Midwife Licensure Exam Midwifery Law, Scope & Community Role (RA 7392) — Scope & Legal Boundaries of Midwifery PracticeSummary

A registered midwife is authorised to conduct care **independently**—without physician oversight or delegation—in the context of normal, low-risk, physiologically uncomplicated pregnancy, labour, delivery, and postpartum. This covers normal spontaneous vaginal delivery, routine prenatal screening and monitoring, postnatal care (including breastfeeding support and EINC/Unang Yakap newborn care), family-planning counselling and provision of certain contraceptives, and maternal-child-health education in the community. Independence means the midwife acts on her own professional authority and accountability within this defined range.

The legal and clinical boundary separating midwifery scope from medical scope is drawn by the term **normal**. A normal pregnancy and delivery are those free of risk factors and complications—physiologically and obstetricially uncomplicated. The moment abnormality appears—whether a risk factor identified on screening (e.g. previous caesarean, very young age, small stature), a complication in pregnancy (e.g. pre-eclampsia, antepartum haemorrhage), an abnormal labour pattern (e.g. prolonged labour, cephalopelvic disproportion), or a fetal/newborn abnormality (e.g. fetal distress, low birth weight)—the case crosses into medical territory and must be referred. This boundary is not arbitrary; it reflects the reality that complications require medical expertise (diagnosis, surgical capacity, advanced pharmacology) that midwifery training does not cover.

In a **defined emergency** where no physician is available and a delay would risk death or grave harm, a midwife is permitted—and expected—to initiate **life-saving measures** within her competence. These include giving an oxytocic drug (e.g. oxytocin IM/IV) to control postpartum haemorrhage, performing basic newborn resuscitation (gentle stimulation, drying, airway clearance, bag-and-mask ventilation if trained), suturing first- and second-degree perineal lacerations (if trained), removing a retained placenta manually, or other first-line emergency acts consistent with BEmONC training. The principle is **stabilise first, then refer**: life-saving first aid is never barred by scope limits. However, these acts are strictly limited to genuine emergencies and must be followed immediately by referral; they do not expand a midwife's routine scope, and they must be performed only by midwives with appropriate training and certification for each specific act.

An **internal (vaginal) examination** to assess cervical dilatation, effacement, station, and presentation is a standard tool in labour assessment. RA 7392 and its IRR recognise that in the **absence of a physician** and in **emergency or urgent situations**, a midwife may perform an internal examination when clinically necessary to guide management and referral decisions. It must be done aseptically (clean technique, warm hands, proper positioning), minimised in frequency to reduce infection risk, and only by a trained and competent midwife. Internal examination is not routine obstetric exploration; it is a targeted, clinical assessment done to answer a specific question (e.g. 'Is labour progressing?' or 'What is the presentation?').

This is the doctrinal and practical heart of midwifery scope. It means the midwife's core clinical skill is not just conducting normal births but **detecting abnormality early and referring in time for it to matter**. The principle has four steps: (1) **Detect early**—screen at every prenatal, labour, and postnatal contact for danger signs and risk factors; (2) **Decide and refer promptly**—do not delay referral hoping the situation will resolve; (3) **Stabilise before and during transfer**—administer first-line measures (e.g. position, fluids, oxygen, basic resuscitation), keep the mother/newborn warm and monitored, and ensure safe transport; (4) **Communicate**—send a clear, written referral note with findings, interventions given, and timing to the receiving physician/facility. Effective recognise-and-refer is what saves lives in resource-limited settings where physician care is distant. It is also the legal defence: if complications were detected and referred promptly, with appropriate documentation, the midwife has acted within scope and within the standard of care.

