Vietnam national competency standards for midwifery: A Delphi study

Introduction

In 2014, with the support of the United Nations Population Fund (UNFPA), the Ministry of Health, in collaboration with the Vietnam Midwives Association, developed the National Competency Standard for Midwives in Vietnam to meet the country’s maternal and child health care requirements (Vietnam Ministry of Health, 2015). Through the competency standards, training institutions have developed midwifery training programs, contributing to enhancing the quality of midwifery human resources. However, after nearly a decade, the National Competency Standard for Midwives in Vietnam needs to be reviewed and supplemented to effectively enhance the quality of midwifery and meet the needs of midwives requirements for the integration of countries in the region and around the world. In addition, the International Confederation of Midwives (ICM) has recommended that competencies need to be updated continuously and in a timely manner as the evidence on health and clinical practice has evolved rapidly and health care needs to change (ICM, 2018a, b).

In Vietnam, Midwifery is a profession with a long history of development with the first training institution being the Indochina Midwifery School. Then, there were many other institutions across Vietnam training midwifery, including intermediate and college levels. In 2013, there were some universities that started training midwives at university level. Since then, most of the trainers involved in the training are university level midwifery lecturers and a part of the specialties are obstetrics and paediatrics. In 2014, the Vietnam Midwifery Association released a set of National Competency Standards for Midwives in Vietnam, marking an important milestone in the practice and training of midwifery in Vietnam.

The ICM has a mission to support the Association of Midwives and develop the midwifery profession globally by supporting midwives to work independently to give the best care to pregnant women and their families. They support safe childbirth and improve the health of women, babies and families. ICM has worked closely with other international organizations to develop and continuously update the international midwifery competency standards, in which the latest competency standards were updated in 2019 (ICM, 2019).

The ICM defines competence as the knowledge, skills and behaviors required by midwives to practice safely in any setting (ICM, 2013, 2017, 2018a, b, 2023). Some other countries have defined the concept of midwifery competence as representing the quality of practice, intergrated knowledge, skills and attitudes in midwifery practice (Yin et al., 2018; The Midwives Council of Hong Kong, 2010; Midwifery Council of New Zealand, 2016). The process of developing competency standards for Vietnamese midwives in 2014 is also based on these definitions of competence, to describe the professional standards set by the profession for members and society.

The National Midwifery Competency Standards has been reviewed and supplemented for a variety of purposes including informing to clients, professions and others about the midwifery competency standards. At the same time, competency standards also serve to inform the approval or recognition process of midwifery education programs; Determining the conditions for midwifery practice for people who have graduated from midwifery in Vietnam; Evaluation of qualified midwives who need to demonstrate their continuing qualifications for their current position; Allowing midwives to define their continuing professional development plan; creating conditions for Vietnam and the world to recognize each other in the midwifery discipline (Vietnam Ministry of Health, 2015).

Midwifery national competency standards include the core competencies required to fulfill the role of a midwife. Therefore, it is important to clearly define midwifery professional competence in order to develop education programs for midwifery qualifications and ultimately to improve midwifery quality. While National Competency Standard for Midwives in Vietnam has been standardized and legally recognized. There are still challenges in implementing the basic competency standards of midwives in 2014, as well as difficulties in developing training programs based on the competency standards. Therefore, the Vietnamese national competency standard for midwives were not universally adopted in educational institutes.

Previously, Vietnam’s midwifery education had three levels including university bachelor (4 years), college bachelor (3 years), and secondary-level programs (2 years) (UNFPA; 2017). Currently, Vietnam’s midwifery education has two main levels of university and college bachelor. However, there was some universities/colleages adopted the Vietnamese national competency standards for midwive education whereas others developed their own standards because unapplicable standards. In addition, the national exam for certification of midwifery practice has been included in the law draft on Medical Examination and Treatment. Accordingly, all midwife graduates must pass a national exam to be granted a practicing certificate. In order to be able to have an accurate assessment tool for midwifery practice competency, the midwifery professional competencies need to be standardized and legally recognized as well as applicable criteria for competency-based education to support assessment of midwifery competencies (UNFPA, 2014).

Therefore, it is very important to review and supplement Vietnam’s midwifery national competency standards. Firstly, midwifery competency standards were reviewed and supplemented after nearly a decade of application to higher education institutions to develop education competencies for midwifery in Vietnam. The institutions develop appropriate graduate outcomes, curriculum, methods and teaching contents. Second, this is the basis for managers to develop competencies for certification, recruitment, appointment, promotion of midwives, planning and creating opportunities for midwives to be trained continuously while working in medical facilities. Consequently, the quality of health care for women and children in Vietnam will be improved. Third, midwifery national competency standards are the basis for midwives at each level to develop their competency in the working process. This study aimed to develop the national competency standards for midwifery in Vietnam.

