Analyzing Legal Frameworks in Emergency Care: Insights for Midwifery Education - A Scoping Review

: Emergency situations in midwifery care during pregnancy, labor, and the postnatal period can arise unexpectedly. It is crucial for midwives to be knowledgeable about the legal frameworks governing the protection provided to them in the execution of their professional responsibilities. This scoping review aims to explore the legal protection provided to midwives in emergency situations through a search of relevant literature in bibliography databases and hand-searching, and employed the Participant, Concept, and Context (PCC) principle to formulate the eligibility criteria. Data extraction was conducted using the PRISMA flow diagram. The analysis was conducted using a meta-aggregation approach to map the legal framework for emergency midwifery care from available studies. The review found key themes that emerged from the review included legal protection and scope of practice, midwives' authority in emergency care, importance of competencies and certifications, challenges and power imbalances in midwifery practice, and midwives' dissatisfaction and professional deviation. This scoping review underscores the importance of legal protection and scope of practice for


Introduction
Midwifery is a globally recognized profession guided by international standards and competencies (ICM, 2019).The global midwifery workforce consists of dedicated professionals who are trained to provide comprehensive, evidence-based care, ensuring positive maternal and neonatal outcomes.The availability, distribution, and quality of midwifery services vary significantly across countries and regions.The World Health Organization (WHO) estimates that approximately 80% of all births globally could be managed by skilled midwives (WHO, 2019).However, it is reported that there is a shortage of midwives in many countries, particularly in low-resource settings, hindering access to essential maternal and newborn healthcare services.Understanding the global situation of the midwifery workforce is crucial to comprehending the challenges and opportunities in delivering quality midwifery care.
Midwifery care is centered around promoting and supporting normal physiological processes throughout pregnancy, childbirth, and the postpartum period (Crowther et al., 2019;Sweeney et al., 2022).While this process is usually a natural and physiological process, emergencies can arise unexpectedly, putting the lives of women and newborns at risk.Emergency situations during pregnancy, labor, and the postnatal period require prompt and effective management to prevent complications and ensure positive outcomes (Mashamba & Ramavhoya, 2021).The ability to respond swiftly and appropriately to emergencies is a critical aspect of midwifery care.Midwives are trained to recognize signs of distress, initiate emergency interventions, and coordinate transfers to higher levels of care when necessary (James et al., 2019) .Their presence and competence in emergency situations can significantly contribute to reducing maternal and neonatal morbidity and mortality.In the realm of general competencies, midwives are entrusted with the responsibility of making independent decisions and taking ownership of their actions.They are obligated to comply with jurisdictional laws, regulatory requirements, and codes of conduct governing midwifery practice (ICM, 2019).These competencies necessitate that midwives possess knowledge regarding the legal and regulatory framework concerning midwifery in their jurisdiction, as well as national, state, and local standards of midwifery practice, ethical principles, ICM guidelines, and other philosophies, values, and codes of ethics relevant to midwifery.In their professional journey, midwives are encouraged to enhance their understanding of evidence-based practices, ensure adherence to legal obligations and ethical principles, fulfill the requirements for maintaining their midwifery registration, maintain and safeguard records as mandated by the health authority, identify any breaches of laws, regulations, and ethical codes, and respond appropriately.Additionally, they should promptly report and document incidents and adverse outcomes as required, while delivering care (ICM, 2019), (WHO/UNPF/ICM, 2022).
Data from WHO shows that only 55% of countries have a national policy on the regulation of midwifery care providers based on the International Confederation of Midwives (WHO-SRH, 2021).Legal frameworks provide the necessary structure and guidance for the practice of midwifery.They define the scope of practice, establish professional standards, and ensure the protection of midwives and the individuals under their care.In the context of emergency midwifery care, clear legal frameworks are essential to support midwives in making critical decisions, acting promptly, and providing safe and effective care.The need for robust legal frameworks becomes even more apparent in emergency situations, where time-sensitive decisions must be made to safeguard the health and well-being of women and newborns.Legal frameworks address issues such as liability, informed consent, documentation, collaboration with other healthcare providers, and the rights of individuals in emergency situations.By establishing clear guidelines and standards, legal frameworks empower midwives to deliver optimal care while upholding ethical principles and protecting.Understanding the legal landscape and identifying areas of improvement is crucial for ensuring not only the professional protection of midwives but also their patients.To have better understanding about this issue, we conduct a review from previous studies aims to identify previous studies concerning the legal protection provided to midwives.
To ensure methodological rigor, the scoping review followed recognized and standardized procedures and guidelines established by The Joanna Briggs Institute.The reporting of the review adhered to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (Tricco, 2018), (Page MJ, 2021)).The protocol was pre-registered on the Open Science Framework on 21 June 2023 (Table 3).
In this review, the research questions are identified as follows: What are the existing legal frameworks and regulations governing the professional protection of midwives in emergencies?and What are the key components of legal protection for midwives in emergencies?

