The profession of midwives in Croatia Evaluation report of the peer assessment mission concerning the recognition of professional qualifications 7.7.-10.7.2008 Executive Summary Currently there is no specific act regulating midwifery education or practice in Croatia which respects the Directive 2005/36/EC. Whilst we were informed that there is a new Act in preparation, we were not provided with an English translation of this draft Act. This limits our ability to comment on the legislative progress made by the Croatian authorities. profession of midwives in Zagreb does not meet the requirements as outlined in the Directive 2005/36/EC and therefore this training programme should cease. The Professional Study of Midwifery, University of Riejka, which is currently a part-time programme, is a first serious step to establish a training programme according to Directive 2005/36/EC, but has to be improved and developed in line with the Directive. We recommend that additional support should be to be provided to midwives in Croatia in order to develop the education and practice of midwives in this country according to the Directive. We recommend a further assessment of the education of midwives in Croatia when the recommendations of this report are adopted. A. Framework PART ONE INTRODUCTION A team of experts from the EU Member States accompanied by European Commission officials performed an evaluation mission (peer assessment) to Croatia from 7 to 10 July 2008 inclusive. The mission was supported by the Office for Technical Assistance and Information Exchange with the candidate countries (TAIEX). This evaluation was carried out in the area of professional qualifications concerning midwives.
B. Purpose of the peer assessment mission The mission was to evaluate the implementation and enforcement of the relevant acquis communautaire, in particular Directive 2005/36/EC on the recognition of professional qualifications. C. Team members The evaluation mission was accomplished by the following experts: GASSER Ludmilla AT Ministry of Health; Deputy Head of Department for Health Professions DALY, Deirdre IE President of European Midwives Association, Lecturer in Midwifery Trinity College Dublin BENOIT TRUONG CANH, Marianne FR Member of French Chamber of Midwives (Conseillère Nationale) D. Programme This report is based on a four-day visit to Zagreb and Riejka. During this time, the team members met with representatives from the State and staff members at the various sites visited. Visits were made to the Secondary (High) School for the profession of midwives, Zagreb, the UNICEF Baby friendly hospital (United Nations Children s Fund Office for Croatia), Posjeta rodilistu u Zagreb (a private hospital which opened in 2008), the University of Riejka (the Professional Study of Midwifery), the Clinical Hospital Centre Riejka, the Croatian Association of Midwives and the Medical Centre Primorskogoranska County. E. Working methods At a preparatory meeting on 3 June 2008 in Brussels, (organised by the European Commission), the experts were introduced to the objective of the peer assessment mission. They discussed a questionnaire on which their report was to be based. Furthermore, they discussed the mission programme among themselves and with 2
representatives from Croatia. The team members were grateful for the opportunity to suggest and make amendments to the questionnaire and to the proposed site visits. This evaluation is based on information provided by Croatian authorities in response to the questionnaire sent out by the European Commission on 9 June 2008 (Annex 1). The completed questionnaire was distributed to the experts before the mission. Additional documentation was provided by the Ministry of Health and Social Welfare and Ministry of Education, Science and Sports at the introductory meeting in Zagreb on Monday July 7 th 2008. I description PART TWO FINDINGS The peer assessment mission concerning recognition of professional qualifications for midwives occurred from 7th -10th July 2008. The peer assessment in Croatia concerning recognition of professional qualifications for midwives included the following meetings and site visits (Annex 2): (i) Meeting with representatives of the Ministry of Health and Social Care, Ministry of Education and Representatives of the Agency for professional qualifications and the Agency for Science and High Education and officials from Science and Sports (as part of meeting organised for all professionals) (ii) Site visit to Secondary (High) School for the profession of midwives, Zagreb and meeting with staff (teachers and mentors). (Midwifery students were undertaking assessments when the team visited. There was no opportunity to meet with students). (iii) Meeting with Ms Radocaj, UNICEF (United Nations Children s Fund Office for Croatia) (iv) Site visit to Posjeta rodilistu u Zagreb (a private maternity hospital which opened in 2008) and meeting with staff (obstetrician, junior doctor and midwives). (iv) Site visit to University of Riejka and meeting with two members of academic staff both of whom also practise at the hospital, (an obstetrician and paediatrician) and three midwifery students undertaking the new extraordinary programme (v) Meeting with two representatives of the Croatian Association of Midwives (vi) Site visit to Clinical Hospital Centre Riejka and meeting with staff (Director of Midwifery and Nursing and Midwives) (vii) Site visit to medical centre Primorsko-goranska County and meeting with staff (viii) Closing meeting with Ministry of Health and Social Welfare and Ministry of Education, Science and Sports. 3
