INTRODUCTION
As stated by Kemp et al.1, the concept of key competencies (core competencies, hereafter KCs), which are essential for a given profession, provides an appropriate framework for defining the indispensable minimum scope and content of lifelong learning, including evaluation systems and the maintenance or reacquisition of KCs. In this research, a key competency is defined as one that must be governed by established conditions for acquisition, maintenance, reacquisition, or revocation, along with mandatory lifelong learning requirements2.
Midwifery is a profession where it is necessary to clearly identify fundamental (key) competencies that outline a clearly defined process of continuous professional development for every midwife3.
Midwifery care is provided by midwives and focuses on maintaining and enhancing women’s health, preventing disease, avoiding harm, managing pre-existing conditions, and, importantly, maintaining or improving the quality of life for women, their children, families, and communities. Uniform and clearly regulated professional standards are prerequisites for the provision of safe and high-quality care4.
Midwifery is an independent scientific discipline underpinned globally by research and interdisciplinary collaboration, emphasizing a multidimensional approach to midwifery care5.
The International Confederation of Midwives (ICM)6 has established and continues to implement basic principles in its documents, which should form the foundation of midwifery care. Primarily, it recognizes that midwives are the most suitable providers of care for healthy women during pregnancy, childbirth, and the postpartum period. Pregnancy and childbirth are typically normal physiological processes, and care should be approached accordingly. Midwifery care is preventive, based on fundamental ethical principles, holistic, continuous, and individualized. It is delivered in partnership with women, empowering them to care for themselves and their children.
Midwifery is a regulated healthcare profession. Education and professional preparation for midwifery practice are regulated and coordinated across European Union (EU) states at a supranational level under Directive 2013/55/EU7. National legislation in individual member countries is derived from these rules. However, practical implementation varies widely among these countries, and the autonomy of midwifery practice is limited by various local factors8.
One such country is the Czech Republic, where midwifery education and other regulatory elements are legislatively established. A consistently high level of education with clearly defined rules is essential at all levels to ensure quality midwifery care9,10.
The basic conditions, structure, and minimum output requirements for midwifery education in the Czech Republic are set by the Qualification Standard for preparing for the profession of midwife11. However, the current form of this standard does not include conditions for evaluating graduates’ knowledge and skills or monitoring the quality of study programs using validated tools, as outlined in global standards such as the ICM Global Standards for Midwifery Education12 and other resources9,13.
Given the nature of the regulated midwifery profession, lifelong learning is a natural component. Like initial qualifications, lifelong learning must be based on evidence-based practice (EBP) and the latest knowledge in the field12,14. However, in the Czech Republic, a unified system of lifelong learning for midwives is lacking. Such a system would specify the frequency and scope of mandatory and optional educational activities, creating a coherent concept for maintaining and continuously improving midwives’ knowledge and skills. Continuous professional development, its monitoring, and its connection to key competencies must become integral to every midwife’s professional approach at the employer and state levels15.
The aim of this study was to identify the key competencies of midwives within the full scope of autonomous midwifery practice in the conditions of the Czech Republic.
METHODS
To achieve the objectives of this prospective study, qualitative data collection methods were employed. These included content analysis of relevant documents, focus group discussions, and the Delphi survey. The COREQ checklist15 was used to describe and assess the study design.
Content analysis of documents
The content analysis served as a foundation for identifying key competencies (KCs). Documents analyzed included the international definition of a midwife5, ICM standards13, national legislation16 and the definition of KCs2.
Additionally, the experiences and direct statements of participants regarding the current situation in midwifery in the Czech Republic were considered within the context of clinical practice needs.
Focus group discussions
Focus group sessions were conducted as semi-structured discussions, leveraging group interaction17. Participants were midwives practicing in various professional roles. Ten midwives with more than five years of experience were invited; five agreed to participate. The participants ranged in age from 32 to 47 years (mean age: 41.2 years), with experience spanning 9 to 24 years (mean experience: 16.4 years).
The focus group sessions for identifying KCs were held in March 2024. Before the initial meeting, all participants signed informed consent forms. Participants received information about the meeting rules and preparatory materials in advance. The session was held in person following a pre-established script. After introductions, participant presentations, and a review of the meeting rules, a guided discussion took place. At the conclusion, a summary of the findings was presented, and moderators confirmed participant understanding of their statements. Two moderators (midwifery educators and members of the professional organization) took notes and recorded the entire meeting.
Delphi survey
The Delphi survey was chosen to evaluate the results of the focus group sessions and achieve consensus. Individual online meetings with experts were conducted via Microsoft Teams. Statements from experts were collected independently to avoid bias from other panel members or moderators18,19.
In this study, consensus was defined as follows: 80–100% agreement – complete consensus; 70–79% agreement – consensus; <70% agreement – no consensus, proposals were considered rejected.
Sixteen healthcare professionals who provide care for women and children in the context of pregnancy and childbirth were invited to participate. The expert panel ultimately consisted of 10 members: 1 community midwife, 1 midwife representing a professional organization, 1 midwife working in a delivery room, 2 midwives in managerial roles, 1 midwife from a neonatology unit, 1 midwifery educator, 2 obstetrician-gynecologists, 1 neonatologist - head of a pediatric department.
