiential learning integrates practice with theory, avoiding teaching and learning which occurs in silos. As part of the experiential learning pedagogy students will engage in significant practice experience through midwifery practicums. Practicums will be organized to reflect a diversity of clinical settings across the continuum of pre-conception, childbirth, to postpartum and will include hospital and community settings. Students will also be required to engage in defined continuity of care experiences where they follow women through their pregnancy, labour, birth and puerperium.

Complementing Experiential Learning in this program is Scenario-Based Learning (SBL) and reflective practice. SBL uses scenarios which reflect realistic situations, for example they may be based on case studies, critical incidents or narratives, which provide contextual material and/or learning triggers and provide an ideal environment for exploring practice, complexities and encourage critical thinking, problem solving and decision-making skills. The learning processes in SBL moves through phases that requires students to engage in the scenario, analyze the situation, identify learning needs, construct knowledge, reflect and apply learning. Scenario based learning is best provided through tutorials and flipped classroom, where students can access pre-tutorial readings and recorded lectures to support the interactive nature of the learning.

A dedicated simulated environment will be developed to provide a safe learning environment where students will have the opportunity through simulation workshops to develop midwifery skills, work in teams, explore scenarios and problems, and practice clinical decision-making. Carefully designed simulation activities will also provide the opportunity to develop communication skills relevant to the women's needs and health problems, including interacting with scenarios representing families from different demographic and cultural backgrounds, which is vital considering India's cultural and demographic diversity. Inter-professional learning may also be fostered through implementing team simulation scenarios.

Reflective practice assists students to learn from experience, both positive and negative and to gain new insights about themselves and practice. Gibbs cyclic model provides a six-stage approach to systematically reflect on an experience or activity; including description, feelings, evaluation, analysis, conclusion and an action plan.

Experiential learning supported by scenario based learning and reflective practice will be integrated throughout the curriculum in both theoretical and practice components. Teaching and learning arrangements will be organized to encourage collaboration and interaction, examples of teaching modes include tutorials and group work, online resources and lectures, smart classrooms, personal research and reflection, experiential workshops, journal club, post clinical reviews.

8.1 Teaching and Learning Methods

Gibbs Cycle

Classroom

Skills lab

Clinical

• Tutorials and workshop

• Lecture cum Discussion

• Experiential learning

• Self-directed learning (Annexure III. Learning resources)

• Problem based learning

• Practice teaching

• Micro teaching

• Audio-video assisted teaching

• Virtual learning - virtual classroom

• *Safe Delivery App/any other apps as self-directed learning

• Skill demonstration

• Simulation

• Scenario based reflective learning

• OSCE (plan and conduction)

• Role play

• Drills

• Microteaching - skill demonstrations

• Videos

• Clinical practice under supervision

• Independent clinical practice

• Bed side clinics

• Reflective learning

• Experiential learning

• Case presentation

• Case studies/discussions

• Health talk

• Clinical rounds/conference

• Drug study and presentation

• Microteaching - theory/skill demonstrations

• Field visit/report

• Logbook (Annexure-II)

Example: *EdTech based learning may be incorporated throughout the curriculum by integration of Safe Delivery App into the various teaching methodologies. The Safe Delivery App is a smartphone application that provides direct and instant access to evidence-based and up-to-date clinical guidelines on BEmONC. The SDA is used as a teaching and learning tool that covers 11 modules: Infection Prevention, Post Abortion Care, Hypertension, Active Management of Third Stage Labour, Prolonged Labour, PostPartum Haemorrhage, Manual Removal of Placenta, Maternal Sepsis, Neonatal Resuscitation, Newborn Management, Low Birth Weight.

8.2 Assessment Methods

8.2.1 Continuous Formative Assessments (Internal Assessment)

• Seminar

• Self-assessment through reflective learning as well as peer review

• Written assignments (Case studies, Case presentation, Case report etc.)

• Case study & Clinical presentation

• Group work

• Literature reviews

• Objective Structured Clinical Examination (OSCE)

• Practical assessments - teaching activities (health teaching sessions), simulation

• Written examination/Test papers - MCQs, short answers & essay type

• Competency Assessment

• Clinical performance/practice evaluation

• Quizzes

• Poster Presentations

• Online learning activities

• Class presentations including case studies

• Debates

• Peer Review

• Continuous assessment.

Midwifery practice experiences and reflection activities will be documented in a practice portfolio compiled over the duration of the program. Feedback will be sought from women and midwives (preceptors) with whom students work.

9. Examination Regulations

9.1 Scheme of Examination

Course/Paper	Int. Ass. Marks	Ext. Ass. Marks	Total Marks	Duration (in hours)
A. Theory
Paper I (Module 1)	25	75	100	3
Paper II (Module 2 & 3)	25	75	100	3
Theory Total	50	150	200
B. Practical
Midwifery	100	100	200
Practical Total	100	100	200
Grand Total	150	250	400

Note: The Theory and practical examination have to be conducted by the Respective examination board approved by the Council

9.2 Eligibility for Admission to Examination

■ Percentage of attendance in theory and practical before appearing for examination should be 90%.

■ Candidate who successfully completes the necessary requirement such as logbook and clinical requirements is eligible and can appear for the final exam.

■ However, students should make up 100% of attendance for integrated practice experience and internship in term of hours and activities before awarding the certificate

9.3. Supplementary Examination

• Failed candidates can appear for the supplementary examination after 6 weeks of the exam failed either theory or practical only.

• Number of attempts - 3

9.4 Examination Pattern (Theory & Practical)

Type of Exam	Internal (formative assessment)	External (summative assessment)
Theory	25 marks (tests, assignments, presentations)	75 marks (10 marks - MCQ, 30 marks - short answers, 35 marks - essay/scenario)
Practical	100 marks (20 for clinical performance + 20 for clinical assignments + 20 for OSCE + 40 for DOP)	100 marks (40 for OCSE + 60 for directly observed practical (DOP)
For practical examination maximum number of students per day = 10 students

9.4.1 Examiners for Practical examination

■ A panel of three examiners: NPM educators-2 (one internal and one external) and medical preceptor-1 (The examiners as well as the medical preceptor must be involved in teaching the program and be familiar with the curriculum)

9.4.2 Qualification of examiners

■ NPM educator, M.Sc. OBG nursing with 5 years of teaching and clinical experience after PG - dual role/M.Sc. OBG nursing with 5 years of experience as faculty with a minimum of 2 years midwifery clinical working experience.

■ Medical faculty/preceptor from Obstetrics and Gynecology, Pediatrics and Public Health with 3 years post PG experience/consultant.

10. Certification

A. Title - Nurse Practitioner in Midwifery (NPM)

B. A title is awarded upon successful completion of the prescribed study program, which will state that she/he

i. Has completed the prescribed course of Nurse Practitioner in Midwifery program for a period of 18 months

ii. Has completed 90% of the theoretical and 100% of the practical instruction hours before awarding the certificate.

iii. Has passed (70% marks both internal and external together) in the theory and practical examination

C. Certification will be done by the Examination Boards as approved by the Council. The SNRC will register NPM as an additional qualification

11. Course Details/Modules

Course Module I:

Foundations to Midwifery

Theory (T) - 90 Hours

Practicum: Skill Lab (SL) - 20 Hours

Clinical (CL) - 180 Hours

Course Aim

This course will enable the students to develop a deep understanding of midwifery as profession and the role and scope of the midwife in both the local and international context utilizing the principles of professional management, leadership and research informed midwifery practice.

Course Description Students will explore the history of midwifery in India; the Indian health care system, Maternal newborn health (MNH) scenario in India, National Family Health Survey; the legal, regulatory and ethical frameworks and requirements of midwifery practice, including code of ethics and professional conduct, jurisdictional laws, local policy and guidelines, respectful behaviour, human rights, humanizing birth, shared decision making, confidentiality and privacy. Midwifery models of care; global significance and the professionalism of midwifery along with the ICM essential competencies; professional accountability and transparency; inter-professional collaboration and teams; teaching, supervision and mentoring skills; personal and professional resilience; moral courage; clinical reasoning; self-care; and professional audit are also included. There will be a specific focus on respectful and compassionate communication and cultural competency. It will also include community responsibility and midwifery leadership. This course will also support students to develop lifelong learning skills including evidence-based practice; critical thinking skills, critical appraisal; research translation; reflective practice; documentation and record keeping.

Course Objectives

1. Demonstrate professional accountability for the delivery of midwifery care as per INC standards that is consistent with moral, altruistic, legal, ethical, regulatory and humanistic principles in midwifery practice

2. Identify the role of midwifery philosophy and practice in transforming maternity care in India and globally

3. Describe the importance of RMNC and develop strategies to promote respectful and compassionate care Demonstrate compassionate and effective communication skills for respectful and culturally competent midwifery care

4. Apply principles of evidence-based practice, critical thinking and reflection to support autonomous midwifery practice. Utilize the assessment and evaluation data to critically analyze and enhance midwifery practice

5. Explore how the midwife collaborates with the inter-professional health care team and value of respectful teamwork

6. Describe the advocacy role of the midwife for women, families and communities

7. Identify and apply legal and ethical principles and provisions for midwifery practice

8. Describe the importance of communication, education and counseling of women and families to participate effectively in midwifery care

9. Understand the role of the midwife as an agent of change for transformative practice

10. Analyse and apply principles of effective leadership, team building, negotiation and conflict resolution skills

11. Discuss appropriate management of midwifery resources and equitable access to midwifery care

12. Review the ethical principles and methodological approaches to research

13. Utilize research to inform practice

Competencies (ICM)

1. Assume responsibility for own decisions and actions as an autonomous practitioner (1a)

2. Assume responsibility for self-care including personal safety and self-development as a midwife (1b)

3. Appropriately delegate aspects of care and provide supervision (1c)

4. Utilize research to inform practice (1d)

5. Uphold the fundamental human rights of individuals when providing midwifery care (1e)

6. Adhere to jurisdictional laws ethical, regulatory requirements, codes of conduct for midwifery practice (If)

7. Facilitate women to make individual choices about care (1g)

8. Demonstrate effective interpersonal communication with women and families, health care teams, and community groups (1h)

