1.1 NMC Regulatory Architecture, RM Registration & The Code

NMC Regulatory Architecture, RM Registration & The Code

Midwifery practice in the United Kingdom is founded upon a rigorous statutory and ethical framework. Every registered midwife must understand the legal foundations of their profession, the architecture of professional regulation, and the standards established by the statutory regulator.

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The Statutory Framework of UK Midwifery Regulation

The primary legislation governing nursing and midwifery in the UK is the Nursing and Midwifery Order 2001 (SI 2002/253), enacted under the powers of the Health Act 1999. This statutory instrument established the Nursing and Midwifery Council (NMC) as the independent regulatory body for nurses and midwives in England, Wales, Scotland, and Northern Ireland, and later nursing associates in England.

The NMC's Statutory Purpose: Protecting the Public

Under Article 3(4) of the Nursing and Midwifery Order 2001, the overarching statutory objective of the NMC is singular and unambiguous: the protection of the public. Article 3(4A) then sets out three objectives through which this overarching objective is pursued:

1. Protecting, promoting, and maintaining the health, safety, and well-being of the public;
2. Promoting and maintaining public confidence in the professions of nursing and midwifery; and
3. Promoting and maintaining proper professional standards and conduct for members of those professions.

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Structure of the Statutory Register and Protected Titles

Under Article 5 of the Nursing and Midwifery Order 2001, the NMC maintains the statutory register of all individuals qualified and entitled to practice. The register is organised into separate parts:

• The nurses' part: Registered Nurses (RN), recorded by field (adult, children's, mental health and learning disabilities nursing), with sub-parts 1 and 2 distinguishing first-level and second-level nurses;
• The midwives' part: Registered Midwives (RM), reflecting the distinct, separate professional status of midwifery in UK law;
• The specialist community public health nurses' part: SCPHN, covering health visitors, school nurses, and occupational health nurses;
• The nursing associates' part: nursing associates, a role regulated in England only.

Protected Title and Protected Function

In the United Kingdom, midwifery enjoys a distinctive legal status that distinguishes it from many other healthcare roles. Under Articles 44 and 45 of the Nursing and Midwifery Order 2001:

• Protected Title: The title "Midwife" is legally protected. It is a criminal offence for any individual who is not registered in the midwives' part of the NMC register to falsely use the title midwife or imply that they are registered.
• Protected Function: The physical attendance upon a woman in childbirth is a protected function. Under Article 45, it is a criminal offence for any person other than a registered midwife or a registered medical practitioner (doctor) to attend a woman in childbirth, except in emergencies where neither is available, or when a student midwife is acting under the direct supervision of an RM or medical practitioner.

This legal protection ensures that childbirth is attended only by qualified, regulated professionals who meet statutory standards of competence and safety.

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Registration Maintenance & Triennial Revalidation

To maintain active registration in the midwives' part of the register, every midwife must pay the annual registration fee (£143 from 1 October 2026, previously £120), report any police charge, caution or conviction promptly, and make health and character declarations when revalidating. Furthermore, every three years, midwives must undergo the NMC revalidation process.

Revalidation was introduced in April 2016 to promote a culture of continuous learning, professional reflection, and public assurance. It ensures that registered professionals remain fit to practise throughout their careers rather than relying solely on initial qualification.

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The NMC Code (2015, Updated 2018): Four Professional Pillars

The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates defines the professional standards that all registrants must uphold. It is organized into four core pillars, each establishing concrete behavioural and clinical obligations.

                    ┌──────────────────────────────────────────────┐
                    │          THE NMC CODE (2015/2018)            │
                    │  "Professional standards of practice and     │
                    │   behaviour for nurses, midwives & NAs"      │
                    └──────────────────────┬───────────────────────┘
                                           │
         ┌──────────────────┬──────────────┴─────┬──────────────────┐
         ▼                  ▼                    ▼                  ▼
┌─────────────────┐┌─────────────────┐┌─────────────────┐┌─────────────────┐
│   PILLAR 1:     ││   PILLAR 2:     ││   PILLAR 3:     ││   PILLAR 4:     │
│Prioritise People││Practise         ││Preserve Safety  ││Promote           │
│                 ││Effectively      ││                 ││Professionalism   │
│                 ││                 ││                 ││& Trust           │
└─────────────────┘└─────────────────┘└─────────────────┘└─────────────────┘

Pillar 1: Prioritise People

Midwives must put the interests of service users first, treating women and their families with dignity and respect:

• Treat people as individuals: Deliver individualized care tailored to the woman's cultural, emotional, and physical needs.
• Listen and respond: Ensure women feel heard, facilitating shared decision-making without judgment or coercion.
• Respect the right to decline: Uphold a woman's right to accept or refuse treatment, respecting maternal bodily autonomy.
• Act as an advocate: Safeguard the vulnerable, recognizing signs of abuse, neglect, or exploitation.

Pillar 2: Practise Effectively

Registrants must deliver care informed by the best available evidence and maintain clinical proficiency:

• Evidence-based practice: Base decisions and advice on up-to-date research, national clinical guidelines (such as NICE and RCOG), and clinical audits.
• Effective communication: Communicate clearly and compassionately, using professional interpreters when language barriers exist.
• Collaborative working: Maintain seamless interprofessional relationships across multidisciplinary teams (MDTs).
• Safe delegation: Ensure tasks assigned to others are appropriate to their role and verified competence.