Experts were selected based on predefined criteria: active professional practice, more than five years of experience, and consent to participate in the study. The experts ranged in age from 32 to 54 years (mean age: 44.8 years) and had professional experience spanning 7 to 33 years (mean experience: 22 years). Including professionals from various roles in maternal and child care ensured diverse perspectives and in-depth discussion of significant competencies.
The involvement of clinical practice representatives and care providers for mothers and children was intended to support the implementation of study results in clinical practice. The focus was on ensuring that the focus group and expert panel members actively contributed to developing the KC framework, which they would use in the future.
The authors adhered to the recommendations of Gallangher-Ford et al.20 and the JBI Evidence Implementation manual21.
Experts were briefed on the objectives and procedures for individual online meetings beforehand. They confirmed their participation by signing informed consent forms. The Delphi process occurred in three consecutive phases.
RESULTS
Focus group findings
During the initial focus group meeting, participants identified 22 key competencies relevant to midwifery practice in the Czech Republic. These competencies were selected based on a systematic review of relevant documents, including the international definition of a midwife5, the definition of KCs2, and Decree No. 55/2011 Coll. as amended16.
Participants evaluated the competencies outlined in these documents using criteria such as the necessity of reassessment, conditions for acquisition and maintenance, potential revocation, and the need for lifelong learning with clearly defined frequency and content. They identified competencies deemed essential for midwives and assessed how these competencies should be integrated into lifelong education.
Initially, the participants disagreed on standardizing the spectrum of KCs for all midwives, regardless of role. Consequently, for each identified KC, the participants specified for which professional position it would be considered critical. The identified KCs were categorized into three main groups (Table 1).
Table 1
Identified key competencies from the focus group and related midwives’ positions and roles
Delphi survey results
The identified set of 22 KCs was evaluated by an expert panel using the Delphi survey. During the first phase, the panel reviewed the competencies, focusing on their relevance to clinical practice, planning for personal development, and their alignment with lifelong learning for midwives in the Czech Republic.
The Delphi process aimed to achieve consensus on the proposed KCs, assess whether any competencies were redundant or missing, and evaluate the target midwifery role for each KC.
In the first round of the Delphi study, the experts proposed a total of 17 modifications during individual meetings, which the authors grouped into nine categories according to their nature. In the second round of the Delphi survey, these modifications were incorporated into the set of key competencies (Table 2) and again presented to the Delphi survey experts during individual meetings in the third round. The experts expressed agreement or disagreement with individual proposals and then, based on the established criteria, the individual proposals were evaluated for ‘complete consensus’, ‘consensus’ or ‘no consensus’.
Table 2
Adjustments to the identified set of key competencies during the Delphi survey
| Category of adjustment | Proposed change | 1st Phase of Delphi survey (Number of proposals) | 3rd Phase of Delphi survey (Consensus)* | |
|---|---|---|---|---|
| Original state | New state | |||
| Renaming competencies | Perioperative care in midwifery | Basic midwifery care related to surgical interventions | 2 | Yes (n=8), No (n=2) Complete consensus 80% |
| Support for physiological childbirth | Support for physiological pregnancy and childbirth | 8 | Yes (n=10), No (n=0) Complete consensus 100% | |
| Support for breastfeeding | Support for nutrition and breastfeeding | 3 | Yes (n=10), No (n=0) Complete consensus 100% | |
| Care for women after termination of pregnancy | Midwifery care in postpartum loss and neonatal death | 2 | Yes (n=9), No (n=1) Complete consensus 90% | |
| Expanding competencies | Supporting organizational change | Incorporate EBP, digital skills, and AI utilization | 1 | Yes (n=7), No (n=3) Consensus 70% |
| Merging competencies | Monitoring fetal status | Assessment of fetal status, intermittent auscultation, and CTG interpretation | 6 | Yes (n=9), No (n=1) Complete consensus 90% |
| CTG assessment during pregnancy and labor | ||||
| Self-development | Self-development and building effective relationships | 2 | Yes (n=7), No (n=3) Consensus 70% | |
| Building effective relationships | ||||
| Removing competencies | Respecting and promoting the organization’s reputation | Incorporated into other competencies | 3 | Yes (n=10), No (n=0) Complete consensus 100% |
| Creating new competencies | - | Adult resuscitation | 10 | Yes (n=10), No (n=0) Complete consensus 100% |
| Content suggestions for competencies | Support for physiological childbirth – include prevention of birth injuries | 2 | Yes (n=9), No (n=1) Complete consensus 90% | |
| Treatment and care for birth injuries – requirement to report a defined number of treatments | 7 | Yes (n=7), No (n=3) Consensus 70% | ||
| Assessment of fetal status, intermittent auscultation and CTG interpretation – requirement to report a defined number of CTG interpretations | 5 | Yes (n=8), No (n=2) Complete consensus 80% | ||
| General recommendations | Target group of midwives for each competency | All competencies for all midwives with structured obligations | 5 | Yes (n=10), No (n=0) Complete consensus 100% |
| Reassessment of competencies every three years for all midwives | 3 | Yes (n=8), No (n=2) Complete consensus 80% | ||
| Introduction of practical/theoretical exams for midwives who do not perform specific competencies in their work | 1 | Yes (n=3), No (n=7) No consensus 30% | ||
| Incorporating the need for EBP into all competencies | 1 | Yes (n=10), No (n=0) Complete consensus 100% | ||
The final set of key competencies revised based on expert consensus from the Delphi survey included a total of 20 KCs for midwives. Out of 17 proposed changes or adjustments to the set of KCs, consensus was reached on 16 proposals (complete consensus: n=12; consensus: n=4; no consensus: n=1). Based on the results of the third phase of the Delphi survey, a final set of 20 KCs for midwives was created (Table 3).