Course Content

Unit	Hours	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
I	T-10 CL-20	• Build rapport with students and educator • Identify the previous experience of student peers and working in groups • Confidently begin their journey as NPM students • Articulate their understanding of becoming an NPM • Describe the vision for the new NPM • Review the structure and function of health care system in India. • Describe the provision of maternity care services exploring the new initiative and guidelines • Discuss trends, issues and complexities in relation to maternity care provision in India	Indian Healthcare System & MNH Scenario Introduction • Vision of the NPM course, overview and expectations • Accessing resources (online) • Seminar, tutorial and working in groups • Overview of course assessments, academic policies and procedures, group norms Indian health care system • Health care delivery system: National, State, District, and Village level with reference to MCH • Trends of maternity care in India • Maternity care services by GoI	• Icebreakers and get-to-know your activities • Tutorial • Group work • Online lecture • Self-directed learning • Integrated clinical practice	• Group seminar on Maternity care services by GoI	• Quiz • Essays • Short answers
		• Explain the epidemiology of maternal and neonatal health in India and various national health programs to address the issues • Discuss the Maternal and newborn health scenario in India • Describe the quality of care in MNH	Maternal and newborn health (MNH) scenario in India • Public Health for midwives • Epidemiological aspects and magnitude of maternal and neonatal health in India • Maternal and newborn health scenario in India • Community audit and death case review • Issues of maternal and neonatal health: Age, Gender, Sexuality, Psycho socio cultural factors, gender disparities • Women empowerment • Quality of Care in MNH	• Discussion and experiential learning • Scenarios • Self-directed learning • Supervised practice in, HSC/CHC	• Preparation & presentation of vital statistics records • Observation & implementation of national health programs at HSC/PHC/CHC • Literature search on MNH care	• Essays • Short answers • MCQ • Observation reports
II	T-18	• Demonstrate understanding of professionalism and exhibit professionalism in the midwifery practice • Explain the history of midwifery, various midwifery care models and the scope of midwifery practice • Apply the midwifery model of care in clinical practice • Describe the characteristics of midwifery care that promote physiological birth process • Explore the physical, social and cultural factors which impact on access to midwife-led care • Contextualize ICM competencies • Discuss autonomy and accountability within the context of midwife led care and continuity of care • Discuss the role of national midwifery organizations in terms of advocacy • Identify importance of inter-professional collaboration community agencies and institutions • Identify and reflect on critical practice incidents • Demonstrate self-reflection to recognise personal and professional limitations • Define and Apply critical thinking and clinical reasoning to care scenarios • Discuss importance of maintaining continuing midwifery competence and professional development. • Formulate a strategy for self-care and managing personal safety in midwifery practice • Demonstrate knowledge to assume responsibility for decisions and actions as an autonomous practitioner • Explore the role of the midwife as preceptor/mentor • Demonstrate understanding of this role in midwifery practice	Professionalism and professional midwifery • Professionalism: meaning and elements, accountability, visibility and ethics in midwifery practice • History of Midwifery • Current scenario: Midwifery in India • Introduction to philosophy of midwifery practice • Contemporary midwifery practice • Models of midwifery care - including distinction between midwives and other providers with midwifery skills • Midwife led care model, job description • Access and barriers to midwifery care, • ICM competencies for basic midwifery practice • ICM global standards of midwifery practice • Scope of midwifery practice: • Roles and scope of Nurse practitioner in midwifery • Trends in Midwifery • Autonomous role of midwife/NPM • Role of Professional organizations (National & state midwifery associations) and advocacy Inter-professional collaboration and teamwork • Framework for quality maternal and newborn care • Integrality framework (Lancet series) • Review of scope of practice and referral pathways • Communication and documentation. Reflective practice and Clinical reasoning • Reflective thinking and practice • Bass model of holistic reflection • Moral courage • Critical thinking and Clinical reasoning • Continuing professional development in midwifery Personal and professional resilience; self-care; human rights • Self-care • Resilience • Moral courage & Ethical practice • Accountability for practice • Support services, debriefing Teaching, mentoring and supervision • Teaching strategies appropriate to midwifery teaching • Mentorship, preceptorship • Clinical supervision • Respectful care and supervision	• Discussion and experiential learning • Self-directed and guided learning • Tutorial • Group work • Self-reflection • Application of midwifery model of care in clinical practice • Group discussion • Critical reflection conversations (groups of three) • Scenario • Group work • Group discussion ? Tutorial • Group work • Scenario based learning • Case review • Tutorial • Group work • Scenario based learning • Role play	• Self-study and self-reading of ICM code of Ethics • Personal philosophy of midwifery practice	• Essays • Short answers • MCQ • Assessment of assignment • Self-reflection and assessment of learning needs in relation to ICM competencies • Summative essay on the lancet series • Summative reflective practice cycle report • Formative reflective exercise • Formative group role play
III	T-6 SL-8 CL-40	• Describe the principles of woman centered care and the benefits to women and their babies • Define midwife-led care and midwifery continuity of care • Identify how midwife-led continuity of care affects maternity care, maternal and newborn outcomes • Link the practice of woman centred care to the provision of respectful maternity care • Develop strategies to promote respectful and compassionate maternity care • Describe the importance of RMNC • Review the principles of cultural competence • Explore the inequities faced by women from diverse cultural and hardto- reach communities • Discuss cultural competence within context of woman-centered care	Woman centered continuity of midwifery care & Respectful Maternity and Newborn care • Relationshipbased care & woman centeredness continuity of midwifery care • Compassionate care • Introduce continuity of care experience requirements within the program Respectful maternity and newborn care (RMNC) • What is RMNC • Type of care expected for women and family • Importance of RMNC in improving quality of care • Clients' rights for health care • Client Privacy • Social accountability, Creating Social and Cultural Barrier Free Environment • Behavior change strategy for RMNC services • RMC for women in MLCU's • RMC at all level of facilities o Preconception o During ANC o During labour o During delivery o During postpartum period • Newborn care integrated into RMC • Respectful communication - bereavement, maternal death, newborn death, IUD, still birth • RMC in complication • RMC during psychological morbidity of women postpartum • RMC for Differently-abled woman • Role of NPM in assuring RMNC in MNH service Integrating cultural competence • Cultural competence • Cultural safety • Cultural diversity • Myths and taboos related to childbirth	• Discussion and experiential learning • Role play • Video - RMNC • Integrated Clinical practice in maternity ward, • Tutorial • Group work • Scenarios • Selfdirected learning	• Role play on RMC • Exercises	• Evidence based essay • Short answers • MCQ • Assessment of clinical performance with Checklist • Self- reflection and assessment of learning needs in relation to ICM competencies • Self-assessment
IV	T-10 SL-8 CL-20	• Articulate the charter for human rights and the influence on midwifery practice • Describe how humanized care can impact on the woman's childbirth experience and communication • Communicate effectively with women, family and professional colleagues fostering mutual respect and shared decision making to enhance health outcomes • Recognize barriers to effective communication and challenges within diverse cultural communities • Discuss the importance of language and communication in promoting normal birth and building women's confidence, including working with pain in labour	Humanization of childbirth and the impact of communication • Humanization of childbirth • Charter of human rights • Respectful and compassionate communication and care • Childbirth experience • Woman centered language *Communication* • Channels and techniques of communication • Culturally sensitive communication • Team communication • Information technology tools in support of communication • Barriers to effective communication • Communication between woman and midwife to build woman's confidence and promote normal childbirth experience	• Interactive workshop • Tutorial • Group work • Scenario based learning • Lecture cum discussion • Communication workshop	• Role play •	Digital records • MCQ • Short answers • Engagement in workshop and reflection report • Evaluation of teaching plan for health education • Assessment of role playing
V	T-6	• Explain, legal and regulatory principles in midwifery practice within the legal framework of India • Describe the provision of maternity care services exploring the new initiative and guidelines • Identify key legislation governing the practice of midwives • Explain the types and elements of consent to health care • Apply beginning level knowledge of the law to common situations encountered within midwifery practice in India • Explore and reflect upon the nature of ethics and diverse moral and ethical outlooks people hold	Legal issues relevant to midwifery • National legal framework for Medical Practice including National Health Policy 2017 • INC regulations & Practice standards for midwifery and its rationale o Policies and procedures o Establishing standing orders and protocols • National Legal framework for midwifery practice and its implications • Adoption laws, MTP act, Pre-Natal Diagnostic Test (PNDT) Act, Surrogate mothers • Scope and specifics of national MNH Guidelines of the MoH&FW • Professional conduct and accountability • Informed consent • Record Keeping • Confidentiality • Documentation	• Discussion and experiential learning • Scenarios • Case discussions • Role play • Debate • Panel discussion	• Presentation - ethical and legal issues in midwifery	• Assessment of presentation
VI	T-4	• Explore and reflect upon the nature of ethics and of the diverse moral and ethical outlooks people hold. • Describe globally accepted ethical principles underpinning ethical maternity health care • Demonstrate understanding of the significance of the INC and ICM code of ethics and code of professional conduct	Ethics in Midwifery • Ethics • Ethical principles • Shared decision making • Ethical decision making • INC Code of ethics, • ICM codes of ethics • Professional boundary • Midwifery Code of ethics and its implications • Ethical (bioethics) issues in maternal and neonatal care • Codes of moral behavior, human rights • Professional values and professional conduct	• Tutorial • Group work • Online lecture • Scenario based learning • Case studies	• Assignment on ethical principles in midwifery and its importance	• Evaluate understanding of the application of ethical principles to situations encountered in midwifery practice
VII	T-6 SL-2 CL-20	• Discuss the principles and practice of health education with women and family throughout the childbearing cycle • Apply the counseling skills specific to reproductive and maternal health	Education and counseling in midwifery • Principles of teaching and learning • Principles and practice of health education throughout the childbearing cycle • Assessment of informational and educational needs of mothers and families • Developing education materials • Counseling • Active listening and Counseling skills specific to reproductive health • Women and family counseling during breaking bad news	• Peer teachingwomen and family education • Patient engagement Exercise (Ex. discharge planning for postnatal care at home) • Counseling sessions - Role play	• Conduct a group health education program for the antenatal women on preparation of labour & childbirth • Prepare education materials on relevant topic	• Assessment of prepared education materials
VIII	T-30 SL-2 CL-80		Community engagement & research informed practice
	T-2	• Discuss importance of ethics in research • Demonstrate knowledge of contemporary research ethics guidelines • Identify areas of research bias and how this influences knowledge production • Describe research limitations and restrictions	A. Research ethics, bias and research limitations • History of research ethics • National and international codes of ethics • Institutional ethics approval • Research ethics, Academic integrity • Types of research bias • Research limitations	• Tutorial • Group work		• Essays • Short answers • MCQ
	T-4	• Identify key philosophical concepts that underpin advocacy in midwifery practice • Identify key theories of change • Describe transformative midwifery practice • Demonstrate an understanding of contemporary leadership • Identify elements underpinning effective team building and negotiation skills • Identify strategies to respond to community needs	Community Responsibility & Leadership Midwifery leadership Midwife's roles • Advocacy, moral courage • Midwifery philosophy • Assertiveness • Human rights • Change theories • Agents of change • Transformative care • InnovationRhesus incompatibility Leadership • Leadership • Personality styles • Team building, Negotiation • Conflict resolution • Respectful communication • Emergency response, community development • Myer Briggs personality style	• Tutorial • Group work • Scenario based learning • Online resources • Personality quiz		• Essays • Short answers • MCQs • Summative continuous assessment - community development plan
	T-6 CL-40	• Describe role of NPM in leadership, management and supervision of maternal and neonatal care in various health care settings including MLCUs • Utilize advocacy skills and cultural competence for promoting midwifery education and midwife led continuum of care • Discuss the sustainable development goals • Explore equitable access to midwifery care • Review strategies for effective management of midwifery resources • Demonstrate knowledge of Midwifery led care units	Management in MLCU • Management • Definition, principles and elements • Management of (time, material and personnel) MLCU/ Maternity unit and NICU • Team management • Soft skills • Transportation services for high risk mothers and newborn • Maintenance of Records & Reports • Nursing and midwifery audit • Clinical audits - MDSR (maternal death surveillance and response); CDR (clinical data repository) • Infection prevention protocols • Quality assurance of MNH services • Quality assurance of midwifery training • Clinical supervision • Introduction, definition and objectives • Principles and functions • Qualities of supervisor • Responsibilities of clinical supervisors • Access to resources and resource management o SDG o Equitable distribution of resources o Resource management o Equity and rights, midwifery led continuity of care units o Environment concerns	• Discussion and experiential learning • Scenarios • Case studies • Role play • Observation	• Exercises/case studies	• Essays • Short answers • MCQ • Summative continuous assessment - midwifery led unit incorporated into community plan
	T-2	• Compare and discuss of qualitative and quantitative research paradigms • Describe methodologies associated with these paradigms	B. Research Informed Practice Introduction to research methodologies • Introduction to methodology • Epistemology and ontology in research • Overview of qualitative and quantitative research paradigms	• Tutorial • Group work • Online resources		• Essays • Sort answers • MCQ
	T-6 CL-40	• Differentiate and describe the main quantitative and qualitative research methodologies • Formulate a research question • Develop a quantitative research question • Critically evaluate an example of quantitative research • Identify and apply critical research tools to quantitative research articles	Quantitative & qualitative research • Overview of quantitative and qualitative methodologies • Research questions in quantitative and qualitative research • Data Collection and Analysis • Statistics • Preparing research proposal • Practice challenges • Research critique • Use of critiquing tool	• Group work • critique of quantitative research paper • Development of Research questions for quantitative research and qualitative research	• Research project proposal plan • Conduct of research	• Group presentation on research methodologies
	T-4 SL-2	• Devise a literature search based on research questions. • Identify key words; employ Boolean operators and MeSH headings • Identify and select relevant literature • Analyse and synthesise research literature. • Conduct a literature review	• Literature review Literature search strategies o Literature search, data base, keywords o Boolean operators • Selection of relevant literature • Critical appraisal, analysis and synthesis • Writing literature review, formulating recommendations	• Tutorial • Self-directed study • Critique and selection of papers	• Review of literatures for research project	• Critical analysis and Literature review
	T-4	• Identify the different sources of Data and Evidence for Midwifery Practice	Data Sources and Evidence for midwifery practice (EBMP) • Facility/District/ State - available registers, HMIS, DLHS • Indian - NFHS, RHS, SRS, HMIS, DLHS, AHS, Census, MOHFW GoI guidelines • Global standards - WHO/ICM recommendations, COCHRANE; State of Worlds Reports • Evidence based Midwifery practice • Data base search	• Tutorial • Self-directed study • Evidence review	• Literature search on MNH care • Research study based on area of work (e.g. WHO Intrapartum recommendations or LAQSHYA indicators) • EBMP - Journal club	• Essays • Short answers • MCQ • Assessment of assignments • Assessment of completed research study presentation and report
	T-2	• Discuss the purpose of research dissemination • Identify research dissemination methods • Apply knowledge translation techniques (design poster) • Design poster based on literature review findings	Research dissemination and knowledge translation • Purpose and methods of research dissemination • Knowledge translation and practice change	• Group work • Designing posters	• Presentation of poster • Group work (critique) • *Research symposium*	• Formative poster and research presentation