Eligibility & study selection
The principle of participant, concept, and context (PCC) was utilized to formulate the eligibility criteria (Table 1), The electronic databases were searched for as the main databases are SAGE, PubMed, Wiley Online Library, Science Direct, and Google Scholar.To complement the search, we also conducted hand-search articles (Table 2).The study selection is designed over a two-part study selection process to exclude those that do not meet the criteria.

Data extraction
This study identified 351 articles with no duplications found.After reviewing the abstracts, 58 studies were selected for full-text review, and out of those, 21 were ultimately considered for further analysis.This process left for analysis 3 studies in evaluating legal frameworks for emergency midwifery care.PRISMA flow diagram of information is found in Figure 1.

Result and Discussion
This study conducted searches in five bibliographic databases and included a hand-search.It is noteworthy that a relatively small number of articles were found, and even after the selection process, only three studies remained for analysis to address the objectives and research questions of this review.We conducted a metaaggregation approach to map the findings from the available literature.
While there is a limited number of eligible articles, each article presents a distinct context.Peymant (2019) examines legal cases concerning midwives in response to patient complaints.Noviyati (2021) emphasizes the importance of establishing clear standards in the management of emergency cases, particularly in remote areas.On the other hand, Susiswo (2022) delves into the authority and legal protection of midwives when performing medical procedures in hospital settings (Table 4).This review examines the existing legal provisions related to the protection of midwives and patients.However, the reinforcement and dissemination of these provisions are not only limited to midwives but also extend to other relevant professions.The accessibility of these legal provisions to the community, especially in terms of legal understanding, appears to be suboptimal.The supervision to ensure the implementation of standards and other related regulations, as well as evaluation and feedback mechanisms, is perceived as insufficient (Table 5).Some legal provisions extracted from the reviewed articles have the potential to ensure the safety of midwives in carrying out their professional duties while also ensuring the quality of services meets expectations and quality assurance (Table 5 and Table 6).

Legal Protection and Scope of Practice
Legal protection for midwives in performing their professional duties is protected by the law (WHO/UNPF/ICM, 2022).Study in Indonesia (Susiswo;Wulan, 2023) reveals that midwives have the authority to offer a wide range of healthcare services, encompassing maternal health, child health, reproductive health, family planning, and delegated tasks.It is essential for midwives to adhere to professional standards, service standards, and standard operating procedures (NMC, 2019).
The implementation of legal safeguards, along with regular evaluations, plays a crucial role in maintaining compliance with professional standards and mitigating the risk of legal consequences (Varkey, 2021).These measures are of utmost importance to safeguard the well-being and professional practice of midwives.Deviations or violations of their authority can lead to disciplinary actions, sanctions, and potential legal consequences.Regular evaluations are conducted to ensure adherence to professional standards and prevent legal issues.Midwives' organization or Midwifery Council provides legal protection for midwives.In Indonesia (Rahmad, 2023) Indonesian Midwives Association (Ikatan Bidan Indonesia/ IBI) will conducts reviews through the Member Defense Council and Midwife Ethics Advisory Council, offering legal assistance to midwives facing claims or lawsuits if they uphold professional standards.

Midwives' Authority in Emergency Care
Midwives play a vital role in providing care during childbirth, especially in areas where access to healthcare facilities is limited.However, the existing legal framework may create interpretation differences regarding the extent of midwives' authority in managing emergency cases (Noviyanti et al., 2021).Discrepancies in the law regarding midwives' authority in managing emergency cases during childbirth, particularly in remote areas need to be clarified, especially due to the uneven distribution of healthcare professionals and the challenging conditions that make it difficult for other more specialized personnel to handle emergency situations.This ambiguity can hinder the timely and effective response to obstetric emergencies.
To address this issue, it is crucial to establish clear guidelines and regulations that define the scope of midwives' authority in emergency care (Beek et al., 2019).This includes clarifying the specific procedures and interventions that midwives are authorized to perform in emergency situations, such as resuscitation, administering medication, and managing complications (Raoofi et al., 2021).