Methods

Procedure

Phase 1: phase 1 consisted of a systematic review to synthesize the initial set of competency standards. A literature review was conducted to identify the Vietnamese and international literature on midwifery competency standards. The review included material from established databases such as the Ministry of Health, ICM, CINAHL, Sciencedirect and Medline as well as conference presentations, national and international publications and reports from regulatory and professional bodies. Keywords included in the literature were “midwifery competency standards”; “bachelor of midwifery”; “professional competency standards”. The literature resources were identified according to the following inclusion criteria: (1) involved midwifery population; (2) addressed the issues of the competency standards, no restriction on publication date and study methodology. The PRISMA Flow Diagram was used to guide the search (Thanh Le et al., 2023).

Initial searches captured 275 records across all databases. Duplicated references were removed, and 105 citations remained for screening. Finally, 15 documents that met the inclusion criteria were included, in which there were 7 research studies and 8 midwifery competency standards. The most relevant literature found are listed as Basic competency standards of Vietnamese midwives (2014); Vietnam Nursing Basic Competency Standard (2012); Basic midwifery competency standards (ICM, 2019); Singapore Midwifery Core Competency Standards (2018); Australian Midwifery Competency Standards (Australia, 2007). Based on the systematic review results, one author listed out all the statements from included papers, the other author linked these statements to specific competencies and both authors discussed this list. Overlapping statements were removed from the list. As a result, the research team proposed the first draft of Vietnamese midwifery competency. This draft of competency with 110 statements were included in the survey of phase 2. The process was presented in Figure 1.

Figure 1. Results of the article selection and flow diagram of the data search process.

Phase 2: A modified Delphi survey with 2 rounds was conducted to reach a consensus on proposed Vietnam Midwifery Competencies. The purposive sampling method was widely used to collect data through official correspondence to hospitals, universities/college training midwives, and Vietnamese midwifery associations. The university coordinated with the Ministry of Health to send dispatches to hospitals, universities, colleges and associations related to midwifery. The dispatches asked each institution to appoint a leader to participate in the survey. There were 75 managers, policy makers, presidents of midwifery associations, head midwives and midwives in obstetric departments and hospitals. This data collection process was carried out in different settings representing different regions of Vietnam. Using this approach, midwives from urban, regional and rural settings, as well as from public and private institutions, were included in the survey. This shows the diversity of the participants. Participants rated importance of each competency statement using a four-point Likert scale (1 = not relevant at all; 4 = relevant) and gave feedback/suggestions in text. The participants were asked to rate the questionnaires and send back to Nam Dinh University of Nursing by the dispatches. The round 1 survey was conducted from October to December, 2020. At the end of the first round of the surveys, the research team met to review the data and revise the statements. The round 1 results provided the competency set with 75 statements, which were included in round 2. The round 2 survey was from February to April 2021 providing the set of competencies with 72 statements. For each round, the team retained the midwifery competencies that reached a consensus level of 80% or more of the participants.

Step 3: the phase to finalize the consensus on the competency standards. The Ministry of Health sent an invitation to attend the workshop on assessment of midwifery competency standards, attached with the expected midwifery competency standards to relevant institutions. The “Developing Midwifery Competency Standards in Vietnam” workshop was conducted within four hours at Nam Dinh University of Nursing under the chairmanship of MOH in June 2021. Participants were representatives from associations related to midwives such as Vietnam Midwifery Association; managers of midwifery training units, hospitals and policy makers. Each institution appointed a representative to attend the workshop and give feedback on the expected midwifery competency standards. The workshop was organized with different representatives from different regions of Vietnam. In particular, the input of regulatory agencies was essential for the common goal of ensuring the consistency of national midwifery competency standards. At the workshop, the Ministry of Health and the manager boards of Nam Dinh University of Nursing presented on importance of midwifery competency standards, the results of Delphi phase and proposed midwifery competency standards. Representatives of the institutions gave feedback and discussed on each criteria in the proposed midwifery competency standards. The Steering Committee and the Professional Committee followed the minutes of the workshop on comments and suggestions of the participants to propose the final version of the national midwifery competency standards. The workshop was a strategy for consultation and feedback on the draft text and for informing the various authorities of the process and results.

