Although essential competencies for midwifery have long been defined by the International Confederation of Midwives (ICM), they have not yet been fully or consistently implemented across Europe.

This is the main finding of a study published in the European Journal of Midwifery led by Chiara Valentini, MSc, from the Nursing and Midwifery Department at City St George’s, University of London in London, England. The researchers interviewed 10 midwives from five European countries — the UK, Germany, Belgium, Bulgaria, and Italy — to examine how midwifery practices compare with the competencies outlined in the ICM.

The ICM framework describes the knowledge, skills, and professional conduct required for high-quality, evidence-based practice and underwent a major revision in 2024. The updated framework increased the number of domains from four to five and revised the competencies to reflect current approaches to evidence-based practice and midwifery-led care. It also places greater emphasis on sexual and reproductive health and rights, physiological childbirth, technology, and gender-based violence.

The five areas currently covered are life skills, sexual and reproductive health and rights, prenatal care, care during labor and delivery, and ongoing care for women and newborns.

Cultural and Organizational Barriers

For the study, the researchers recruited two midwives from each country: one affiliated with a national professional association and one working independently. Participants ranged in age from 25 to older than 54 years and took part in individual, semi-structured interviews lasting about 1 hour.

Analysis of the interviews showed that the implementation of ICM competencies is influenced by factors at three main levels: cultural, structural, and professional.

At the cultural level, the researchers identified the social undervaluation of midwifery and its subordinate position relative to medicine. The medicalization of childbirth can also shift practice away from ICM competencies related to physiological care.

Challenges in Italy

Speaking with Univadis Italy, part of the Medscape Professional Network, Paola Lubinu, a midwife and organizational lead at the University Hospital of Sassari, president of the Interprovincial Order of Midwives of Sassari and Gallura, lecturer at the University of Sassari, and councilor for the Italian Federation of Orders of the Midwifery Profession (FNOPO), said, “In Italy, unfortunately, this picture is still relevant.”

From a regulatory perspective, Lubinu noted that midwives in Italy are autonomous professionals with defined competencies and responsibilities. National and international guidelines also support midwives in exercising their professional competencies and encourage collaboration between midwives and physicians on the basis of their respective responsibilities, without clinical subordination.

“In practice, however, the degree of autonomy varies considerably depending on the work setting, the organization of services, and the professional culture within individual settings,” she said.

At the structural level, the study identified regulatory and bureaucratic barriers, as well as difficulties accessing midwifery care. At the professional level, key barriers include gaps between education and practice and limited opportunities for continuing education and international exchange. Staff shortages and burnout were also reported across the countries included in the study, although their impacts varied.

“The situation for midwives in Italy reflects many of the challenges affecting the National Health Service, although with some profession-specific characteristics,” Lubinu said. She also highlighted the growing difficulties in recent years related to staff shortages, increasing workloads, and challenges in maintaining models of care that provide true continuity.

“One of the main problems concerns staffing, which in many settings is insufficient for the level of care required. Staff reductions, combined with increasing clinical complexity among the women receiving care and administrative demands, have intensified workloads and reduced the time available for personalized care,” she said.

Moving Abroad

These working conditions can affect the quality of care midwives are able to provide and, in some cases, their decision to remain in the profession. Lubinu noted that the phenomenon of “brain drain” also affects midwives, with some choosing to move to countries where they perceive better economic conditions, career opportunities, professional autonomy, and social recognition.

“The UK, Ireland, Switzerland, Germany, and the countries of Northern Europe have historically been attractive destinations because of healthcare models that give midwives a central role in managing physiologic pregnancies and childbirth,” Lubinu said.

She also pointed to another trend: “Some midwives are leaving hospital work for community practice, private practice, or, in some cases, leaving the public healthcare system altogether. The most common reasons include the search for a better work-life balance, more sustainable working conditions, and greater recognition of their skills,” she said.

Ways to Improve

How can the situation be improved? Valentini and colleagues argue that creating supportive environments and strengthening the acquisition of essential competencies across Europe requires collaboration among academic institutions, healthcare organizations, and midwifery associations. The ultimate goal is to strengthen professional identity and improve maternal and neonatal health outcomes.

According to Lubinu, strengthening midwifery requires complementary measures covering education, service organization, and recognition of the profession.

“First and foremost, it is essential to invest in models that enable midwives to fully exercise the competencies required by law. We also need training and professional development initiatives,” she said. She also emphasized the importance of investing in university education, continuing education, and advanced skills while promoting midwifery research and professional leadership.

“A profession that creates scientific evidence, participates in research, and takes on organizational roles is a stronger profession, better able to contribute to innovation in the healthcare system,” Lubinu said.

Her final recommendation is cultural: a greater awareness of the midwife’s role among both public and healthcare professionals.

“Ultimately, promoting midwifery is not a professional demand but a health policy choice. Investing in this profession means making the system more efficient, more appropriate, and more focused on the needs of women and families,” she said.

More Than Childbirth

Midwifery is one of the world’s oldest professions. According to the Manifesto for the Midwifery Profession and for the Protection of Women’s and Family Health, published by the FNOPO, “Even Plato, when speaking of Socrates, often referred to the midwife, so called because she was able to ‘deliver’ the newborn from the pregnant woman’s body.”

Yet many people remain unfamiliar with the full scope of midwifery practice.

“In the public imagination, midwives continue to be identified almost exclusively with childbirth. In reality, according to the competencies defined by the ICM and incorporated into Italian professional practice, midwives support women throughout their sexual, reproductive, and maternal and child health journey, well beyond the delivery room,” Lubinu said.

The roles that remain less widely recognized include the following:

• Prevention and health promotion: Midwives provide emotional and sexual health education, counsel women on contraception and fertility, support pregnancy planning, and promote healthy lifestyles before conception. These interventions contribute to reproductive health but often receive little attention.
• Management of normal pregnancies: Midwives are the primary professionals responsible for monitoring low-risk pregnancies. They perform clinical assessments, support couples through childbirth preparation, identify potential risk signs early, and coordinate care with physicians and other healthcare professionals when necessary. They also collaborate with multidisciplinary teams in the management of high-risk pregnancies and medically assisted reproduction programs.
• Postpartum care and parenting support: After birth, midwives care for the mother and newborn, support the initiation and continuation of breastfeeding, monitor physical and psychological recovery, identify potential difficulties early, including problems related to emotional well-being and postpartum depression, and support families during the baby’s first months of life.
• Pelvic floor health: Prevention, assessment, and rehabilitation of pelvic floor disorders are an expanding area of midwifery practice that can help prevent and manage urinary incontinence, pelvic pain, and complications related to pregnancy and childbirth.
• Community and preventive care: Midwives work in family planning clinics, community-based services, women’s health clinics, screening programs, and health education initiatives covering different stages of life, from adolescence to perimenopause and menopause, in collaboration with other healthcare professionals.

“I believe the most important challenge is precisely to move beyond a narrative that identifies the midwife solely with the moment of birth. Childbirth is certainly one of the defining aspects of the profession, but it does not encompass its entire role. Today, the midwife is a professional dedicated to women’s and family health, with clinical, educational, and interpersonal skills that support individuals throughout their reproductive journey,” Lubinu said.

She believes that raising awareness of the full scope of midwifery also means promoting more appropriate access to services and recognizing the contribution that midwives can make to prevention, continuity of care, and maternal and neonatal health outcomes.

Lubinu reported having no relevant conflicts of interest.

This story was translated from Univadis Italy, part of the Medscape Professional Network.