We wish to express our sincere gratitude to all those involved in planning and preparing this programme. We especially wish to thank all the staff who gave their time and effort in order to make our visit informative and enjoyable. Throughout the entire visit, we were deeply impressed by the enthusiasm displayed by all staff and their desire to achieve legislative changes in Croatia which would ultimately lead to the mutual recognition of midwives in Croatia as outlined in Directive 2005/36/EC. The education of midwives in Croatia. We were informed that since April 2008, there are two programmes for the education of midwives in Croatia. In the interests of clarity, these programmes will be described separately. (i) Midwifery education programme at the Secondary (High) School for the profession of midwives, Zagreb. Members of the Ministry of Health and Social Welfare and the Ministry of Science Education and Sports, whom we met on Monday 7th July in Zagreb, informed us that there were currently 263 students enrolled in the Secondary (High) School for the profession of midwives. This is the only Secondary (High) School for midwives in Croatia and it is located in Zagreb. The programme offered is of four year duration followed by one year internship. Each year two classes are enrolled in this school and occasionally to meet the country s needs, midwives receive practical experience in several other cities throughout Croatia (Annex 1, page 9). We have no further details on the organisation of the theory and practice of the programme or the method of student supervision that occurs outside the secondary school in Zagreb. The average age of entry is 15 year and this is after 8 years of elementary school. The midwives who successfully complete this programme are not permitted to work independently. The general and specific competencies cited in the completed preassessment questionnaire describe this midwife as working under doctor s supervision at all times. (Annex 1, pages 11-13). On the site visit to the Secondary school we were grateful to have the opportunity to discuss the organisation and content of this programme in detail. The staff described the programme content as comprising of a mix of general (year one and two) and professional education (year three and four) organised as follows: Year 1: Students have theoretical instruction and practice in laboratories Year 2: Students are introduced to the hospital setting (under the direct supervision of mentors in the hospitals). Year 3: Students engage in the care of gynaecology patients and attend labour ward in groups of eight under the supervision of mentors Year 4: Students practise in hospital (in the local hospital in Zagreb and in other hospitals throughout Croatia). Students record all their practice activities in a diary which is signed by a mentor or midwife. (This diary is not a record of antenatal, postnatal, newborn examination 4
examinations or attendances at labour and birth but merely a record of daily activities in the clinical area). The practical aspect of the programme is delivered in the morning followed by theoretical instruction in the afternoon. Students go to antenatal clinics and perform external examination of women. Students in labour ward practise alongside midwives who carry out care, including delivery of the baby, in the presence of a doctor. Midwives and midwifery students do not write in the woman s record of care. All recordings and documentation, including the record of the birth, are completed by the doctor who is responsible for all the care given. Midwives and students do not practise midwifery in primary care areas. This is the responsibility of a primary health care (public health) gynaecologist. On completion of the four year programme, students undertake a State examination, the Matura, at the Ministry of Health and Social Care Students who successfully complete the examination, can, if they choose, present themselves for an entry examination to a university. In order to practise as a midwife, students must undertake one year internship. During this one year period, students practise with a mentor. This includes 9 months hospital practice and 3 months practice in the primary care setting. According to the peer assessment questionnaire, the nine moths in hospital/birth centres includes: 3 months care of infants and preterm newborns; 4 months care of pregnant women, parturient woman and lying-in women and 2 months care of gynaecology patients. The 3 months in the primary health care units includes: one month in the early detection of malignant diseases of women s genitals and 2 months in pregnancy and birth control counselling (Annex 1). On completion of the internship period and after the mentor validation, in order to be able to practise as midwives, students must pass a national theoretical examination at the Ministry of Health and Social Care. The staff present at the meeting wished to see legislative changes in Croatia which would enable them to practise as midwives (according to the EU Directive 2005/36/EC). The staff described all the decision making throughout all aspects of pregnancy, birth and the puerperium as being the responsibility of the doctor. Summary This midwifery education programme at the Secondary (High) School for the profession of midwives does not fulfil the requirements of the EU Directive 2005/36/EC in terms of numbers of years studying prior to entry onto the programme, programme content, minimum practice requirements and importantly, in terms of achieving autonomy of practice. 5
