While much is known about the values and experiences of midwives in developed settings, there is a significant dearth of information regarding the self-
perceived role of midwives in developing countries. Sub-Saharan Africa is no exception to the limited insight available regarding the role of the midwife in developing
countries. As a result, holistic exploration into the local midwifery context is required to gain understanding of the midwives’ role. The United Republic of Tanzania, in which this study was conducted, is presented as an example of a developing country in Sub- Saharan Africa.
Midwifery in Tanzania. 2.4.1
In order to understand the contrast between the role of the midwife in a
developed country such as Australia and the role of the midwife in a developing country such as Tanzania, it is first necessary to explore the origins of midwifery in Tanzania, as well as its current educational and ethical frameworks. During the pre-colonisation era, childbirth care for women in Tanzania was provided by female family members or traditional birth attendants. These family members and birth attendants received hands- on training in skills passed down through generations, with no official education system (Moyo & Mhamela, 2011). In the 1880s, Germany gained control of Tanzania, during which time qualified nurses were introduced, with the first nurse arriving from Germany in 1888 (Moyo & Mhamela, 2011). From 1919, Britain occupied Tanzania after
defeating Germany at the end of World War I, and also brought nurses and midwives to the country. At that point, there was a direction from the British Colonial Government to establish nursing and midwifery education in Tanzania. The Tanzania Nursing and
Midwifery Council (TNMC) was subsequently established in 1952 (Moyo & Mhamela, 2011). Since Tanzania gained independence in 1961, nursing and midwifery have continued to be identified as the same profession through its registration systems, with the vast majority of midwives subsequently being qualified as nurse-midwives
(UNFPA, 2011). The timeline of events leading to nursing and midwifery regulation in Tanzania today is illustrated in Figure 2.1.
Nurses and midwives in Tanzania are regulated by the Tanzanian Government and TNMC, in accordance with the following documents:
• Nursing and Midwifery Act (2010) (The United Republic of Tanzania, 2010b)
• Nursing and Midwifery (Practice) Regulations (2010) (The United Republic of Tanzania, 2010a)
• Code of Professional Conduct for Nurses and Midwives in Tanzania (2007) (TNMC, 2007a)
• Standard of Proficiency for Midwifery Practice in Tanzania (2007) (TNMC, 2007b).
The origins of these four documents, which are illustrated in Figure 2.1, will now be discussed.
Pre-colonialisation Female family members and traditional birth attendants provided childbirth care, with no formal training system
Figure 2.1. Timeline of events leading to nursing and midwifery regulation in Tanzania
today. 2000 Act updated 2010 Nursing and Midwifery Act updated 2010 Nursing and Midwifery Regulations released 2002 Ministry for Health produced the Code of Ethics for Nurses and Midwives 2002 TNMC adapted the Code of Ethics 2007 Code of Professional Conduct for Nurses and Midwives in Tanzania 2007 Standard of Proficiency for Midwifery Practice in Tanzania
First nurse arrived in Tanzania in 1888
Nurses and midwives migrated from Britain to establish nurse training schools
TNMC 1952 TNMC established Tanzanian Government 1953
Tanzanian Nurses and Midwives Registration Ordinance Cap enacted
(Act)
1961
Tanzania gained independence
Present day
1997
Nursing and Midwifery Act introduced
(updated version of 1953 Cap)
TNMC (n.d.)
Code of Ethics and Etiquettes (adopted from
the International
Confederation of Nurses) 1880–1919
German occupation of Tanzania
1919–1961
British occupation of Tanzania
2.4.1.1 Tanzanian Nursing and Midwifery Act (2010).
The Tanzanian Nursing and Midwifery Act (2010) outlines the requirements for the registration and endorsement of nurses and midwives, and regulates these
professions for the purpose of maintaining standards of competence and conduct. This includes directives for the establishment and management of the TNMC, as well as orders for the registration and disciplinary management of nurses and midwives (The United Republic of Tanzania, 2010b).