Any deviation from normal is an indication for referral. Key conditions that must be referred include: **high-risk pregnancy** (very young or advanced maternal age, grand multiparity, short stature, previous caesarean, previous complicated delivery); **hypertensive disorders** (pre-eclampsia with elevated BP, proteinuria, headache, blurred vision, oedema; eclampsia with convulsions); **haemorrhage** (antepartum—placenta praevia, placental abruption; postpartum—bleeding not controlled by routine measures, retained placenta); **abnormal presentation** (breech, transverse lie, brow/face); **labour abnormalities** (prolonged labour, obstructed labour, cephalopelvic disproportion); **fetal distress** (abnormal fetal heart rate, meconium-stained liquor); **multiple pregnancy, preterm labour, PROM with complications**; **maternal medical comorbidities** (diabetes, heart disease, severe anaemia, bleeding disorders, infection); **need for surgery** (caesarean section); and **newborn abnormality** (asphyxia beyond basic resuscitation, prematurity needing higher care, sepsis, congenital anomaly). This is not an exhaustive list but rather illustrative; the principle is: if the midwife's training and experience in *normal* care do not adequately prepare her for the case, it must be referred.

RA 7392 (the Midwifery Act of 1992) defines the legal scope of midwifery practice and the conditions under which a midwife may practise. It also creates liability: a midwife who practices **beyond her scope**—that is, who manages or attempts to manage a case that should be referred, or who performs acts not authorised by law or regulation—is in violation of the Act. Consequences can include suspension or revocation of the midwife's license by the Professional Regulation Commission (PRC) Board of Midwifery, civil liability to the patient (for negligence), and potentially criminal charges (e.g. for negligent injury under the Revised Penal Code). Liability can follow even if the patient outcome is good—the violation is in the act itself, not solely in harm. Conversely, a midwife who stays within scope, documents carefully, and refers appropriately has a strong legal defence, even if the referral outcome is not ideal. This is why scope knowledge is not academic; it is protective.

Records are not clerical busywork; they are the midwife's legal and clinical protection and are themselves **within scope**. For every case, a midwife should maintain a complete record: maternal and obstetric history, assessment findings, vital signs, monitoring (including a **partograph** during labour showing cervical dilatation, descent, maternal vital signs, and fetal heart rate over time), interventions given, condition of mother and newborn, and the **timing and reason for any referral**. Good documentation demonstrates that the midwife stayed within scope, recognised danger signs, and referred appropriately; poor or absent records make even correct management indefensible if an outcome is questioned. Community records also feed into the Field Health Services Information System (FHSIS) and Target Client List for public-health monitoring. A practical rule: **if it was not recorded, it will be treated as not done**—meaning the midwife cannot later claim she gave an intervention or made an observation if there is no record of it.

These ethical duties apply to every act within scope and are part of the Board's Code of Midwifery Ethics. A midwife must obtain **informed consent** before any examination or procedure—including an internal examination, even in labour. The woman (or her legally authorised representative) must understand what the midwife intends to do, why, and what the alternatives are. A midwife must protect the **confidentiality** of client information—health records, personal details, family situation—unless disclosure is legally required or necessary to prevent imminent harm. The midwife also respects the woman's **dignity, modesty, and cultural practices** around birth: some women prefer female attendants only, some have cultural or religious practices around birth and the umbilical cord, some wish family members present or have specific postpartum rituals. Respecting these while maintaining safety is part of competent, ethical midwifery. Violating consent (e.g. performing an internal examination without consent) is a breach of ethics and potentially a criminal violation (assault) irrespective of clinical justification.

Prenatal (antenatal) care is a core independent function of the midwife and covers several elements: **history-taking** (past obstetric and medical history, family history, present complaint); **physical and obstetric assessment** (vital signs, weight, height, palpation of abdomen and uterus); **monitoring of pregnancy progress** (fundal height, fetal heart tones, maternal vital signs, weight gain); **laboratory assessment** (blood type, haemoglobin, urinalysis at intake and each visit; blood pressure trending); **immunisation** (tetanus toxoid, as per DOH schedule); **supplementation** (iron and folic acid for all pregnant women; additional micronutrients for those at risk); **health education** (nutrition, hygiene, birth planning, danger signs, family planning); and—critically—**risk screening at every visit** to identify women who are no longer low-risk and need referral. The midwife conducts prenatal visits on a schedule aligned with DOH policy (typically monthly until 28 weeks, fortnightly until 36 weeks, then weekly), and records findings systematically. Each visit is an opportunity to detect emerging complications (gestational hypertension, anaemia, infection, malpresentation) and refer if needed.