Pillar 3: Preserve Safety

Safety is paramount across all maternity settings:

• Work within competence: Recognize personal and professional limits, seeking prompt assistance and referring when complications arise.
• Duty of Candour: Be open, honest, and transparent when errors occur or when care does not go as planned.
• Escalate concerns: Raise immediate alarms regarding unsafe staffing, inadequate equipment, or poor clinical practice.
• Medicines management: Safely prescribe, supply, dispense, and administer medications in full compliance with law and clinical governance.

Pillar 4: Promote Professionalism and Trust

Midwives must uphold the reputation of the profession at all times, both inside and outside the workplace:

• Personal integrity: Act with honesty, probity, and trustworthiness in professional dealings and public life.
• Social media conduct: Maintain strict patient confidentiality and professional boundaries on digital and social platforms.
• Cooperation with regulators: Respond promptly and transparently to regulatory investigations and legal proceedings.
• Leadership and mentorship: Support students, colleagues, and junior staff, fostering an open and reflective workplace culture.

Adherence to The Code is mandatory. Failure to comply can trigger fitness to practise proceedings, leading to formal sanctions including conditions of practice, suspension, or permanent striking off from the register.

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The NMC Test of Competence (ToC 2021) Midwifery CBT Specification

For international midwives educated outside the UK or European Economic Area (EEA), and UK midwives returning to practice after a prolonged career break, the NMC Test of Competence (ToC 2021) serves as the gateway to registration in the midwives' part of the register. The ToC evaluates candidate competence against the Future Midwife: Standards of proficiency for registered midwives (2019) and comprises two independent components:

1. Part 1: Computer-Based Test (CBT), delivered globally via Pearson VUE test centres;
2. Part 2: Objective Structured Clinical Examination (OSCE), undertaken in a dedicated UK clinical simulation test centre.

CBT Architecture: Part A vs. Part B

The Midwifery CBT is delivered in a single 3-hour testing appointment at a Pearson VUE testing facility, divided into two distinct, independently scored parts:

Test Policies, Retakes, Fees & Validity Periods

The NMC enforces rigorous administrative and retake rules to preserve test integrity while providing fair progression pathways:

• Examination Fees:
  • Combined Part A and Part B initial sitting: £83 total.
  • Part A resit (if Part B was passed): £50.
  • Part B resit (if Part A was passed): £70.
• Attempts per Application: Candidates are permitted a maximum of three attempts per application, and all attempts must be taken within one year. Each sitting counts as an attempt, and only the failed part needs to be resat (both parts: £83).
• Mandatory Waiting Period: A mandatory waiting period of at least 10 days must elapse between sittings before attempting a resit.
• Cooling-Off Period: If an applicant does not pass after three attempts, their application closes, and a six-month cooling-off period must elapse before submitting a brand-new application.
• Validity & Timing:
  • The CBT (Parts A and B) and the OSCE (Part 2) must both be passed within 2 years of each other.
  • Once both CBT and OSCE are successfully passed, the overall Test of Competence remains valid for 5 years toward registration.

Clinical Guidance Hierarchy Tested on the CBT

Midwifery CBT questions are authored and updated to reflect UK evidence-based national standards. High-yield guidance frameworks tested throughout Part B include:

• National Institute for Health and Care Excellence (NICE):
  • NG201: Antenatal Care Schedule, Routine Screenings & Clinical Monitoring.
  • NG235: Intrapartum Care (physiological labour, stages of labour, third-stage management), with NG229 Fetal Monitoring in Labour covering intermittent auscultation, CTG criteria).
  • NG194: Postnatal Care (maternal involution, mental health, neonatal feeding, red flags).
  • NG195: Neonatal Infection: Antibiotics for Prevention and Treatment (early-onset sepsis, red flags, benzylpenicillin/gentamicin).
  • NG3: Diabetes in Pregnancy (fasting $\ge 5.6\text{ mmol/L}$, 2-hour $\ge 7.8\text{ mmol/L}$).
• Royal College of Obstetricians and Gynaecologists (RCOG):
  • Green-top Guidelines: High-risk obstetric complications including Antepartum Haemorrhage (No. 63), Postpartum Haemorrhage (No. 52), Shoulder Dystocia (No. 42), and Cord Prolapse (No. 50).
• Resuscitation Council UK:
  • Newborn Life Support (NLS) Algorithm: 5 initial inflation breaths (sustained 30 cmH2O pressure for 2–3 seconds), ventilation breaths at 30/min, and 3:1 cardiac compression-to-ventilation ratio if heart rate remains < 60 bpm.
• MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK):
  • Surveillance reports highlighting systemic maternal health disparities (in the 2026 report covering 2022–24, maternal mortality was nearly three times higher for Black women than White women and twice as high in the most deprived areas), thrombosis and thromboembolism as the leading cause of death, cardiac disease as the leading indirect cause, and mental health conditions as a major cause during and after pregnancy, and the urgent imperative of active multidisciplinary safety escalation.