(ii) Professional Study of Midwifery, University of Riejka An extraordinary programme for the education of midwives commenced in April 2008 at Riejka University. We were provided with the curriculum for this programme (described as part-time) at the first meeting with members of the various Ministry Officials in Croatia on July 7 th 2008, and were provided with further details of the programme structure on visiting the University of Riejka (Annex 3). The programme commenced in April 2008 and we were informed that whilst the theoretical content of first year of the programme had been developed, year two and year three of the programme (the organisation of theoretical hours and the organisation of practice) were not yet organised or planned. The total number of theoretical and practical instruction is stated as 4500 hours or 180 ECTS points (Appendix 4). The students were described as part-time, attending the university one week per month, attending classes and lectures, sometimes from 8am to 8pm making their theoretical week content greater than 40 hours. The remainder of their time was spent in their usual employment as midwives (all the students on this programme had already completed the midwifery education programme at the Secondary (High) School for the profession of midwives and had practised for at least 2 years prior to commencing this extraordinary programme in April 2008). These midwives were employed in several hospitals throughout Croatia and not just in the Clinical Hospital in Riejka. We understand from the discussions that this practice component is their regular working practice and paid employment and not actually the practice component of the extraordinary programme. The future programme was described as having (approximately) 30-35% theory time and 60-65% practice. Whilst the specific method of curricular inspection and approval (clinical and academic) was unclear, the programme was described as being developed in 1996 with University permission/approval to deliver the programme granted in 2008. We were informed that midwifery education curricula from other EU states had been accessed and used in the development of this curriculum. The absence of legislation permitting midwives to practise autonomously in Croatia was described as limiting curricular development and the pursuit of the autonomous role of the midwife. We were informed that 29 students are currently undertaking this programme and that the access criteria employed was as follows: (i) Successful completion of the four year secondary school programme and internship (midwife) (ii) two years of practice (iii) Completion of an entrance examination The peer assessment questionnaire states that the baccalaureus of the nursing profession is a prerequisite for the programme but discussions with the staff in the University of Riejka stated that this was not a requirement for the current cohort of students. This point needs to be clarified. 6
Extraordinary study for midwives in Riejka: curriculum detail On arrival in Zagreb on Monday July 7th 2008, we were provided with a copy of the curriculum of this new extraordinary programme. The programme is a three year parttime programme (Annex 3). Whilst the curriculum development and content is under the control of the University, initial analysis of the content would seem to indicate that the modules described do not include specific explicit detail on the role of the midwife, the development of decision making skills for autonomous practice, documentation of care, legislative framework and processes of referral to the obstetrician. There is a lack of clarity between the hours devoted to theory and practice. For example, clinical practice for health care is described as 120 hours in year one yet we were also informed that there were no practice in year one (Annex 3). We were informed that the first year was organised but that years two and three were not yet developed. The practice aspects of years two and three in particular were described as not yet planned. We were informed that the university was planning to seek assistance from midwifery lecturers from other EU countries to help them develop both the theoretical and practice components. A potential problem for gaining practical experience as midwifery students is that the students on this programme are currently working in this and other hospitals as midwives. This may lead to potential conflict between work and practical training during the study. The absence of a law on midwives and midwifery was stated as the reason for the underdevelopment of years two and three of the programme. Without doubt, the absence of law prevents the development of practice, the development of the practical training and the inability to write a midwifery education curriculum that reflects the activities of the midwife according to the Directive 2005/36/EC. This may account for the current curriculum having a medical and nursing dominance. The practical training is mentioned in the curriculum in term of hours but it is not described in sufficient detail to demonstrate that the minimum requirements for practical training as stated in Directive 2005/36/EC are being achieved. Summary This information on the extraordinary programme, together with the absence of legislation permitting midwives to fulfil the activities of the midwife means that this programme, even if viewed as a top up or bridging programme to the four year secondary school programme, does not fulfil the requirements of Directive 2005/36/EC on midwives. 7