Table 3
Modified set of identified key competencies after focus group and Delphi survey
Suggestions related to recommendations for supplementing certain KCs or general recommendations were secondary outcomes of the described phase of the study. These represent a valuable source of insights, which were already considered beneficial at this stage. They became one of the sources of information used in the subsequent phase of the study, focused on preparing descriptions of individual KCs in the context of lifelong learning for midwives and defining its structure and content.
DISCUSSION
The purpose of this study was to present findings on the identification of key competencies for midwives in the Czech Republic using qualitative research methods: content analysis of documents, focus groups, and the Delphi survey.
Midwifery is a regulated profession requiring clear and consistent guidelines for all key aspects. The regulation of education, particularly its content, structure, and delivery methods, serves as a primary tool for improving the care provided by midwives and stabilizing their position within the healthcare system. While the European directive outlines the rules for regulating the profession, their national implementation must be adapted to the specific conditions of each country7,22.
The issue of KCs is closely tied to the education of healthcare and other professional groups. However, in the Czech Republic, the content and form of lifelong learning for midwives have not been defined at the national level, even though the obligation to pursue such learning is legally compulsory22.
Midwifery education in the Czech Republic is currently offered at the undergraduate level, specifying the range of skills and knowledge that midwives are expected to acquire. These requirements are based on formally verified learning outcomes. As noted by Phillippi and Avery23 in their revision of the competencies outlined by the American College of Nurse-Midwives, basic KCs serve as a foundation for midwifery education, practice, and policy in any national healthcare system.
This study views KCs as a clear indicator of the essential skills and knowledge required of midwives. As Butler et al.24 point out, identifying KCs is critical for adequately regulating midwifery practice. This includes knowledge, skills, and professional behavior necessary for providing individualized care to clients while adapting to the demands of healthcare systems and socio-economic conditions25. As Li et al.26 suggest, competency assessment tools can be valuable for selecting a qualified midwifery workforce.
Hola et al.2 describe KCs as competencies with a defined framework for acquisition, evaluation, and integration into lifelong learning. The authors of this study pursued the identification of KCs to provide a basis for developing the content and approach to lifelong learning for midwives. The absence of clear guidelines in this area has been identified as a barrier to the development of the profession.
The study employed a mixed research design, involving midwives and other experts, to systematically identify KCs. Through the analysis of legislation (Decree No. 55/2011 Coll., as amended) and other relevant documents, participants identified a set of 20 KCs. These competencies should be periodically evaluated for each midwife as part of continuous professional development. Assessment methods should include performance monitoring and completion of mandatory lifelong learning programs.
The findings and identified competencies of this study are tailored to the Czech Republic’s healthcare and educational systems. While the methodology can be applied to other contexts, the specific competencies may not align with the needs of other countries.
The research design proved effective for identifying KCs and may be applicable to other national healthcare systems or non-physician healthcare professions.
Strengths and limitations
This study has several limitations. The methodological approach used in the study has its limitations and these must be taken into account. In the studies used, it is necessary to take care of adequate selection of participants to ensure objectivity and relevant results. We consider the number of focus group participants to be sufficient, but the results may have been influenced by the experiences of individual participants. The experts of the Delphi survey sufficiently covered the spectrum of expertise involved in midwifery care and related fields. The rapid evolution of evidence-based practice (EBP) and new technologies in healthcare may necessitate ongoing updates to the identified competencies.
Despite these limitations, the study provides a robust foundation for defining key competencies and structuring lifelong learning for midwives in the Czech Republic, and the process for identifying them can be used in other systems.
CONCLUSIONS
The autonomous practice of midwives requires clear regulations governing the profession. Identifying KCs in the context of national and European legislation, as well as international definitions of midwifery, contributes to structuring the content and approach of lifelong learning for midwives. Lifelong learning activities should be tailored to maintain or enhance these KCs, taking into account factors that influence competency levels.
The research design of this study should be an effective and optimal design for identifying key competencies also in other countries.
The authors aim to develop a detailed description of the identified KCs and propose a framework for lifelong learning for midwives in the Czech Republic. This framework will incorporate a clear structure for continuous professional development, which is a critical regulatory element of the profession.