Although focused predominantly on the requirements for registration, the Act also provides guidance on how nurses and midwives should practice. The Act states that nurses and midwives not practising in accordance with national standards may be
investigated under ‘professional misconduct’ directives (The United Republic of Tanzania, 2010b). This includes ‘abusing a client verbally, physically, sexually or emotionally … abandoning a client who is in need of attentions … [and] failing to maintain the standards of practice and the code of ethics of the profession’ (The United Republic of Tanzania, 2010b, p. 46).
2.4.1.2 Tanzanian Nursing and Midwifery (Practice) Regulations (2010). The Tanzanian Nursing and Midwifery (Practice) Regulations (2010) were developed in conjunction with the Nursing and Midwifery Act (2010) to provide an overall guide for the governance of nursing and midwifery (The United Republic of Tanzania, 2010a, 2010b). The regulations include scant information regarding the role of nurses and midwives; however, they do mandate that Tanzanian nurses and midwives must maintain the necessary skills and knowledge base to demonstrate competent practice (The United Republic of Tanzania, 2010a). However, this has not been readily available prior to the involvement of Western educators (Jones, 2011). The regulations also mandate that nurses and midwives must not neglect, abuse or harm a patient, and
must keep legible and precise records to demonstrate accountability for their practice. Additional regulations include safeguarding patient information and dignity, and working with others to promote the wellbeing of those in their care and the community (The United Republic of Tanzania, 2010a).
The TNMC, which was established in 1953 during the British occupancy of Tanzania, is the national nursing and midwifery registering authority (Moyo &
Mhamela, 2011). The role of the TNMC is to ensure the integrity of the professions and wellbeing of the community (The United Republic of Tanzania, 2010b). The TNMC was established under Part IV of the Tanzanian Nursing and Midwifery Act (2010), which states that the Council must ‘establish, keep and maintain a register and a roll of qualified nurses and midwives’ and may ‘strike off … any registered or enrolled person who fails to comply within the provisions of this Act’ (The United Republic of
Tanzania, 2010b, p. 40, 43). In 2007, the TNMC released two documents—the Code of
Professional Conduct for Nurses and Midwives in Tanzania (2007a) and the Standard of Proficiency for Midwifery Practice in Tanzania (2007b)—both of which are
concerned with the professional and ethical conduct of midwives, thus providing guidance for appropriate practice.
2.4.1.3 Code of Professional Conduct for Nurses and Midwives in Tanzania
(2007).
The Code of Professional Conduct for Nurses and Midwives in Tanzania
(2007a) outlines the professional expectations of nurses and midwives. The Code
requires nurses and midwives be accountable for their practice, protect patients from harm, and maintain professional competence and reputation (TNMC, 2007a). Nurses and midwives must also ensure that they practice without ‘undue delay, risk or
the distribution of resources. The Act recognises that the professions are constantly evolving and, as a result, nurses and midwives must be aware of and integrate new practices based on research, and, throughout their careers, further develop knowledge and skills (TNMC, 2007a).
2.4.1.4 Standard of Proficiency for Midwifery Practice in Tanzania (2007). The Standard of Proficiency for Midwifery Practice in Tanzania (2007b) is the only midwifery-specific regulatory document that reflects the International Code of
Ethics for Midwives and was developed to improve the quality of midwifery education
and practice (TNMC, 2007b). The Standard states that midwives should provide ‘client- centred’ care, provide a therapeutic environment for women, ensure the provision of psychological support to women, have an adequate scope of knowledge to undertake midwifery tasks, and demonstrate evidence-based care (TNMC, 2007b). Specific skill requirements are also addressed, including the obligation of midwives to have
competent skills in neonatal resuscitation and management of sepsis, eclampsia, maternal haemorrhage and shock (TNMC, 2007b).
These four documents were created with the intention of guiding Tanzanian midwives in how they practice. Another important aspect to understand is the midwifery education system in Tanzania because this initial training provides a basis for how midwives are prepared for their role and scope of practice (Nursing Training Section, 2003). This is discussed in the following segment.