Course Module II:

Normal Pregnancy, Birth, Puerperium and Care of Newborn

{1. Basic Sciences applied to midwifery, 2. Normal pregnancy, birth & puerperium and 3. Care of newborn}

Theory (T) - 100 Hours

Practicum: Skills Lab (SL) - 40 Hours

Clinical (CL) - 980 Hours

Course Aim Drawing on the Council's philosophy and ICM essential competencies for midwifery practice, the course aims to enhance the Knowledge and skills to promote physiological birth and provide skilled, knowledgeable, respectful and compassionate midwifery care to the woman and newborn in both community and institution. The review of knowledge of basic sciences that include anatomy and physiology of reproduction and fetal development, pharmacology & diagnostics and infection control supports the midwifery practice in facilitation of normal physiological birth.

Course Description This course module is designed to enable the NPMs to review the principles of related biological and behavioral sciences and midwifery to promote physiological birth and provide respectful quality care that includes anatomy and physiology of male and female reproductive system, conception, menstruation and ovulatory cycle; normal physiological changes that occur in pregnancy, labour, birth and puerperium; fetal growth and development, fetal circulation; normal neonatal physiology; development and pharmacology & diagnostics and infection control.

Antenatal care that includes assessment and screening, antenatal education and empowerment; Intrapartum care that includes 1st, 2nd 3rd and 4th stage of labour, assessment of progress, supporting women in labour and birth, promotion of physiological birth; working with pain with non-pharmacological and pharmacological pain relief, assessment of fetus, assessment of perineal trauma, perineal suturing; active and expectant management of 3rd stage, timely referral; and postnatal care that includes maternal care, transition to parenthood - mother, father and family, promoting attachment, skin to skin, establishing breastfeeding, managing breastfeeding challenges, documentation, reporting, community care are dealt in detail. It will address the knowledge and skills required to develop quality practice skills care for the newborn and promote a healthy transition to life that includes immediate care of the newborn, newborn assessment, essential newborn care; complete physical examination; newborn health needs; nutritional needs of the newborn, skin to skin; breastfeeding; maternal newborn bonding; growth and development of the infant; prophylactic measures; immunisaton; providing evidence based information to parents; consideration of cultural norms; and respectful care to newborn.

Course Objectives

1. Demonstrate professional accountability for the delivery of midwifery care as per the Council's standards that are consistent with moral, altruistic, legal and ethical and regulatory and humanistic principles in midwifery practice

2. Discuss the anatomy and physiology of the female reproductive system and conception

3. Explain fetal and placental growth and development

4. Describe the maternal physiological changes that are associated with pregnancy, labour and birth and puerperium

5. Assess and provide pre pregnancy care including counseling

6. Assess and provide care for women in the antenatal, intranatal and postnatal period including conduction of normal deliveries

7. Assess and provide care for neonates

8. Describe the primary physiological adaptations that the newborn undergoes following birth and the physiological basis of secure bonding and attachment.

9. Demonstrate sound knowledge of applied pharmacology and principles of prescribing

10. Identify and use medicines appropriately in midwifery, obstetric emergencies and complex situations as per GoI guidelines

11. Implement infection control practices in maternal and newborn care facilities

Competencies: (ICM)

1. Adhere to jurisdictional laws, regulatory requirements, code of conduct for midwifery practice (1f)

2. Provide pre-pregnancy care (2a)

3. Determine health status of woman (2b)

4. Assess the fetal wellbeing (2c)

5. Monitor the progression of pregnancy (2d)

6. Promote and support health behaviors that improve their wellbeing (2e)

7. Provide anticipatory guidance related to pregnancy, birth, breastfeeding, parenthood, and change in the family (2f)

8. Detect, manage, and refer women with complicated pregnancies (2g)

9. Assist the woman and her family to plan for an appropriate place of birth (2h)

10. Promote physiologic labour and birth (3a)

11. Manage a safe spontaneous vaginal birth and prevent complications (3b)

12. Provide care of the newborn immediately after birth (3c)

13. Provide postnatal care for the healthy woman (4a)

14. Provide care to healthy newborn infant (4b)

15. Promote and support breast feeding (4c)

1. Basic Sciences applied to Midwifery

Theory: T - 40 hours, Skill Lab: SL - 12 hours, Clinical: CL - 210 hours

A. Maternal, Fetal and Newborn Physiology

Unit	Hours	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
1	T-3 SL-4	• Review the reproductive system • Understand the female hormonal cycle (ovarian and uterine)	Review of anatomy & physiology of human reproductive system • Anatomy and physiology of human reproductive system: • Hormonal cycles ? Female pelvis and Fetal skull (with fetopelvic relationships)	• Discussion and experiential learning • Self-directed learning	• Presentations/seminars • Demonstration - female pelvis and fetal skull	• Essays • Short answers • MCQ
2	T-4 SL-2	• Understand the process of fertilization and conception • Understand placental development and function • Demonstrate knowledge of fetal growth and development in early pregnancy.	Embryology and Fetal growth and development • Fertilization and Implantation • Embryological development • Placental development • Placental function; blood brain barrier • Fetal development • Fetal circulation • Fetal nutrition	• Tutorial • Group work • Online lecture • Self-directed learning	• Foetal circulation - schematic representation	• Evaluation of the assignment
3.	T-3 SL-2	• Recognize physiological changes in early pregnancy across the body systems • Understand the interaction of pregnancy hormones	Physiological changes in pregnancy • Physiological changes in early pregnancy including; cardiovascular, hematological, endocrine, digestive, respiratory, uterine, renal, immune system musculoskeletal, integumentary • Hormones of pregnancy • Ongoing signs of pregnancy	• Tutorial • Group work • Online lecture • Self-directed learning		• Quiz • Educational resource development

B. Pharmacology and Diagnostics

Unit	Hours	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
1	T-3	• Discuss the role of pharmacology in safe and effective midwifery practice • Discuss factors that determine the safe use of medicines • Describe the regulation, scheduling and classification of medicines in India • Define pharmacodynamics and its role in medication use • Understand the principles of pharmacokinetics	Review of Pharmacology • Role of pharmacology in safe and effective midwifery practice • Classification and schedule of drugs • Principles of safe drug administration • Regulation, safe use of medicines • Pharmacokinetics and pharmacodynamics Mechanisms of • Drug action/reaction • Drug absorption, • Drug distribution • Metabolism and excretion, • Principles of pharmacokinetics and pharmacodynamics	• Lecture • Group work • Self-directed study		• Quiz
2	T-3	• Understand how medicine moves between the blood and the placenta or breast milk and factors that affect this movement • Identify important considerations for the use of medicines during pregnancy and breastfeeding • Identify medicines known to cause birth defects • Identify medicines that may adversely affect breastfeeding • Explain the prevention and treatment(s) of drug side effects	Medicines in pregnancy and breastfeeding • Blood brain barrier • Teratogens and its effect • Medicines and Birth defects • Pregnancy risk and drug classification • Advice to women and family (including special precautions while taking medicines)	• Lecture • Group work • Self-directed study		• Quiz
3	T-4	• Demonstrate an understanding of the pharmacological basis of action of medicines used to manage conditions in pregnancy • Describe the adverse effects associated with medicines • Explain the prevention and treatment(s) of drug side effects • Demonstrate an understanding of the pharmacological basis of treatments used in the management of pain • Identify specific analgesic medicines that are not recommended for use during pregnancy and breastfeeding	Commonly used medicines and their side effects • Classification, Mechanism of action, Dosage, Uses, Side effects • Drugs use in pregnancy, labour and breast feeding: Oxytocin, ergometrine, Misoprostol, analgesia • Antibiotics • Antipyretics and • Anti-inflammatory agents • Antiemetic • Laxatives • Vitamins, • Antifungal • Anthelminthic.	• Scenarios • Case study • Tutorial • Group work • Self-directed study	• Drug presentation & Case reports	• Case study • MCQ • Short answers • Essays
4	T-10 CL-90	• Understand and implement the principles of safe drug administration • Administer the correct drug treatment as per regulations • Understand medicine calculations • Prescribe permitted drugs for women as per the protocols	Prescription and safe administration of medicine • Fundamentals of prescribing • Principles of prescribing and factors influencing it • Implications of wrong practices related to prescribing (using case studies) • Prescriptive role of Nurse Practitioners • Professional, legal and ethical issues relevant to prescribing practice • o Process and steps of prescribing • o Prescribing competencies • List of drugs that can be administered by nurse practitioner as approved by GoI • Implications of wrong practices related to prescribing (using case studies) • Side effects (classification and management) • Drug calculations and the 8 rights of drug administration • Safe drug administration • Informed consent • Documentation: accurate and complete records	• Scenarios • Case study • Tutorial group work • Simulation workshop • Reflective learning log and interactive discussion/ learning • Experiential/Clinical placement under the preceptorship of medical expert • Integrated Clinical practice in maternal neonatal areas • Writing prescription • Review of literaturelaws and regulations, trends of nurse prescribing practice	• Drug dosage calculation • Drug presentation & Case reports	• Simulated OSCE • MCQs • Short answers • Essays • Case-study analysis
5	T-3 CL-40	• Demonstrate understanding of supplementation • Identify nonpharmacological principles of working with pain	Non Pharmacological Therapy: Complementary therapies and supplementation • Vitamin supplementation • Complementary therapies • o Acupressure, Acupuncture • o Yoga • o Reflexology o Water birth	• Scenarios • Case study • Tutorial group work	• Demonstration of various complimentary therapies during labor	• Simulated OSCE • MCQs • Short answers • Essays
6	T-3 SL-2 CL-40	• Identify screening tools used to determine risk • Understand the use of technology in pregnancy and labour • Consider the over use of technology in midwifery care • Demonstrate skills in performing selected diagnostic/screening procedures for women	Technology and diagnostics • Screening, use of ultrasound • Ferning • Speculum exam • Bishops score • CTG - Clinical reasoning, • Vaginal smear • Visual inspection with acetic acid (VIA) • PAP smear • Collection, treatment of various specimens, and preparation of them for Examination	• Scenarios • case study • Tutorial group work • Simulation workshop • Demonstration on collection of various specimens and specific tests		• Essays • Short answers • Simulated OSCE