**EINC** (Essential Intrapartum and Newborn Care) is a WHO-endorsed package of simple, evidence-based practices that every birth attendant should provide for every labour and birth. In the Philippines, this is operationalised through the **Unang Yakap** (First Embrace) protocol, a DOH-led initiative that gives newborns a strong start in life. The protocol encompasses: (1) **Proper drying and stimulation** of the newborn immediately after delivery to prevent heat loss and initiate breathing; (2) **Skin-to-skin contact** (kangaroo care) between mother and baby within the first hour, with no separation unless medically necessary; (3) **Delayed cord clamping** (waiting 1-3 minutes after delivery before clamping the umbilical cord) to ensure placental blood transfer and reduce anaemia in infancy; (4) **Early initiation of breastfeeding** within the first hour, supporting exclusive breastfeeding; (5) **Rooming-in** (mother and baby together 24/7) to facilitate bonding and breastfeeding; (6) **Newborn screening** (mandated by RA 9288, the Newborn Screening Act of 2004, covering metabolic and critical congenital disorders); and (7) **Immunisation** per the DOH schedule. The midwife is the primary provider of EINC/Unang Yakap and must be trained in each component and able to counsel families on the benefits.

A trained midwife is a **frontline family-planning (FP) provider** and this role is reinforced by **RA 10354** (Responsible Parenthood and Reproductive Health Act of 2012). The midwife may counsel all couples on family-planning options—natural methods (calendar, symptothermal), barrier methods (male/female condoms), hormonal methods (combined oral contraceptive pills, progestin-only pills, injectables such as DMPA), and long-acting reversible contraceptives (IUDs, implants). The midwife may dispense and counsel on pills, injectables, and condoms without requiring physician referral. With appropriate DOH certification and training, the midwife may also insert **intrauterine devices (IUDs)** and place **subdermal progestin implants**. The midwife counsels based on the client's reproductive goals, medical eligibility, and preference, respects the woman's autonomy, and provides information on side effects, efficacy, and reversibility. Family planning is not a 'medical' act in the sense of treating disease; it is a preventive, woman-centred service that the midwife is authorised to provide independently. Counselling also includes information on prevention of sexually transmitted infections (STIs) and discussion of the RH Law's protections regarding information, access, and freedom from coercion.

**BEmONC** (Basic Emergency Obstetric and Newborn Care) is the minimum level of care a facility must provide to manage life-threatening obstetric complications. It includes: (1) parenteral antibiotics, (2) oxytocics (to control bleeding), (3) anticonvulsants (for eclampsia), (4) vacuum or forceps delivery (assisted vaginal delivery), (5) manual removal of placenta, (6) manual removal of retained products, and (7) basic newborn resuscitation. A **BEmONC facility** is typically a hospital or large health center staffed with trained personnel (midwives, nurses, doctors) who can provide these services 24/7. A **CEmONC** (Comprehensive EmONC) facility adds caesarean section and blood transfusion capacity. When a midwife refers a complication, she refers to the nearest BEmONC or CEmONC facility that can manage the case. In the Philippine context, this often means a rural health unit (RHU) or municipal/provincial hospital. The midwife's role is to **stabilise and transfer safely**—ensuring the woman is in labour gown, has IV access if possible, has received initial interventions (e.g. IV oxytocin for bleeding, anti-hypertensives for severe hypertension), and is accompanied by her records and a clear referral note.

**RA 8344** (Newborns' Protection Act) as amended by **RA 10932** (Magdalo Law or Anti-Hospital Deposit Law) prohibits hospitals and health facilities from demanding a deposit or advance payment before providing **emergency care**. Any woman presenting with signs of labour or obstetric emergency must be admitted and managed immediately, without delay for payment. A facility that refuses or delays treatment because of lack of deposit is in violation of law and liable to penalties. This law protects pregnant women and newborns, especially poor and vulnerable populations, and is critical in the referral context: when a midwife transfers a mother with an emergency (e.g. severe bleeding, eclampsia, obstructed labour) to a hospital, she can assure the family that the hospital must treat the woman immediately, without waiting for money. The midwife should be familiar with this law and may cite it if a family is hesitant to go to the hospital due to cost concerns.