The Legal context of midwifery in Croatia Currently there is no specific act regulating midwifery education or practice in Croatia. Reference was made in the peer assessment questionnaire to the role of the Ministry for Science, Education and Sports in ensuring that minimum training requirements are met (Annex 1, page 7). The role of the Ministry of Health and Social Welfare, pursuant to the Health Care Act, Ordinance on internship of Health Workers and Ordinance on the criteria on accepting Health Workers into internship programmes in this extraordinary programme remains unclear. The responsibility for approving the totality of the programme, both theory and practice, therefore remains unclear and ambiguous. This is applicable to both programmes. We were not informed of any Act governing the provision of the current Secondary School programme of midwifery education and would welcome further clarification on this. The peer assessment questionnaire states that the Ministry of Science, Education and Sports ensures that minimum training requirements are met whilst the overall supervision of admission into and implementing internship is under the competence of the Ministry of Health and Social Welfare, pursuant to the Health Care Act (Annex 1, page 10). This legal context requires immediate attention as, according to Directive 2005/36/EC (Article 3), the structure and level of the professional training, probationary or professional practice shall be determined by the laws, regulations or administrative provisions of the member state concerned or monitored or approved by the authority designated for that purpose. We were informed by the Ministries and others that there will be a midwifery act regulating the profession (competences, existence of a chamber, role and activities of the midwife etc.). The Ministry was unable to provide us with an English translation of this Act (described as being in draft format) and this limits the scope of this report. We are unable to pass comment on the legislative progress made by the Croatian ministries. Additional communication was sent to the Ministry in Croatia (23 rd August 2008) requesting an English translation of this Act (draft) but no further information has been provided. The Croatian Association of Midwives informed us that there are approximately 2500 midwives in Croatia. The number is approximate as there is no register of midwives presently in Croatia. There was a midwife register or membership of the Croatian Nursing Chamber but this apparently ceased to exist in 2004, the reason for this is not known. We were informed (in the peer assessment questionnaire, page 11, and verbally) of a decision to differentiate between the midwives educated via the Secondary (High) School midwifery education programme and the new extraordinary programme at the University of Riejka. It was suggested that, following the legislative change and the enactment of legislation on midwives, midwives from the secondary school of midwifery programme would be called midwife assistants and midwives education on the new extraordinary programme will acquire the qualification of baccalaureus of midwifery and title of midwife (as understood in the context of Directive 2005/36/EC). 8
PART THREE CONCLUSIONS A. Overall assessment The midwifery education programme being taught at the Secondary School for the profession of midwives does not meet the requirements for the education of midwives as outlined in Directive 2005/36/EC. All the staff we met were fully aware of this situation and were eager to see remedial legislative changes in the education of midwives in Croatia. All personnel were aware (i) that the entry requirement did not meet the requirements of the Directive 2005/36/EC, (ii) that the content did not meet the requirements and (iii) that midwives educated on this programme practised under the constant supervision of a doctor and did not practise autonomously in any area of maternity care. The absence of legislation on the profession and practice of midwives was cited as limiting the development of the practice and education of midwives in Croatia. In an attempt to address the anomalies in the current midwifery education programme, a higher level education programme commenced at the University of Riejka in April 2008. This part-time, three year programme, is still at a developmental stage: the theoretical content of year one has been developed but year two and year three are not yet developed or planned. This inhibits the full assessment of this programme in terms of its future ability to meet Directive 2005/36/EC. A new Act governing midwifery in Croatia is in preparation. The Ministry was unable to provide us with an English translation of this draft act during the site visit and subsequent to the site visit, and this limits the scope of this report. B. Recommendations 1. Legislation governing the education and practice of midwives is required. This Act must state allow for the midwife to fulfil the Directive 2005/36/EC. This legislation should be enabling for midwives to practise autonomously in Croatia and enable the development of the profession of midwives separate and distinct from the profession of medicine and nursing. We were informed by officials during our visit that a separate chamber for midwives was under consideration. This is essential for the development and recognition of the separate profession of midwifery and the protection of childbearing women. Registration should be mandatory in order to practise and this chamber should be responsible for renewing the licence annually. This may dependent on fulfilling the required continual professional development studies. There should be separate procedures for legislative and judicial issues. We recommend a separate registration framework for midwives under the authority of a 9