C. Infection Control

Hours	Unit	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
T-4 SL-2 CL-40	Infection Control	• Explain the infection control policies • Demonstrate skills in infection control practices • Explore and reflect on the role of NPM and health team in infection prevention	Infection Control • National guidelines and institutional policy • Principles of prevention of infection • Standard precautions for prevention of infections o Hand washing o Use of protective attire o Processing of used items/equipment o Proper handling and disposal of sharps o Maintaining a clean environment o Biomedical waste disposal *National infection control guidelines o Role of NPM and health team in infection prevention/control	• Discussion and experiential learning • Games • Demonstration using IP materials • Skill demonstrations - infection practices to reach expert level in IP • Videos • Clinical practice • Self-directed learning • Safe Delivery App module on IP	• Review notes on national guidelines • Draw from clinical experience and write infection control related practice standards	• OSCE/OSPE

2. Normal Pregnancy, Birth and Puerperium

Theory: T - 50 hours, Skill Lab: SL - 22 hours, Clinical: CL - 680 hours

Unit	Hours	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
1	T-4 CL-40	• Identify and implement the chain of referral system • Identify and apply policies and protocols required to stabilize women and newborn for referral	Chain of Referral system • Review of Laws and regulations of India that govern midwifery practice • Existing chain of referral system • Limitations and possibilities of other health care providers • Policy and protocols for referral, range of strategies • Conditions requiring referral, when, where and how to refer for each condition • Transport arrangements: community resources, advice to families and referral note • Follow up: feedback on cases referred • Records and reports on referrals	• Discussion and experiential learning • Supervised clinical practice	• Writing referral slip/note • "Emergency referral" action cards in the safe delivery app (SDA)	• Essays • Short answers • MCQ
2	T-4 SL-2	• Facilitate a [partnership] with women through continuity of care • Explain the significance of pre pregnancy care • Recognize birth as a normal life event for women and their families • Provide preconception care for eligible couples • Provide information and develop skills to enable shared decision making in midwifery practice • Understand and advocate for planned parenthood	Beginning the pregnancy journey • Pre pregnancy Care • Review of Sexual development (Self Learning) • Socio-cultural aspects of human sexuality (Self Learning) • Evidence based screening for health problems such as diabetes, hypertension, thyroid conditions, and chronic infections that impact pregnancy • Pre-conception counseling (including awareness regarding normal births) • Planned parenthood • Genetic counseling (Self-Learning) • Assess and confirm pregnancy•	Discussion and experiential learning • Demonstration • Role play – counselling • Tutorial • Group work • Case study	• Preconception counseling • History taking and assessment of health status of women • Assessment of nutritional status and screening of women	• Evaluation of skills using checklist • Assessment of clinical performance with using checklist • Evidence based essay
3	T-6 SL-2 CL-50	• Respond effectively to women's individuality, lack of knowledge their social and cultural contexts. • Explain the significance of antenatal care for the women and family • Demonstrate skills in providing antenatal care, health education for pregnant women and continuity of care • Promote equity and access to care during pregnancy • Recognize birth as a normal life event for women and their families. • Describe the need for documentation and record keeping	Pregnancy assessment and midwifery care during 1st Trimester • Review of Normal pregnancy • Review of Maternal nutrition and malnutrition • Diagnosis of pregnancy - signs and symptoms, differential diagnosis, confirmatory tests • Definition, nature, objectives and importance of antenatal care √ Building partnership with women following RMC protocol • Antenatal assessment: History taking, physical examination, breast examination, obstetrical and pelvic examination (Leopold's maneuvers), laboratory investigation • Identification and management of minor discomforts of pregnancy • Antenatal care and counseling (lifestyles in pregnancy, nutrition, shared decision making, risky behavior in pregnancy, counseling regarding sexual life during pregnancy etc.) • Screening for antenatal anxiety • Screening for family violence √ Point of Care and One Stop service during ANC • Danger signs during pregnancy √ Birth preparedness and complication readiness (including promoting "Normalcy during pregnancy") √ Childbirth preparation √ Respectful care and compassionate communication • Recording and reporting √ Clinical procedures as per the GoIs guideline √ Various models of ANC and their evolution √ GoI current model of ANC provision √ Role of Doula/ASHA's √ Role of nurse practitioner in midwifery	• Discussion and experiential learning • Demonstrations • Bed side clinics • Case discussions • Seminar • Nursing rounds • Supervised clinical practice in antenatal OPD and ward • Self-directed learning • Skilled Birth Attendant module • Online lecture • Scenario based learning	• Health education • Case presentation • Bed side clinic • Clinical Conference • Antenatal history taking and assessment • Draw a micro-birth plan • Laboratory investigations : perform and interpret - UPT, Hb estimation, HIV/Syphilis testing; urine analysis for albumin and sugar • Assessment of fetal wellbeing • Antenatal counselling	• Essays • Short answers • MCQ • Assess clinical skills using procedure checklists • Assess clinical performance using rating scale • OSCE/OSPE
4	T-5 SL-2 CL-45	• Demonstrate knowledge of midwifery practice throughout the 2nd trimester • Maintain woman centered relationshipbased care • Assess fetal growth and development • Discuss management for existing disease or pathology • Facilitate ethical midwifery practice promoting maternal autonomy and choice	Midwifery care during 2nd trimester of pregnancy • Education and management of physiological changes and discomforts of 2nd trimester • Rh negative and prophylactic anti D • Second trimester tests and health education • Interpreting screening results • Health education on IFA, calcium and vitamin D supplementation, glucose tolerance test, immunization etc. • Informed decision making • Antenatal assessment: abdominal palpation, fetal assessment, auscultate fetal heart rate -Doppler and pinnards, • Assessment of fetal well-being: fetal pattern, DFMC, biophysical profile, Non stress test, cardiotocography, USG, Vibro acoustic stimulation, • 2nd trimester antenatal care, √ Women centered care √ Respectful care and compassionate communication √ Referral and collaboration, empowerment √ Ongoing risk assessment √ Maternal Mental Health √ Role of Doula/ASHAs	• Tutorial • Group work, • Online lecture • Scenario based learning • Case study • Simulation workshop	• Case presentation • Bed side clinic • Clinical Conference • Antenatal history taking and assessment • Assessment of fetal wellbeing • Antenatal counselling	• Quiz • Competency based assessment • OSCE
5	T-5 SL-3 CL-50	• Demonstrate knowledge of midwifery practice throughout the 3rd trimester • Maintain woman centered relationshipbased care to develop birth plan • Provide antenatal and preparation for birth and breastfeeding education to build each woman's confidence	Midwifery care during 3rd trimester of pregnancy • Physiological discomforts during 3rd trimester • Third trimester tests and screening • Fetal engagement in late pregnancy • 3rd trimester antenatal education classes, • Birth preparedness and complication readiness • Health education on exclusive breastfeeding √ Danger signs of pregnancy - recognition of ruptured membranes √ Ongoing risk assessment √ Cultural needs √ Women centered care √ Respectful and compassionate communication √ Alternative birthing positions-women's preferred choices • Role of Doula/ASHA's	• Tutorial • Group work • Online lecture • Scenario based learning • Case study • Simulation workshop • Demonstration of birthing position	• Case presentation • Bed side clinic • Clinical Conference • Antenatal history taking and assessment • Draw a micro-birth plan • Assessment of fetal wellbeing • Antenatal counselling	• Quiz (end of course exam) • Competency based assessment
6	T-5 SL-2 CL- 120	• Apply the physiology of labour • Describe how a midwife builds a woman's confidence and provides respectful cares for the women during labour • Encourage the role of birth companion during labour • Discuss the effect of the midwife's (and other team members) language on the woman's emotional wellbeing • Discuss how to maintain an environment for labour in which the woman feels safe • Working effectively with pain during labour	Midwifery care during first stage of labour Review of • Normal labour and birth • Onset of birth/labour • Per vaginal examination (if necessary) • Stages of labour √ Organization of labor room- Triage, preparation for birth √ Positive birth environment √ Respectful care and communication First Stage: • Physiology of normal labour • Monitoring progress of labour • Using Partograph • Pain relief in labour (nonpharmacological and pharmacological) • Assessing and monitoring fetal well being • Psychological support - Managing fear • Activity and positioning for labour • Nutrition during labour • Care during 1st stage of normal labour √ Positive childbirth experience for women √ Birth companion for labour √ Safe environment for mother and newborn to promote bonding √ Role of Doula/ASHA's √ Evidence based theories (eg: becoming a mother) and practice in relation to labour interventions	• Discussion and experiential learning • Bed side clinics• Case discussions • Seminar • Simulation • Video • Demonstrations • Supervised clinical practice in labour ward • SBA, IMNCI, NSSK modules • LaQshya guidelines	• Bed side clinic • Health education • Case presentation • Clinical Conference • Case study • Plotting and interpretation of partograph • Supervised clinical practice	• Essays • Short answers • MCQ • OSCE/OSPE • Assessment of skills using procedure checklist • Assess clinical performance with rating scale
7	T-5 SL-2 CL- 120	• Apply knowledge of the physiology of birth to midwifery care • Discuss how the midwife provides care and support for the women during birth to enhance physiology and promote normal birth	Midwifery care during second stage of labour • Physiology (Mechanism of labour) • Signs of imminent labour • Intrapartum monitoring √ Birth position of choice • Warm compresses • Vaginal examination (if necessary) • Management-preparation and supporting birth • Psychological support • Non directive coaching √ Role of Doula/ASHA's	• Tutorial • Group work • Online lecture • Scenario based learning • Case study • Simulation Workshop	• Clinical scenarios	• Essays • Short answers • OSCE/OSPE
8	T-5 SL-2 CL- 100	• Assessment and care of the newborn immediately following birth.	Midwifery care during 3rd Stage of labour • Physiology - placental separation and expulsion, homeostasis • Physiological management of third stage of labour • Active management of third stage of labour • Examination of placenta, membranes and vessels • Assess perineal, vaginal tear/injuries and suture if required • Immediate perineal care • Essential newborn care (ENBC) • Initiation of breast feeding • Skin to skin contact • Vitamin K prophylaxis • Newborn resuscitation	• Tutorial • Group work • Online lecture • Scenario based learning	• Case study • Simulation	• Essays • Short answers • OSCE/OSPE
9	T-3 SL-3 CL-20	• Discuss the impact of labour and birth as a transitional event in the woman's life • Ensure initiation of breast feeding and adequate latching	Midwifery care during 4th Stage of labour • Observation, Critical Analysis and Management of mother and newborn • Maternal assessment, observation fundal height, urine output, blood loss √ Documentation and Record of birth √ Breastfeeding and latching √ Managing uterine cramp √ Alternative/complementary therapies √ Role of Doula/ASHA's √ Various childbirth practices • Safe environment for mother and newborn to promote bonding	• Tutorial • Group work • Online lecture • Scenario based learning • Case study • Simulation Workshop		• Essays • Short answers • OSCE/OSPE
10	T-8 SL-4 CL- 135	• Demonstrate integration of the role of midwife in the care of woman • Explore the maternal physiological changes following birth • Understand the physiology of lactation and composition of breast milk • Demonstrate skill in caring for postnatal women • Understand homeostasis and nutritional requirements of the newborn	Postpartum care/ Ongoing midwifery care of women Review of • Normal Postpartum period • Physiology of puerperium • Post-natal assessment and care - facility and home-based care • Perineal hygiene and care • Bladder and bowel function • Minor disorders of puerperium and its management • Physiology of lactation and lactation management √ Postnatal counseling and psychological support √ Normal postnatal baby blues and recognition of postnatal depression √ Transition to parenthood • Care for the mother from 72 hours to 6 weeks after the delivery √ Cultural competence (Taboos related to postnatal diet and practices) √ Evidence based practice in relation to postnatal and newborn care. • Knowledge on Postpartum family planning methods • Follow-up	• Discussion and experiential learning • Demonstration • Simulations • Bedside rounds/clinics • Case discussion • Role play • Safe Delivery App video on feeding	• Seminar • Case studies • Clinical presentation • Counseling mothers for breast feeding - techniques and position • Health talk • Postnatal assessment • Supervised clinical practice in postnatal ward and OPD	• Essays • Short answers • MCQ • Assessment of skills with procedure check list • OSCE/OSPE