Results

The study participants in Rounds I and II had similar characteristics in terms of their years of work, education, current position, and workplace. The majority of participants in both rounds had worked for 10-19 years, followed by those who had worked for 1-9 years and those who had worked for 20-29 years. In terms of education, most participants had an undergraduate degree, followed by those with a master’s degree and then those with a diploma/certificate or doctorate. Most of the participants in both rounds worked as midwives, followed by doctors and managers. The most common workplace was an obstetrics and gynecology hospital, followed by an obstetrics and gynecology department and a midwifery education institution. The participants’ characteristics were presented in Table 1. The full dataset can be found under Underlying data (Thanh Le et al., 2023).

The research results indicated that midwifery competency was mostly rated as quite relevant or higher (over 80%). The statements in competency standards on effective communication competency, comprehensive, consistent and continuous quality of care and maintaining a safe environment through the use of quality assurance and risk management strategies were the highest rating (97.8%). Some participants rated “not relevant at al” and “somewhat not relevant”, in which the criterion related to the midwife’s communication competency was rated at only 70.5%. Participants provided comments on the text that it is necessary to adjust some criteria of the competency for future feasibility of evaluating these competencies for the midwife. At the same time, the criteria should connect to each other and to specific competency. Some participants said that the criteria should only be given as a guideline framework to ensure feasibility and relevance in case there are changes to other related guiding documents.

The final set of competency standards for Vietnamese midwifery was structured into 4 areas, 11 standards and 43 criteria; along with the general skills of midwifery. Each area represents a basic role of the midwifery. The competency standards was divided into 4 areas of (1) Midwifery Professional Practice; (2) Care management; (3) Midwifery management; (4) Professional development. Each standard represents a section of the field and covers a task for the midwifery. Furthermore, the midwifery competency benchmark provides a set of general skills that midwives should be able to perform.

Based on the results shown in Table 2, the fist area of competecy stadards for Vietnamese midwifery is professional practice in compliance with ethical and legal regulations. The graduate midwives are expected to have a thorough understanding of their positions, roles, functions, and duties. They were able to perform midwifery interventions according to standards and guidelines while practicing within laws, policies, and regulations. Midwives maintained complete and clear care documentation and records. They ensured their physical, cognitive, psychological, and emotional well-being in order to provide safety services for clients.

Midwives also demonstrated obligation and responsibility for care within the scope of practice and level of competence, following the required competency of midwives while respecting the values, customs, beliefs, and spiritual practices of the individual, family, and community of customers.

Care management is the essential aspect of midwifery competency standards. Midwives could communicate clearly through verbal/nonverbal means in writing and other means of communication. They developed a midwifery care plan in collaboration with the healthcare team, client, and family while conducting a comprehensive, systematic assessment to provide a continuum of healthcare services, and creating a safe care environment. Midwives also implemented, evaluated and adjusted the plan of care, and demonstrated critical thinking, problem-solving, and clinical reasoning in decision-making.

The results demonstrated that they also engaged in continuous quality assurance and improvement activities; assigned, monitored, and supervised the work of other supportive care workers; and implemented continuous quality improvement in care delivery.

The third important area of the midwifery competency standards is midwifery management. Midwives demonstrated the ability to make appropriate management decisions; applied positive thinking skills to problem-solving; implemented and critized new initiatives and changing processes; sought help and advice to manage tasks effectively; collect, analyze, and use incident data and trends to improve care and service strategies; and effectively use and manage resources. They also applied measures and guidelines in safe midwifery practice, participated in projects and initiatives to improve quality and ensure safety, analyzed possible risks in the working environment, and supported and cooperated with care team members in risk management. They maintained and enhanced their professional roles; participated in projects and research; applied evidence-based midwifery practice; corrected deficiencies in knowledge, skills, and continuous learning; contributed to policy development; demonstrated an understanding of the basic knowledge of scientific research processes; and participated in research and innovative technical improvement.

Discussion

This study develops a set of midwifery competency standards in Vietnam. The basic midwifery competency standards issued by MOH in 2014 were developed based on the ICM’s midwifery competency standards updated in 2013 while this competency benchmark is constantly updated and verified by practice. Moreover, the Vietnamese midwifery competency standards are structured according to the common template of the Singapore midwifery core competency standards and the International Basic Midwifery Competency Standard (ICM) to meet the requirements of regional and international integration (ICM, 2018a, b; Singapore Nursing Board, 2018). Research results showed that the midwifery competency standards, after being developed through the Delphi process changed significantly. Most of the participants found this competency standard to be relevant and important for Vietnamese midwives.