Importance of Competencies and Certifications
The International Confederation of Midwives (ICM) has established the Essential Competencies for Midwifery Practice, which serve as a comprehensive framework defining the minimum knowledge, skills, and professional behaviors required for individuals to use the title of "midwife" when entering the field of midwifery.These competencies, as outlined by the ICM, set the standard for midwifery practice worldwide.They encompass the essential elements that a midwife should possess and demonstrate in their professional role, including in critical and emergency situation (ICM, 2019) (Li et al., 2022).Noviyanti (2021)  The existence of these competency standards and certifications is driven by the increasing demand for safe and high-quality healthcare, advancements in technology, and a growing awareness of legal requirements.By defining the required competencies, these standards ensure that midwives are equipped with the necessary skills to provide effective care to pregnant women, mothers, and newborns.They serve as a benchmark to assess the proficiency of midwives and promote a standardized approach to midwifery practice (Macfarlane et al., 2023;Meffe et al., 2020).Discrepancies in regulation regarding the extent of midwives' jurisdiction in handling emergency cases, especially in remote areas, may lead to differing interpretations of midwife roles and obligations.This situation has the potential to influence the quality of emergency care delivered.Furthermore, continuous monitoring and evaluation of midwives' competencies, as specified in professional standards, are essential for upholding the quality of midwifery services and mitigating the risk of legal ramifications (Brydges et al., 2021).
Midwifery educational institutions play a significant role in this regard.A newly graduated midwife will soon undergo a competency examination to assess whether they are competent to enter the workforce and carry out midwifery tasks.Therefore, midwifery educational institutions need to have a comprehensive curriculum, proper simulation and skill training, adequate clinical practice, as well as guidance, supervision, and collaboration with midwifery practice institutions (such as hospitals, clinics, and community health centers) to provide diverse practical experiences that cover various midwifery situations.Midwifery educational institutions also usually organize specific competency examination preparation programs to assist students in mastering the exam content, understanding the format and requirements of the competency examination they will face.These programs may include competency examination simulations, practice questions, as well as discussion sessions and understanding of relevant midwifery practice standards (Netshisaulu & Maputle, 2018;WHO, 2013).

Challenges and Power Imbalances in Midwifery Practice
The study conducted in Iran (Peyman et al., 2019) shows the difficulties encountered by midwives in their professional practice, specifically highlighting the presence of power imbalances and mistreatment that undermine their status.The hurdles faced by midwives, which have a negative impact on their job satisfaction and the quality of related to midwives' experience dissatisfaction due to several factors, including legal disputes, insufficient support, and a lack of recognition of their rights.These challenges contribute to a stressful work environment, ultimately affecting the standard of care delivered by midwives (Rostami et al., 2015).It is crucial to address these issues to prevent a shortage of midwives and ensure the provision of optimal maternal and newborn health services.
Recognizing and respecting the professional standing of midwives is key to mitigating power imbalances and addressing mistreatment (Lokugamage et al., 2022).Empowering midwives and providing them with adequate support and resources are essential steps in strengthening the profession (Hermansson & Mårtensson, 2011).By improving the professional status and working conditions of midwives, job satisfaction can be enhanced, leading to improved outcomes for midwives as well as the mothers and infants under their care (Jeavons, 2019).
Efforts should also be directed towards tackling the systemic factors that contribute to power imbalances in midwifery practice.This involves advocating for policy changes, fostering collaboration and communication among healthcare providers, and implementing measures to safeguard midwives from unjust litigation and mistreatment.