3. Care of Newborn

Theory: T - 10 hours, Skill Lab: SL - 6 hours, Clinical: CL - 90 hours

Unit	Hours	Learning Outcomes	Content	Teaching Learning Activities	Assignments	Methods of Assessment
1.	T-2	• Discuss the need for compassionate, family centered midwifery care of the newborn and how this is provided • Discuss how the woman and family's views and beliefs are respected • Understand that actions and interventions carried out on baby need to be fully explained and informed consent obtained	Family centered care • Concept of Family centered care • Partnership and cultural competency • Respectful care and communication • Informed consent and shared decision making	• Tutorials and group work • Scenarios	• Group discussion on family centered midwifery care	• Essays • Short answers
2	T-2 SL-4 CL-30	• Discuss preparation for newborn at birth • Explain the midwife's role in observing and assessing the newborn immediately after birth • Explore the physiological adaptions that the newborn undergoes following birth • Demonstrate skills in caring for normal newborns in the presence of mother	Ongoing care of newborns • Assessment and management of normal neonates Review of: • Normal neonate - physiological adaptation • Newborn assessment and care • Screening for congenital anomalies • Care of newborn from 72 hours to 6 weeks after the delivery (Routine care of newborn) • Skin to skin contact • Thermo regulation • Infection prevention (asepsis and hand washing)	• Discussion and experiential learning • Demonstrations • Self-directed learning • Seminar • Case discussion • Safe Delivery App module on newborn management and risk management • Supervised clinical practice in postnatal ward/NICU/Nursery	• Case presentation/ Case study • Health talk • Newborn assessment	• Essays • Short answers • MCQ • Assessment of skills with procedure check list • Assessment of clinical performance with rating scale
3	T-3 CL-30	• Identify the newborn at risk and give relevant immediate care • Understand the process to refer unwell newborns • Educate the mother and family on prevention, recognition, and management of common newborn problems	Risk identification and referral • Risk Identification and referrals • Minor disorders of newborn and their management • Newborn screening, • Signs of distress and risk assessment, • Identification of complications, management and referral as per IMNCI protocol • Documentation and record • Health education to the mother and family about the management of common newborn problems	• Tutorials and group work • Scenarios • Simulation workshops • Online lecture		• Case study
4	T-2 SL-2 CL-20	• Discuss the benefits of breastfeeding for the baby and mother Understand the composition of breast milk. • Discuss the recommendation of exclusive breastfeeding for six months • Explain how to help a mother succeed with the first breastfeeding and recognize if the baby is breastfeeding well. • Explain and demonstrate how to express breast milk and storage • Understand the BFHI	Nutritional needs of the newborn and establishing breastfeeding • Breastfeeding • Breast milk composition • Benefits of breastfeeding for the newborn and mother • Lactation management: Breast feeding techniques and positions, rest and nutrition for mother during breastfeeding • Exclusive breastfeeding • Expression and storage of breast milk • Signs of hunger • Supportive environment for breastfeeding • Baby Friendly Hospital Initiative (BFHI) guidelines • Health education to mother and family on breastfeeding	• Tutorials and group work • Scenarios • Simulation workshops • Online lecture		• Formative quiz • Competency based OSCE • Summative exam
5	T-1 CL-10	• Understand the midwife's role in immunization • Demonstrate skill in immunization of the newborn.	Immunization • Immunization • Importance of immunization • Health education to family on current immunization schedule	• Tutorials and group work • Scenarios • Simulation workshops • Online lecture • Self-directed learning	• Case scenariomidwife's role in immunization	• Demonstrate skill in immunization of the newborn

course Module III:

Complex Care of Woman and Care of Compromised Newborn

Theory (T) - 40 Hours

Practicum: Skill Lab (SL) - 35 Hours

Clinical (CL) - 570 Hours

Course Aim This course will prepare the student to provide skilled, knowledgeable, compassionate and respectful midwifery care across the continuum of childbirth for mothers facing deviation from normalcy, in both community and institution. This course will examine the physiological impact of pre-existing health challenges and medical disorders experienced during pregnancy as well as pathophysiological response to deviations from normal and complications in the woman, fetus and newborn.

Course Description This course will build on the knowledge obtained from the previous courses and will examine the pathophysiological impact of nutritional deficiencies, pre-existing medical disorders and existing disease burden in India as well as pathophysiological response to deviations from normal; including hypertensive, endocrine, haematological, haemorrhagic, metabolic disorders and obstetric emergencies. This module is designed to enable the NPMs to develop skills in identifying women with deviations from normal during the antenatal, intranatal and postnatal period and abnormal newborns and provide specialized care for them. The NPMs would be able to implement the national health programs with special reference to family welfare and women's health. The module consists of Perinatal Psychological Health, Complex care of woman and care of compromised newborn.

Course Objectives

1. Assess and provide care for women in the antenatal, intranatal and postnatal period facing complications

2. Assess and provide care for neonates with problems

3. Identify deviations from normalcy, stabilize and transport women and neonates to the higher centers

4. Explain how common pre-existing health challenges interact with the physiological changes during pregnancy to increase the risk of complications.

5. Explain the pathophysiological responses that occurs in the woman, fetus and newborn in response to deviations from normal and obstetric emergencies

6. Understand the pathophysiology underlying common fetal and neonatal disorders, complications and congenital abnormalities

7. Recognize and assess deviations from normal physiology during pregnancy, labour and birth and the puerperium

8. Plan and provide evidence-based and compassionate, woman-centred midwifery care for women experiencing complications during the antenatal, intrapartum and postpartum period.

9. Demonstrate effective clinical skills and appropriate use of technology in the care of women with complications and/or obstetric emergency

10. Understand the impact of complications on the psychological, social and cultural wellbeing of women and their families and the importance of continuity of care.

11. Describe the legal responsibilities associated with complications during the antenatal, intrapartum and postpartum period

12. Identify the need for referral and inter-professional collaboration in managing the care of women with complex needs.

13. Recognize woman who experiences physical and sexual violence and partner abuse and provide appropriate support and referral

14. Promote health of families and communities and provide family welfare services

Competencies (ICM)

1. Assess the health status, screen for health risks, and promote general health and well-being of women and infants(1j)

2. Prevent and treat common health problems related to reproduction and early life(1k)

3. Recognize conditions outside midwifery scope of practice and refer appropriately(1l)

4. Detect, manage, and refer women with complicated pregnancies (2g)

5. Provide care to women with unintended or mistimed pregnancy (2i)

6. Detect and treat or refer postnatal complications in woman(4d)

7. Detect and manage health problems in newborn infant (4e)

8. Care for women who experience physical and sexual violence and abuse (1m)

9. Provide family planning services (4f)

1. Perinatal Psychological Health

Unit	Hours	Learning Outcomes	Content	Learning Activities	Assignments	Assessment
1	T-2 CL-20	• Describe common mental disorders impacting on pregnancy • Describe the principles of care for women with mental disorders in the perinatal period • Explain the impact of anxiety and depression on women and their families • Describe the tools and process for psychological screening in the perinatal period • Describe the management of mental disorders in the perinatal period	Perinatal mental health disorders • Perinatal mental health • Perinatal anxiety and depression • Severe mental illnesspsychosis • Borderline personality disorder • Comorbidity and complexity in mental health • Substance abuse and mental illness • Trauma informed care principles • Assessment and screening, • EPND • ANRQ • WEMWBS • Referral, management plans • Managing suicide risk • Psychopharmacology • Compassionate care and communication	• Tutorial • Group work • Scenario based learning • Reflective practice • Case study	• Online resources on perinatal mental health	• MCQ • Short answers • Essays • Continuous assessment including case report
2.	T-1 CL-20	• Explore the impact of perinatal death and trauma on the woman and her family • Demonstrate a sound understanding of the process of grief and the response of the midwife to support bereaved families	Perinatal death, trauma and grief • Post-traumatic stress disorder • Grief, debriefing, grief counselling • Domestic violence, signs of abuse	• Tutorial • Group work • Simulation workshop • Scenario based learning• Reflective practice	• Journal club - perinatal mental health	• MCQ • Short answers • Essays
3.	T-1 CL-20	• Consider the impact of postnatal transition on perinatal mental health • Explain the importance of mother infant attachment • Develop strategies to promote personal wellbeing	Perinatal wellbeing • Transition, maternal wellbeing • Mother-infant attachment • Circle of security • Personal mental wellbeing strategies• Knowledge of supports and services and for women	• Tutorial • Group work • Simulation workshop • Reflective practice • Supervised clinical practice	• Group work - Scenario based learning	• Educational resource • Group presentation