Research results indicated that the set of midwifery national competency standards was built to reflect the up-to-date criteria and competency standards, which presented the characteristics of midwifery care according to the reproductive process of a person’s life cycle. That is, midwives in midwifery care serve individuals of all ages and form long-term, ongoing relationships with clients. This element of continuity of midwifery care is reflected throughout the competency statements and helps define the scope of midwifery practice in this particular role. In addition, the areas of competence and statements identified in this study may serve as a framework to guide midwifery roles and responsibilities. Bäck et al. (2017) developed a Swedish midwifery competency standards that described the competence and role of midwives, not limited to, care for the reproductive periods of the clients, vaccinations and immunizations, care for prenatal women, during labor and postpartum, infant development, breastfeeding, medications, reproductive health education and, follow-up on admission, PAP smear, maintainance of health policies and procedures (Bäck, Hildingsson, Sjöqvist, Karlström, 2017). The competency standards covers four key areas of care including midwifery practice in compliance with regulations and professional ethics, care management, midwifery management and career development in which there are 11 standards and 43 criteria. Moreover, the competency standards also reflect general skills, which is a set of skills that midwives perform in their career. Along with midwifery professional competencies, general skills define the requirements for applying for a midwifery license in Vietnam. Included in this document are 112 skills common to midwives covering seven key skill groups in the care of women through the reproductive and neonatal periods.

The competency standards identified may serve as a guiding framework for assessing midwifery performance and contributions and assist researchers and other stakeholders (e.g. employers) to generate evidence on the effectiveness of midwives’ contribution to the prevention and reduction of maternal and child mortality and the broader reproductive health care system. To date, there is still limited research to support the assessment of midwives’ contributions to the reproductive health care system, particularly regarding the impact of midwives on clients, providers system-level results. Nove et al. (2021) performed a study on low- and middle-income populations estimating the potential impact of midwives in reducing maternal and neonatal mortality.

Due to the growing number of midwives in the reproductive health care workforce, recent research in this area suggested a need for undergraduate programs that specifically target this role (Gavine et al., 2019). The role of competency standards is to establish minimum requirements for training and to assess midwifery skills during midwifery training. These competency-based training institutions are the basis for developing specific curricula to enhance the readiness of midwifery students before entering the clinical practice environment. This set of competency standards also supports policy makers; provides a list of essential skills that a bachelor of midwifery needs to perform when practicing midwifery; provides guidelines for developing an assessment plan for the midwifery practice certification exam. Well-defined national competencies may also aid in this role integration by assisting with staff recruitment through the development of job descriptions, interview guides, and the use of identification tools, guidelines as well as other relevant literature (Mharapara et al., 2022). A standardized set of competencies may serve as a framework for developing a well-defined scope of practice (Hastings-Tolsma et al., 2018). This may enable midwives to practice to the best of their abilities in a reproductive healthcare environment, optimize the performance of their interdisciplinary team, and deliver high-quality midwifery care services to their clients throughout their life (Chakraborty et al., 2023).

This study has several limitations. The views of all midwives and those involved in midwives in Vietnam cannot be fully expressed during the review and supplementation process, only designated units will be selected to participate. Recognizing this limitation, the research team made every effort to ensure that the most representative midwifery units were selected to participate. The consultation team will also select those that will make an important contribution related to midwifery such as midwifery unit leaders in educational and practice roles nationally and in policy and expertise. The time frame of the study is limited so the stage of confirming the competency standards by observation of midwifery practice will not be carried out which also means that the competency standards cannot be verified in practice settings. However, the participants in the survey and consultation process are those who work in a range of units closely related to midwives such as the midwifery association, the ministry of health, midwifery training schools and state and private maternity hospitals.

The additional review also resulted in participant reports on the applicability of the competency benchmarks that helped policymakers recognize the importance of next steps to further strengthen the applicability of competency standards and to ensure that they are relevant to midwives working in different settings across the country. For example, some participants responded that it was not possible to use or meet all competency standards due to organizational and systemic barriers. Incorporation of competency standards into employment contracts, position description and evaluating the results of the job performance will support the acquisition of more competency standards, and at the same time provide a toolkit to assess midwifery clinical practice. Developing a framework of midwifery training program based on competency standards is urgent after the promulgation of this competency standard.