Midwives' Dissatisfaction and Professional Deviation
Several factors contributing to midwives' dissatisfaction, including legal litigation, lack of support, and disregard for their rights.Midwives in underdeveloped countries often express dissatisfaction with their job and perceive adverse outcomes in midwifery as hindrances to continuing their profession.This dissatisfaction leads midwives to deviate from standard practices, resorting to increased caesarean sections and excessive paperwork in an attempt to avoid legal conflicts (Peyman et al., 2019).
This theme sheds light on the challenges faced by midwives and their discontent with the current state of their profession.It emphasizes the importance of addressing the underlying causes of dissatisfaction to prevent a potential shortage of midwives in the future.By tackling issues related to legal litigation, lack of support, and the disregard for their rights, it is possible to improve job satisfaction and foster a more stable and fulfilling professional environment for midwives.This scoping review highlights the significance of legal protection and the scope of practice for midwives in ensuring their professional standards, service delivery, and safeguarding their well-being.The implementation of legal safeguards, along with regular evaluations, is crucial for maintaining compliance with professional standards and minimizing legal consequences.Midwifery organizations and councils play a vital role in providing legal assistance to midwives facing claims or lawsuits while upholding professional standards.Clear guidelines and regulations are needed to define the extent of midwives' authority in emergency care, particularly in remote areas where access to specialized personnel is limited.Competency standards and certifications are essential to equip midwives with the necessary skills and knowledge for safe and effective care provision.Addressing power imbalances, mistreatment, and job dissatisfaction among midwives is vital for strengthening the profession and ensuring optimal maternal and newborn health services.Efforts should be made to improve working conditions, support midwives, advocate for policy changes, and mitigate the factors contributing to professional deviation.Some limitations are recognized in this study.The review is limited to midwives and nurse midwives, excluding nurses working in the obstetrics department or midwifery care.Additionally, grey literature, articles published before 2019, and studies written in languages other than English and Indonesian were not included.Future research is suggested to consider expanding the scope to include nurses in obstetrics and midwifery care, incorporating grey literature, older publications, and studies in different languages.By adopting this broader approach, the comprehensiveness and diversity of the evidence can be enhanced.

Conclusion
Enhancing legal protection for midwives in emergency situations is crucial for upholding professional standards and optimizing maternal and newborn health outcomes.This can be achieved by establishing clear guidelines and regulations to define the scope of midwives' authority in emergency care provision.Additionally, continuous monitoring and evaluation of midwives' competencies, along with efforts to improve job satisfaction and prevent professional deviation, contribute to maintaining the quality of midwifery services.Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

Eligibility criteria 6
Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

Information sources* 7
Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.
2 Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.2 Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review. 2

Data charting process ‡ 10
Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

2, 14
Data items 11 List and define all variables for which data were sought and any assumptions and simplifications made.

2, 6
Critical appraisal of individual sources of evidence §

12
If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

Synthesis of results 13
Describe the methods of handling and summarizing the data that were charted.3

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

3-4, 14
Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.11

Critical appraisal within sources of evidence 16
If done, present data on critical appraisal of included sources of evidence (see item 12).NA

Results of individual sources of evidence 17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.12, 13 Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives.
Click here to enter text.DISCUSSION

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

4, 5
Limitations 20 Discuss the limitations of the scoping review process.5 Conclusions 21 Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

FUNDING Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review.Describe the role of the funders of the scoping review.Improvement in the interpretation and application of the law to ensure consistent and effective handling of emergency cases, particularly in remote areas.
Strengthening the provisions related to emergency care, specifying the scope of midwives' authority and responsibilities in emergency situations.Minister of Health Decree Number 369 of 2007Defines professional standards for midwives, ensuring adherence to specific guidelines and requirements in their practice.Regular updates and revisions of the decree to align with advancements in midwifery practices and address emerging challenges in emergency care.UUNo 4 Tahun 2019 tentang Kebidanan (Law Number 4 of 2019) Specifies the scope of midwifery practice, including emergency care and referrals.
emphasizes the crucial role of midwives possessing the required competencies and certifications.The Indonesian government has established competence standards for midwives, which outline the necessary knowledge, skills, and behaviors for safe and responsible midwifery practice across different healthcare settings (Simanullang & Dioso, 2020).These standards are supported by various legal provisions, including Law Number 36 of 2009 on Health, Government Regulation Number 36 of 2014 on Health Workers, and Minister of Health Decree Number 369 of 2007 on the Professional Standards of Midwives.

5
JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.Patients can expect midwives to provide comprehensive midwifery care, including maternal health services, child health, women's reproductive health, and family planning, in accordance with the regulations outlined in Minister of Health Regulation Number 1464 of 2010.To practice, midwives must obtain a license from the local Health Office, and the regulation specifies the authority and responsibilities of midwives in their practice.

Table 6
Legal Framework for Midwifery in Emergency Care: Strengths and Opportunities for Improvement