2. Complex care of the woman

Unit	Hours	Learning Outcomes	Content	Learning Activities	Assignments	Assessment
1	T-2	• Demonstrate ability to detect complications early, take appropriate action and timely refer a woman for management at higher level • Highlight the midwives' roles and responsibilities in early diagnosis • Demonstrate skill in undertaking a risk assessment and referral • Discuss legal and ethical practice in relation to complex care • Discuss collaboration and team work in management of complexity • Effective communication, collaboration, team work and referral	Principles of recognition and assessment of risk • The midwife within own scope of practice recognises and assesses deviations from normal • Demonstrates effective clinical skills and critical knowledge for women with complications during the pregnancy (definition, signs and symptoms, management as per protocols and guidelines in place) • Assessment skills and clinical judgment based on the adequate decision-making framework • Documentation and follow up on her risk assessment • Law and ethics in relation to complex care • Effective communication • Collaboration, team work and referral	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning	• Clinical scenarios - Women with complications	• MCQ • Short answers • Essays
2.	T-2 CL-30	• Assess women with miscarriage and provide post abortion care	Complex care in case of Miscarriage and post abortion care • Definition and classification of abortion • Etiology, modes of termination of pregnancy • Diagnostic evaluation for abortion • Management of abortion • Post abortion care including psychological support • MTP act	• Discussion and experiential learning • Demonstrations • Case discussions • Safe Delivery app modules on post abortion care	• Discussion and experiential learning • Demonstrations • Case discussions	• Assessment of clinical performance with rating scale
3	T-5 SL-5 CL-60	• Demonstrate knowledge in midwifery practice to recognise, assess and manage deviations from normal physiology during the pregnancy • Demonstrate competencies to provide care during pregnancy	Recognition and Management of problems during Prepregnancy and Pregnancy • Gender based Violence • Culture sensitivity • Emotional abuse and physical neglect • Female genital mutilation • High-risk pregnancy • Review of Complications during pregnancy (definition, causes, signs and symptoms, diagnosis management and complications) o Bleeding in early pregnancy: √ Abortion √ Ectopic pregnancy √ Hydatidiform mole o Bleeding in late pregnancy: √ Antepartum haemorrhage (APH) - Placenta previa, Abruption placenta o Hyperemesis gravidarum o Pregnancy induced hypertension√ Pre-eclampsia and management √ Eclampsia o Multiple pregnancy o Oligo/Polyhydram nios o Role of NPM in managing Medical conditions in pregnancy √ Anemia in pregnancy √ Gestational diabetes mellitus √ Cardiac disease √ Pulmonary disease √ Thyrotoxicosis, √ Epilepsy √ Sexually transmitted diseases √ HIV/AIDS √ Rh incompatibility √ Infections in pregnancy - urinary tract infection, bacterial, viral, protozoal, fungal - malaria, dengue, TB o Intrauterine growth restriction o Premature rupture of the membranes o Prolonged rupture of membranes o Multiple pregnancy, o Placental dysfunction o Intrauterine fetal death o Gynecological disorders complicating pregnancy o Adolescent pregnancy, elderly primi gravida and grand multipara • Decision making for management and referral	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning • Clinical practice • Presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning • Bedside clinics • Demonstration • Simulation • Safe Delivery app modules on Hypertension etc. • Supervised clinical practice in antenatal ward/OPD/ Obstetric IUC	• Health assessment, screening and management of high risk mothers • Health education • Case presentation/ Case study • Procedures to be performed/ assisted per the log-book	• Formative quiz, summative final examination • Essays • Short answers • MCQ • Assessment skills using procedure checklist • Assess clinical performance with rating scale • OSCE • Evaluation of case study/case presentation
4	T-5 SL-5 CL-100	• Demonstrate knowledge in midwifery practice to recognise and assess deviations from normal physiology during labour • Discuss malpresentation during labour • Demonstrate competencies to provide care during complications in labour • Provide first line measures to treat or stabilize identified conditions • Explain timely refer for management at higher level • Identify, provide initial management and refer women with problems during labour within the scope of midwifery practice. • Facilitate communication link between the midwife, women and families. • Collaborate with the obstetricians in the management of obstetric emergencies and complications • Ensure safe environment for the mother and newborn.	Complex care in labour • Complications in labour (definition, signs and symptoms, management as per protocols and guidelines in place) • Preterm labour and antenatal corticosteroid management • Induction and augmentation of labour • Precipitate labour • Prolonged and obstructed labour • Fetal distress in labour, • Malposition and malpresentations (definition, signs and symptoms, management as per protocols and guidelines in place) √ Transverse lie √ Oblique lie √ Breech √ Face √ Brow √ Compound Presentation √ Unstable lie √ Occipito-posterior positions √ Rhesus incompatibility √ Document and keep accurate record	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning • Clinical practice • Presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning • Bed side clinics • Demonstration • Self-directed learning • Seminar • Case discussion • Simulations • Safe delivery app modules • Supervised clinical practice in labour room/obstetric casualty/Obstetric IUC, operation theatre	• Case Presentation • Bed side clinic • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination • OSCE • Essays • Short answers • MCQ
5	T-4 SL-4 CL-30	• Recognise and respond effectively to emergencies or urgent situations • Demonstrate competencies to provide care during complications of birth • Seek for appropriate help • Collaborate effectively with health professional in managing the emergency • Timely refer for management at higher level • Provide appropriate psychosocial support to the woman and their families	Complex care during birth • Obstetric emergenciesdefinition, signs and symptoms • Role of NPM in managing the emergencies as per protocols and guidelines in place • Amniotic fluid embolism • Obstructed labour • Constriction ring, ruptured uterus • Cord prolapse • Vasa previa • Shoulder dystocia • Uterine inversion role of NPM • Postpartum hemorrhage: types, causes and management o Manual removal of placenta o Bimanual compression of uterus o Aortic compression, o Uterine balloon tamponade • Vaginal and cervical inspection • Rapid initial assessment and management of different shocks • Blood transfusion • Pharmacology for emergency obstetric	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning • Clinical practice • Presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning • Bed side clinics • Demonstration • Self-directed learning • Seminar • Case discussion • Simulations • Safe delivery app modules • Supervised clinical practice in labour room/obstetric casualty/ Obstetric IUC, operation theatre	• Case Presentation • Bed side clinic • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination • OSCE • Essays • Short answers • MCQ
6	T-3 SL-2 CL-30	• Demonstrate knowledge regarding the need for intervention during birth • Demonstrate skills to assist or perform intervention during birth when required for emergency care • Counsel and support women (and families) with complications and emergencies	Interventions during complicated birth Forceps delivery • Indications and contraindications • Preparation for procedure • Dangers to mother and child • Management of Forceps delivery Vacuum extraction • Indications and contraindications • Preparation for procedure • Dangers to mother and child • Management of vacuum extraction Caesarean section • Types e.g. elective or emergency • Indications and contraindications • Pre-operative care • Procedure (role of the midwife) • Post-operative care Episiotomy, perineal and cervical lacerations; suturing • Destructive delivery/ embryotomy • Pharmacology for surgical conditions, document and keep accurate record	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning • Clinical practice • Presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning	• Case Presentation • Bed side clinic • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination • OSCE • Essays • Short answers • MCQ
7	T-1 SL-2 CL-30	• Demonstrate knowledge of the deviations from normal during the third stage of labour. • Demonstrate competencies to provide care during complications of the third stage of labour	Complex care during the third stage of labour • Complications of third stage -definition, signs and symptoms • Management as per protocols and guidelines in place	• Tutorials • Group discussion • Scenario based learning • Role play • E-learning • Clinical practice • Clinical presentation • Simulation workshop • Low dose high frequency skill development • Discussion and experiential learning • Bed side clinics • Demonstration • Self-directed learning • Seminar • Case discussion • Simulations • Safe delivery app modules • Supervised clinical practice in labour room/obstetric casualty/ Obstetric IUC, operation theatre	• Case Presentation • Bed side clinic • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination • OSCE
8.	T-2 CL-50	• Identify, provide initial management and refer women with postnatal problems within the scope of midwifery practice • Develop rapport with the women and families for continuity of care	Complex care during the puerperium (Recognition and Management of postnatal problems) Review of: • Physical examination, identification of deviation from normal • Review of puerperal complications and its management o Puerperal pyrexia o Puerperal sepsis o Urinary complications o Secondary Postpartum hemorrhage o Vulval hematoma o Breast engorgement including mastitis/breast abscess, feeding problem o Thrombophlebitis o DVT o Uterine sub involution o Vesico vaginal fistula (VVF), Recto vaginal fistula (RVF) o Postpartum blues/psychosis • Decision making about management and referral • Clinical procedures as per the guidelines	• Discussion and experiential learning • Bedside clinics	• Preparation of health talk • Clinical presentation-plan & report • Self-directed learning • Seminar • Case discussion • Supervised clinical practice in postnatal ward/postnatal OPD/obstetric casualty/ operation theatre ? Safe Delivery App module on Sepsis • Discussion on variety of case studies/ simulation scenarios to practice decision making	• Essays • Short answers • MCQ • Assessment of skills with procedure check list
9	T-1 SL-2	• Demonstrate knowledge and ability to manage basic life-saving skills and adult CPR	Resuscitation of the woman • Basic life-saving skillsadult CPR	• Experiential learning • Reflection • Role play • E-learning • Simulation workshop • Low dose high frequency skill development		• OSCE

3. Care of the Compromised Newborn

Unit	Hours	Learning Outcomes	Content	Teaching and Learning Activities	Assignments	Assessment
1.	T-1 SL-2	• Discuss the scope of midwifery practice in care of the compromised newborn • Describe the Indian context for newborn care and the different level of interventions • Discuss Indian contribution in meeting the sustainable development goals (SDGs) • Appreciate the importance of bonding in case of a compromised newborn • Communicate respectfully and compassionately with the mother and her family despite complex situation of care • Understand the importance of evidence-based practice in improving the quality of care provided	Context of neonatal care in India and the approach of different models of newborn care • Newborn mortality - major causes in India • Models of newborn care in India - NBCC; SNCUs; NICU • Home based newborn care program • History taking and physical examination of newborn • Identification of high-risk • Adequate documentation and record keeping • Civil Rights and Vital Statistics (CRVS) • Birth notification and Birth registration • Information to parents on importance of registering births • Issuance of birth notification and Linkage to a birth registration point	• Tutorials • Group discussion • Scenario based learning • Reflection		• Critical reflection • Evidence based review/ report
2	T-2 SL-2	• Demonstrate knowledge to detect complications of the newborn early, take appropriate action and timely refer at higher level • Distinguish normal variation in newborn appearance and behaviour from those indicating pathologic conditions • Discuss complication at birth affecting the newborn	Care of Compromised neonate during birth • Needs of pre-term and low birth weight infants (definition, signs and symptoms of common health problems and complications; immediate and ongoing treatment and management) • Complications at birth affecting the neonate (definition, signs and symptoms of common health problems and complications; immediate and ongoing treatment and management); respiratory distress, birth injuries, hypothermia and hyperthermia, newborn sepsis; recognize the need for suction/ventilation; perform basic resuscitation of a newborn baby using appropriate equipment; calculation of drug dose and administration of specified drugs; arrange referral and/or transfer as needed	• Tutorials • Group discussion • Scenario based learning • Reflection • Clinical practice • Seminar presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning • Demonstration • Self-directed learning • Seminar • Case discussion • Safe delivery app video on newborn resuscitation, newborn management and low birth weight module • Supervised clinical practice in NICU/PN ward/well baby clinic	• Clinical presentation • KMC • Newborn assessment • Newborn resuscitations • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination; OSCE • Essays • Short answers • MCQ • Assessment of skills with procedure check list • Assessment of clinical performance with rating scale
3	T-1 CL-20	• Demonstrate knowledge to detect complications of the newborn presenting an infection, take appropriate action and timely refer at higher level • Demonstrate competencies to provide care for the sick newborn and discuss his/her condition and prognosis • Collaborate effectively with health professional in managing the newborn situation	Compromised newborn with infection • Neonatal infection (definition, signs and symptoms of common health problems and complications; immediate and ongoing treatment and management) • Sepsis, meningitis, pneumonia, etc • Diarrhea Respiratory Infections, Pus or lesions/eyes, Red foul smelling umbilicus, Abdominal distension, Swollen limb or joint • Pemphigus neonatorum, Omphalitis, Neonatorum tetanus • Care of infants born of HIVpositive mother; ARV prophylaxis (national PMTCT guideline) • Symptoms and treatment of withdrawal from maternal drug use • Prevention of mother-to-child transmission of infections such as HIV, hepatitis B and C • Calculation of drug dose and administration of specified drugs • Document and keep accurate record • Protocols for screening for infectious conditions	• Tutorials • Group discussion • Scenario based learning • Reflection • Clinical practice • Seminar presentations • Simulation workshops • Low dose high frequency skill development • Discussion and experiential learning • Demonstration • Self-directed learning • Seminar • Case discussion • Safe delivery app video on newborn resuscitation, newborn management and low birth weight module • Clinical practice in NICU/PN ward/well baby clinic	• Clinical presentation • KMC • Newborn assessment • Newborn resuscitations • Procedures to be performed/ assisted/ observed as per the log-book	• Formative quiz, summative final examination • OSCE • Essays • Short answers • MCQ • Assessment of skills with procedure check list • Assessment of clinical performance with rating scale
4.	T-1 CL-20	• Demonstrate knowledge to detect complications of the newborn presenting a metabolic disorder, take appropriate action and timely refer at higher level • Demonstrate competencies to provide care for the sick newborn and discuss his/her condition and prognosis • Discuss metabolic disorders of the newborn	Compromised newborn with metabolic disorder • Metabolic disorders (definition, signs and symptoms of common health problems and complications; their immediate and ongoing treatment) • Jaundice, Inborn errors of metabolism, • Hypo-glycaemia • Baby of diabetic mother • Phenylketonuria • Immediate identification and care to the sick neonate • Calculation of drug dose and administration of specified drugs; • Document and keep accurate record • Protocols for screening for metabolic conditions	• Tutorials • Group discussion • Scenario based learning • Reflection • Clinical practice • Seminar presentations • Simulation workshops • Low dose high frequency skill development		• Formative quiz, summative final examination • Essays • Short answers • MCQ • Assessment of skills with procedure check list • Assessment of clinical performance with rating scale
5	T-1 SL-2 CL-20	• Demonstrate ability to detect complications of the newborn presenting a metabolic disorder, take appropriate action and timely refer at higher level • Demonstrate competencies to provide care for the newborn with abnormal condition and discuss his/her condition and prognosis • Discuss abnormal conditions of the newborn	Compromised newborn with abnormal condition • Abnormal conditions of the newborn (definition, signs and symptoms of common health problems and complications; their immediate and ongoing treatment), • Cerebral dysfunction/irritation/hemorrh age • Congenital and genetic malformations • Muscle-skeletal disorders; Soft tissue abnormalities • Chromosomal abnormalities • Haemolytic and hemorrhagic diseases of the newborn • Immediate identification and care to the sick neonate • Calculation of drug dose and administration of specified drugs; document and keep accurate record • Protocols for screening for congenital abnormalities	• Tutorials • Group discussion • Scenario based learning • Reflection • Clinical practice • Clinical presentations • Simulation workshops • Low dose high frequency skill development		• Formative quiz, summative final examination • Essays • Short answers • MCQ • Assessment of skills with procedure check list • Assessment of clinical performance with rating scale
6.	T-1 SL-2 CL-40 •	Discuss the implementation of the IMNCI in the context of India • Describe midwifery's contributions in improving community and family health practices; promote health education • Demonstrate competencies in providing care for the newborn within midwifery practice	Global public health action in neonatal and childhood care • Integrated management of neonatal childhood illness (IMNCI) Three components: • Capacity building of health workers • Health system strengthening and improving community and family practice • Cost-effective strategy which can improve child survival (In Indian context main focus on capacity building and less attention on system strengthening or improving community practices)	• Tutorials • Group discussion • Scenario based learning • Reflection • Clinical practice • Clinical presentations • simulation workshops • low dose high frequency skill development • Risk assessment	• Group work- Clinical condition and management as per IMNCI	• Formative quiz, summative final examination • OSCE
7	T-1 SL-2 CL-30	• Demonstrate ability to detect feeding complications of the compromise newborn • Discuss the different modes of feeding a compromised newborn	Feeding in compromised newborn Feeding problems of the newborn • Calculation of fluid requirements • Promote EBM whenever possible and appropriate/formula feeds/tube feeding • Maintain the bonding • Provide adequate care for the mother in case of weaning;	• Tutorials • Group discussion • Experiential learning • Reflection • Clinical practice • seminar presentations • simulation workshops • Low dose high frequency skill development • Group discussion	• Demonstrate competencies in feeding compromised newborn	• MCQ • Short answers • Essays • OSCE/OSPE