Chamber for Midwives separate and distinct from the Chamber for Nurses. 2. We recommend that the Croatian authorities and legislature ensure that no other legislation exists in Croatia which will inhibit or impede midwives from fulfilling the activities according to Directive 2005/36/EC (including the prescription and administration of medications necessary for fulfilling the activities of the midwife or the supervision of midwives practices by any other profession such as doctors or obstetricians.). 3. We recommend that the current midwifery education programme at the Secondary (High) School for the profession of midwives cease. The future of the students on this programme is ambiguous in the context of EU accession and the changes in midwifery education under discussion. We strongly recommend that the term midwife assistant' should not be used. The term and name midwife should only be used for those who meet the activities outlined in Directive 2005/36/EC. The use of the term midwife assistant will lead to confusion within and outside Croatia and cause particular confusion for women seeking the services of a midwife in future years. 4. The extraordinary programme for the education of midwives in Riejka appears to be founded on the will of a small number of people eager to facilitate changes in midwifery education. The absence of legislation on midwifery education and practice is limiting curricular development and practice. We recommend that the education and practice of midwives be explicit in law, enabled by law and communicated widely in Croatia. 5. The current extraordinary programme is described as a three year part time programme. The part-time nature of the programme means that it currently does not and cannot fulfil the requirements of Directive 2005/36/EC. We note the fact that the entry requirements for this programme require a potential student to have 4 years education as a midwifery student (at the Secondary (High) School for the profession of midwives); two years practice and possibly further higher education. This means that potential students have 7 years of education and 2 years of practice before commencing a midwife registration education programme that meets Directive 2005/36/EC. We recommend that this is reviewed in the context of curricular review and development. The absence of curricular detail (especially the practice component) and the absence of the development of year two and year three severely limit the ability of the team members to comment on the programme s future ability to fulfil Directive 2005/36/EC. We recommend that the current programme be reviewed and developed in line with Directive 2005/36/EC and this should be explicit throughout. In relation to curricular content and detail, we recommend that the current curricular content be reviewed and amended to include modules on the role of the midwife; midwives in society, midwifery in European and international contexts; physiology and pathophysiology of pregnancy; understanding normality; developing decision making skills and patterns of referral to obstetric colleagues (amongst other modules). The curriculum must avail of every opportunity for teaching and supervising students in 10
practice. Consideration must be given to the development of midwife educators and lecturers. If midwives are to learn the fundamentals of their profession then must learn from other midwives, in academic education and in practice. As stated previously the law prohibits this presently therefore legislative changes are required as a matter of urgency if the students recruited in April 2008 are to learn to be autonomous midwives who can enjoy the provision of acquired rights. 6. We recommend that the additional support be provided to Croatia (possibly via TAIEX) in order to develop the education and practice of midwives. Midwife educators must be developed and be in university based posts in order to educate midwives who learn a philosophy for midwifery (as opposed to a philosophy of obstetrics). This can be achieved by educating midwife educators to the required level and by enabling midwives and midwife educators to experience the education of midwives in EU countries where midwifery education is particularly well established. 7. We recommend that the Croatian authorities undertake a national promotion programme promoting and informing the public and professionals of the role of the midwife and the development of any new education programme for midwives. (The development of the role of the midwife will impact on many other professions and on woman and society within Croatia). We were informed that there are approximately 400 primary care gynaecologists and 200 hospital based gynaecologists in Croatia. We were informed that nurses in the primary care setting deliver aspects of care to pregnant and postpartum women. Any changes to midwifery education and practice will impact on these other professionals and we recommend that the Croatian authorities plan the efficient progression of midwifery education and practice. ANNEXES 1. Responses to the questionnaire from the Croatian side 2. Mission programme 3. Curricular document Extraordinary programme for the education of Midwives, University of Riejka (available in hard copy only) 4. Bibliography of documents 5. N.N. 11