**RA 9288** (Newborn Screening Act of 2004) mandates that all newborns born in the Philippines be screened for metabolic and critical congenital disorders that, if detected early and managed, can prevent death or severe disability. The screening is done from a heel prick on the newborn (typically on day 2–3 of life) and tested at a licensed newborn screening centre. Disorders screened include congenital hypothyroidism, phenylketonuria (PKU), galactosaemia, and critical congenital heart defects, among others. The midwife's role is to: (1) counsel the mother prenatally and immediately postpartum on the importance of newborn screening; (2) ensure the screening sample is taken at the appropriate time; (3) send the sample to an accredited centre promptly with proper documentation; (4) ensure the family receives the results and understands any follow-up needed; and (5) refer for further evaluation if a positive screen is found. The DOH funds this screening in public facilities, making it accessible. Newborn screening is a preventive, life-saving intervention and is part of the midwife's essential newborn care role.

The **Field Health Services Information System (FHSIS)** is the Philippine DOH's national health information system that collects data on health services, maternal and child health outcomes, and programme coverage from all levels (barangay, municipality, province, region, national). Midwives, as frontline health workers in barangays and RHUs, feed data into FHSIS through their records—pregnancies registered, prenatal visits, deliveries conducted, referrals made, postpartum visits, newborn care, family planning services, and vaccinations. The **Target Client List (TCL)** is a community-based tool that lists all pregnant women, women of reproductive age seeking FP, and newborns in a given barangay, enabling the midwife and health team to monitor coverage and outreach. The **Partograph**, used during labour, is also a standardised FHSIS tool. By keeping accurate, timely records, the midwife contributes to the information that DOH uses for planning, monitoring progress toward health targets (e.g. reducing maternal mortality), and identifying gaps in service. This emphasises that midwifery practice is not isolated; it is part of a larger public-health system.

The midwife's independent role in normal care (prenatal, delivery, postnatal) is inseparable from the duty to screen for abnormality at every visit and refer promptly if danger signs appear. The two form a continuous cycle: routine care with embedded risk assessment, referral when needed. Without this cycle, independent scope would be reckless; with it, it is safe and appropriate.

EINC/Unang Yakap defines what the midwife *does* for every normal newborn immediately after birth (drying, skin-to-skin, delayed cord clamping, early breastfeeding, rooming-in). It operationalises the midwife's independent scope in the immediate postpartum period and is the evidence-based standard. Newborn screening and immunisation extend this scope into the early weeks of life.

RA 7392 defines the midwife's scope broadly to include family planning. RA 10354 reinforces this and positions the midwife as a key FP provider. This scope, exercised well, enables women in rural/remote areas to access modern contraception, spacing births, and reproductive autonomy—outcomes that improve child health, maternal health, and economic well-being. Scope is thus linked to public health outcomes.

Individual midwife records (prenatal checks, deliveries, referrals) are aggregated into FHSIS data at the barangay, municipal, and national levels. This data drives DOH planning, identifies areas of high maternal/newborn mortality, and targets resources. A single midwife's accurate record thus contributes to population-level health surveillance and strategy.

Emergency acts (oxytocic for bleeding, basic resuscitation, manual placental removal) are **not alternatives to referral**; they are **precursors to referral**. The midwife stabilises the mother/newborn with emergency measures and then refers immediately. This relationship is critical: confusing it (thinking the midwife can manage a complication if she does an emergency measure) is a common scope violation.

This is the causal chain at the heart of midwifery impact. Routine, systematic screening detects risk factors and complications early. Early detection enables prompt referral. Timely referral improves outcomes (fewer maternal deaths, fewer severe morbidities, fewer perinatal deaths). Failure at any step in this chain—poor screening, delayed referral, inadequate stabilisation—breaks the chain and leads to preventable mortality.

This law removes a major barrier to referral: fear that the hospital will refuse to treat without money. Knowing this law, midwives can reassure families and facilitate timely referral without delay. The law thus supports the midwife's duty to refer and the family's access to care.

These duties underpin every act within scope. They are not separate from clinical care; they are integral to it. A midwife who respects autonomy, protects privacy, and honours culture builds trust with women and families, enabling better health outcomes and more effective care. Violating these duties damages the therapeutic relationship and opens the midwife to ethical and legal liability.