4. Healthy families and Communities

Unit	Hours	Learning Outcomes	Content	Learning Activities	Assignments	Assessment
1	T-1 SL-2	• Discuss the scope of midwifery practice in public health to promote healthy communities • Demonstrate knowledge of principles of epidemiology, sanitation, community diagnosis and vital statistics or records in community-based midwifery	Public Health approach: Information, Education and Communication (IEC) • Community Mobilization • Development committee in Primary Health Care Services • Community Diagnosis • Situational Analysis • Health Education/Promotion, incl. guidance and counseling/social and behavior change communication (SBCC) • Apply the principles of community mobilization to promote maternal, newborn and child health • Conduct a comprehensive assessment of maternal and newborns, including their families, at community level.	• Tutorials, group discussion • Scenario-based learning • Role play • E-learning • Clinical practice	• Role play - SBCC	• Develop a public health action and implement that includes SBCC
2	T-1 SL-3 CL-30	• Explore the role and responsibilities of the midwife towards social norms on family planning • Demonstrate knowledge of national standards, protocols and regulations in the provision of quality family planning services, including referral for advanced management • Demonstrate knowledge of different family planning methods, including emergency contraception • Demonstrate competencies in providing differentiate counselling on FP to woman/man/coup le, adolescent girl/boy	Family planning • Planned Parenthood, • Impact of early frequent childbearing • Definition and history of FP national and international • Legal and Rights aspect of FP • Socio-economic, cultural, religious beliefs • myths, misconceptions and custom which affect clients' • Acceptance of FP • Health education and counseling in family planning using Balanced Counselling Strategy (BCS) • Male and Community Leaders involvement in family planning • Human rights aspects of FP adolescents/youth friendly services for FP • Create a safe, secure and effective counselling space • Various family planning methods method of administration, mode of action, advantages and disadvantages, effectiveness, side effects, indication and contradictions, complications, client instruction • Create a safe, secure and effective counselling space • Collaborate with key stakeholders in providing midwifery and family planning care in the community	• Tutorials, group discussion • Scenario-based learning • Role play • E-learning • clinical practice, seminar presentations; • simulation workshops: • low dose high frequency skill development • Discussion and experiential learning • Demonstration • Self-directed learning • Supervised clinical practice in PN ward/PN OPD/FP ward/ PHC/CHC/HSC		• Formative quiz, summative final examination • OSCE
3	T-1 CL-20	• Demonstrate competencies in mainstreaming Gender in the midwifery practice • Integrate concepts of gender-based violence and sexual and reproductive health in managing childbearing families • Provide compassionate care and legal guidance o survivors of GBV; if required direct to protection centers/shelters	Gender related issues in SRHR • Definition of Gender • Gender prescribed roles • Human rights and Legal frameworks - international, regional and national • Situation of the girl child and the status of women in society • Gender based violence • Concept of obstetric violence • Root causes, effects (physical, psychological and sexual) • Effects of gender related issues on SRHR • Gender inequalities in reproductive health issues • Strategies to overcome gender-based violence • Advocacy for equal opportunities for men and women • Family Protection Centers for abused individuals • Special courts for abused people • Gender sensitive health services/provisions including family planning • Male involvement in SRH issues	• Tutorials, group discussion • Scenario-based learning • Critical reflection • Role play • E-learning	• Group work- Situation analysis of women in the society and obstetric violence	• MCQ • Short answers • Long Essays

12. Annexures

Annexure - I

Roles and Responsibilities of the NPMs

The unique and major role of NPMs is promoting the health of women and childbearing families. The NPMs

■ Work with women to promote self-care and the health of women, infants and families

■ Respect and treat women with human dignity and as persons accorded full human rights

■ View pregnancy as a normal physiologic life event

■ Monitor the physical, psychological, spiritual and social well-being of the woman and her immediate family throughout the childbearing cycle

■ Provide the woman with personal culturally appropriate advice, education, counselling, support and antenatal care

■ Provide respectful maternity care

■ Render continuity of care to women from pre pregnancy, antenatal, during labour, childbirth and immediately postpartum and ongoing support during the postnatal period

■ Establish rapport in order to develop self-confidence in the woman to give birth and adapt to her new family dynamic

■ Minimise unnecessary technological interventions during childbirth

■ Identify the onset of complications, give emergency care and refer women and or newborns who require obstetrical or other specialist attention

■ Focus on health promotion and disease prevention throughout the child bearing cycle

Annexure -II

Clinical Logbook for Npm (Procedural Competencies/Skills)

S.No.	Specific procedural competencies/skills	Performs independently/ Performs collaboratively with doctor/Assists doctor in procedures (P/PC/A)*	Date & signature of the faculty
1	ANTENATAL CARE
1.1	Health assessment of antenatal woman: History taking, Physical examination and obstetrical examination	P
1.2	Urine pregnancy test	P
1.3	Estimation of hemoglobin using sahli's hemoglobinometer/true Hb-P	P
1.4	Preparation of peripheral smear for malaria	P
1.5	Urine testing for albumin and sugar	P
1.6	Point of care HIV test	P
1.7	Point of care syphilis test	P
1.8	Preparation of mother for USG	P
1.9	Perform USG	PC
1.10	Kick chart/DFMC (daily fetal movement count)	P
1.11	Preparation and recording of CTG/NST/CST	P
1.12	Preparation/Assisting woman for antenatal investigations - amniocentesis, cordocentesis, Chorionic villus sampling A
1.13	Antenatal counseling - diet & exercise	P
1.14	Administration of TT/Td-P	P
1.15	Prescription of iron and folic acid tablets
1.16	Prenatal counseling and care of general and vulnerable groups such as adolescent pregnant mothers	P
2	INTRANATAL CARE
2.1	Identification, assessment and admission of woman in labour	P
2.2	Perform CTG	PC
2.3	Vaginal examination during labour including Clinical pelvimetry	P
2.4	Plotting and interpretation of partograph	P
2.5	Preparation for delivery - physical and psychological	P
2.6	Setting up of the delivery room/unit	P
2.7	Pain management during labour - non-pharmacological	P
2.8	Conduction of normal delivery	P
2.9	Episiotomy only if required and repair	P
2.10	Essential newborn care	P
2.11	Active management of third stage of labour	P
2.12	Examination of placenta	P
2.13	Care during fourth stage of labour	P
2.14	Initiation of breast feeding and lactation management	P
2.15	Assessment and weighing of newborn	P
2.16	Administration of Vitamin K	P
3	POSTNATAL CARE
3.1	Postnatal assessment and care	P
3.2	Perineal/episiotomy care	P
3.3	Breast care	P
3.4	Postnatal counseling-diet, exercise & breast feeding	P
3.5	Postpartum family planning	P
4	NEWBORN CARE
4.1	Assessment of newborn including gestational age	P
4.2	Baby bath	P
4.3	Kangaroo Mother Care	P
4.4	Identification of minor disorders of newborn and their management	P
4.5	Neonatal immunization - Administration of BCG, Hepatitis B vaccine-P	P
5	CARE OF WOMAN WITH COMPLICATIONS/HIGH RISK MOTHER
5.1	Identification of antenatal complications - pre-eclampsia, anemia, Antepartum hemorrhage	P
5.2	Glucose challenge test/Glucose Tolerance test	P
5.3	Administration of MgSO4	P
5.4	Identification of fetal distress and its management	P
5.5	Preparation of woman for emergency/elective caesarean section and assisting in caesarean	A
5.6	Prepare the mother and perform vacuum delivery when favourable	P
5.7	Vacuum delivery	PC
5.8	Diagnosis of malpresentations and malpositions	P
5.9	Diagnosis and management of cord presentation/cord prolapse	P & PC
5.10	Early diagnosis of preterm labor	P
5.11	Prepare assess suitability for and conduct breech delivery when favorable	P
5.12	Breech delivery	PC
5.13	Infection prevention during labor and newborn care	P
5.14	Diagnosis and management of prolonged labour	P
5.15	Prepare and perform low forceps operation	P
5.16	Forceps operation	A
5.17	Manual removal of the placenta	PC
5.18	Diagnosis and initial management of PPH - Bimanual compression of uterus, Balloon tamponade for atonic uterus, Aortic compression for PPH, Application of anti-shock garment, prescription and administration of fluids and electrolytes through intravenous	P & PC
5.19	Repair of perineal and vaginal tears (upto II degree)	P
5.20	Repair of perineal and vaginal tears (above II degree)	PC
5.21	Identification and first aid management of obstetric shock	P
5.22	Manage obstetric shock	PC
5.23	Diagnosis and management of puerperal sepsis	P & PC
5.24	Management of breast engorgement	P
5.25	Management of thrombophlebitis	P & PC
6	HIGH RISK NEWBORN
6.1	Identification of highrisk newborn	P
6.2	Neonatal resuscitation	P
6.3	Assisting in neonatal diagnostic procedures A
6.4	Feeding of high risk newborn -EBM(spoon/paladai)	P
6.5	Insertion/removal/feeding - Naso/oro gastric tube	P
6.6	Administration of medication - oral/parenteral	PC
6.7	Neonatal drug calculation	P
6.8	Oxygen administration	P
6.9	Care of neonate in incubator/warmer/ventilator	P
6.10	Neonatal intubation/ventilator	PC
6.11	Care of neonate on phototherapy	P
6.12	Assist in exchange transfusion A
6.13	Organizes different levels of neonatal care	P
6.14	Transportation of high risk newborn	P
7	FAMILY WELFARE
7.1	Family planning counseling	P
7.2	Distribution of temporary contraceptives - condoms, OCP's, emergency contraception	P
7.3	Insertion and removal of Interval IUCD	P
7.4	Insertion and removal of PPIUCD/PAIUCD	P
7.5	Preparation of the woman for Postpartum sterilization	P
7.6	Prepare and assist in tubectomy A
8	OTHER PROCEDURES
8.1	Prepare and assist for D&C/D&E operations A
8.2	Perform Manual Vacuum Aspiration	P & PC
8.3	Post abortion care	P
8.4	Post abortion family planning services	P
8.5	Post abortion counseling	P
8.6	Pre-conception nutritional assessment, screening HIV,Cervical cancer	P
8.7	Preconception counseling and care	P
8.8	Pap smear	P
8.9	Visual inspection with acetic acid/iodine	P
8.10	Counseling on breast self-examination	P
8.11	Conduction of maternal and perinatal death audit	PC
8.12	Maintenance of registers	P
8.13	Maintenance of records	P

* When the learner is found competent to perform the skill, the faculty/trainer will sign it.

Learners: are expected to perform the listed skills/competencies many times until they reach level 3 competency, after which the faculty signs against each competency.

Faculty/Trainers: Must ensure that the signature is given for each competency only after they reach level 3.

• Level 3: competency denotes that the leaner is able to perform that competency without supervision

• Level 2: Competency denotes that the learner is able to perform each competency with supervision

• Level 1 :competency denotes that the learner is not able to perform that competency/skill even with supervision

Annexure - III

Clinical Requirements For Npm Program

S.No.	Clinical Requirement	Date	Signature of the Faculty/Preceptor
1	Antenatal assessment and care - 70
2	Postnatal assessment and care - 70
3	Assessment of labour using partograph - 40
4	Per vaginal examination if required - 20
5	Witnessing Conduction of birth - 10
6	Conduction of delivery (independent) - 40
7	Assisting conduction of abnormal/assisted delivery - 15
8	Placental examination - 10
9	Episiotomy and suturing if indicated - 10
10	Insertion of Interval IUCD - 5
11	Insertion of PPIUCD/PPIUCD - 5
12	Newborn assessment - 25
13	ENBC - 25
14	Newborn Resuscitation - 5
15	Kangaroo Mother care - 5
16	Antenatal care study - 1 Diagnosis:
17	Postnatal care study - 1 Diagnosis:
18	Newborn care study - 1 Diagnosis:
19	Clinical presentation – 4 ■ Antenatal : ■ Intra natal : ■ Postnatal : ■ Newborn :
20	Health talk ■ Antenatal - Topic: ■ Post-natal - Topic ■ Newborn - Topic: ■ Family welfare - Topic:




21	Counseling mothers &family members 1. 2.
22	Bed side clinics - 2 1. 2.
23	Clinical Seminar/Clinical Conference Topic:
24	Drug study, presentation and report - 1 Drug:
25	Visits - report • Peripheral health facility
26	Project/Journal Club: Evidence based midwifery practice (Individual/Group) - 1 Topic:
27	Continuity of Care experiences 15

Signature of the Program coordinator

Annexure - IV

Clinical Experience Details for Npm Program

Area of Posting	Clinical Condition	Number of days care given	Signature of Faculty/Preceptor

Signature of the Program coordinator

Annexure - V

Learning Resources

GoI Guidelines (MNH)

• LaQshya - Labour Room Quality Improvement Initiative Guideline

• Guidelines for standardization of labour rooms at delivery point

• Dakshata - Empowering Providers for Improved MNH Care during Institutional Deliveries

• SBA-Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs, Hand book and trainers Guide

• IMNCI training modules, photo and chart booklets

• Navjat Shishu Suraksha Karyakram guidelines

• Routine Immunization Handbook for Health Workers

• Postpartum FP handbook for Service Providers

• IUCD reference manual for medical officers and nursing personnel

• PPIUCD reference manual

• Operational guidelines: Introduction of Haemophilus influenza b (Hib) as Pentavalent Vaccine in Universal Immunization Program of India

• Use of antenatal corticosteroids in preterm Labour

• Facility based IMNCI (F-IMNCI) (Participants manual and Chart booklet)

• Guidance note on use of Uterotonics during labour

• Vitamin K prophylaxis at birth (in facilities)

• National guideline for calcium supplementation during pregnancy

• National guideline on management of Hypothyroidism during Pregnancy

• National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus

• Screening for Syphilis during pregnancy

• National guidelines Respectful newborn care - Child Health Division, MoHFW

• Guidance for Mentoring and support visit - DAKSHATA

• Guideline on midwifery services in India-2018

Other Resources

• WHO Report on Strengthening quality midwifery care and midwifery education

• The Lancet Series 2014, 2018 - Midwifery Quality Maternal and Newborn Care (QMNC) Framework

• ICM Essential Competencies for midwifery Practice (2019)

• WHO midwifery educator competencies

• Safe delivery app

Annexure - VI

Icm Statement on Midwifery and Model of Care

Midwifery care is provided by an autonomous midwife in collaboration with the maternity care team. Midwifery competencies (knowledge, skills and attitudes) are held and practised by midwives, educated through a preservice/ pre-registration midwifery education programme that meets the ICM global standards for midwifery education.

The ICM's definition of midwifery reflects its core statement of philosophy and model of care the key points of which follow.

• Pregnancy and childbearing are usually normal physiological processes

• Pregnancy and childbearing is a profound experience, which carries significant meaning to the woman, her family, and the community.

• Midwives are the most appropriate care providers to attend childbearing women.

• Midwifery care promotes, protects and supports women's human, reproductive and sexual health and rights, and respects ethnic and cultural diversity.

• It is based on the ethical principles of justice, equity, and respect for human dignity.

• Midwifery care is holistic and continuous in nature, grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women.

• Midwifery care is emancipatory as it protects and enhances the health and social status of women, and builds women's self confidence in their ability to cope with childbirth

• Midwifery care takes place in partnership with women, recognising the right to self-determination, and is respectful, personalised, continuous and non-authoritarian.

• Ethical and competent midwifery care is informed and guided by formal and continuous education, scientific research and application of evidence.

ICM Model of Midwifery Care (ICM 2014).

• Midwives promote and protect women's and newborns' health and rights.

• Midwives respect and have confidence in women and in their capabilities in childbirth.

• Midwives promote and advocate for non-intervention in normal childbirth.

• Midwives provide women with appropriate information and advice in a way that promotes participation and enhances informed decision-making.

• Midwives offer respectful, anticipatory and flexible care, which encompasses the needs of the woman, her newborn, family and community, and begins with primary attention to the nature of the relationship between the woman seeking midwifery care and the midwife.

• Midwives empower women to assume responsibility for their health and for the health of their families.

• Midwives practice in collaboration and consultation with other health professionals to serve the needs of the woman, her newborn, family and community.

• Midwives maintain their competence and ensure their practice is evidence-based.

• Midwives use technology appropriately and effect referral in a timely manner when problems arise.

• Midwives are individually and collectively responsible for the development of midwifery care, educating the new generation of midwives and colleagues in the concept of lifelong learning.

Annexure - VII

References

1. Government of India (2018) Guidelines on Midwifery Services in India, Ministry of Health and Family Welfare Government of India and National Health Mission, India

2. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, Diaz V, Geller S, Hanson C, Langer A, Manuelli V, Millar K, Morhason-Bello I, Castro CP, Pileggi, VN, Robinson N, Skaer M, Souza, JP, Vogel, JP & Althabe, F (2016) 'Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.' The Lancet, 388(10056): 2176-2192

3. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5

4. ICM 2013 International Confederation of Midwives Global Standards for Midwifery Education (2013) accessed in August 2019 at https://www.internationalmidwives.org/assets/files/general-files/2018/04/icm-standardsguidelines_ ammended2013.pdf

5. ICM Essential Competency Standards for the Midwife (ICM 2018) accessed on 12th July 2019 at https://www.internationalmidwives.org/our-work/policy-and-practice/essential-competencies-for-midwiferypractice. html

6. Renfrew M, McFadden A, Bastos M, Campbell J et al. (2014) Midwifery and quality care: findings from a new evidence informed framework for maternal and newborn care. Lancet 384; 1129-1145

7. WHO (2019) Strengthening Quality Midwifery Education Framework for Action, Universal health Coverage 2030, World health Organisation, Geneva

8. International Confederation of Midwifery accessed in August 2019 at https://www.internationalmidwives.org/

9. Every woman Every Child The Global Strategy for Women's Children's and Adolescents 2016-2030 (2015) accessed on 14th July 2019 at https://www.who.int/life-course/partners/global-strategy/ewec-globalstrategyreport- 200915.pdf?ua=1

10. Chorazy M and Klinedinst K (2019) Learning by doing: A model for incorporating high-impact experiential learning into an undergraduate public health curriculum > Frontiers in Public Health Journal 7(31):1-6 accessed on 14th July 2019 at https://www.frontiersin.org/articles/10.3389/fpubh.2019.00031/full

11. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall (1984)

12. Dewey J. Experience and Education. New York, NY: Collier Books (1938)

13. National Institute for Health and Care Excellence (2012) Antenatal Care, Quality Statement 2 Services - continuity of care. NICE, UK. Viewed online in August 2016 at https://www.nice.org.uk/guidance/ qs22/chapter/quality-statement-2-services-continuity-of-care

14. Australian Nursing and Midwifery Accreditation Council (ANMAC) (2014) Midwife accreditation standards, ANMAC, Canberra accessed on 15th July 2019 at https://www.anmac.org.au/sites/default/files/documents/ ANMAC_Midwife_Accreditation_Standards_2014.pdf

15. Midwifery Council of New Zealand (2015) Standards for approval of pre-registration midwifery education programmemes and accreditation of tertiary education organisations (2nd edition) July 2015 Wellington, New Zealand accessed in August 2019 at https://www.midwiferycouncil.health.nz/sites/default/files/ professional-standards/ Midwifery_Standards_2015_web_final.pdf

16. Nursing and Midwifery Council (2009) Standards for pre-registration midwifery education. London UK accessed in August 2019 at https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-forpreregistration- midwifery-education.pdf

17. Smith M, Warnes S and Vanhoestenberghe A (2018) Scenario-based learning in Teaching and Learning in Higher Education: Perspectives from UCL, Ch. 10 Ed Davies, J and Pachler N. UCL Institute of Education Press, University College, London.

18. Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford

19. WHO (2015) Improving the Quality of care for Reproductive, Maternal, Neonatal, Child and Adolescent Health in South-East Asia. World health Organisation. South East Asia

20. Cooper S, Cant R, Porter J, Bogossian F, Mckenna L, Brady S, and Fox-Yound S (2012) Simulation based learning in midwifery education: A systematic review. Women and Birth, Volume 25, Issue 2, 64-78

21. Coffey F (2015) Learning by simulation - is it a useful tool for midwifery education? New Zealand College of Midwives Journal Issue 51 30-36

22. Finlay L (2008) Reflecting on 'Reflective practice'. 1st ed. [ebook] The Open University. Available at: http://www.open.ac.uk/opencetl/files/opencetl/file/ecms/web-content/Finlay-(2008)-Reflecting-on-reflectivepractice- PBPL-paper-52.pdf [Accessed July 12th 2019]


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