Midwives: a new framework for expanded responsibility

By Nathalie Boudet-Gizardin, Partner and Noor Hill

Midwives: a new framework for expanded responsibility

The reform of the midwives' code of ethics, stemming from decree no. 2025-1426 of December 30, 2025, is part of a broader transformation of the organization of perinatal care and has practical implications for professional practice. The work initiated in February 2026 on fertility, as well as on perinatal and maternal health, reflects a desire to more closely structure the pathway from the initial parental project to the postpartum period.

In this context, the role of midwives takes on particular importance. The evolution of their clinical skills, the rise of independent and mixed practice, as well as the tensions observed in the organization of maternity wards, made it necessary to clarify the ethical framework applicable to the profession.

The complete rewriting of the code does not stem from a proliferation of new obligations. It is part of a movement to align with the ethical rules applicable to other medical professions, foremost among them physicians. Requirements relating to professional independence, the primacy of established scientific knowledge, the regulation of communication, and the protection of vulnerable individuals have long been enshrined in the medical code of ethics.

The decree's contribution lies less in its regulatory innovation than in aligning the body of regulations applicable to midwives with those of other medical professions. This harmonization fully recognizes their place within the medical field and clarifies the relationship between legal competence, ethical responsibility, and professional oversight. It thus contributes to a broader movement toward consolidating professional status within a changing legal and European environment.

Clarification of the regulatory framework and affirmation of the medical nature

The new code no longer defines professional competencies. These fall exclusively under the legislative and regulatory provisions of the Public Health Code. Professional ethics are not intended to define the scope of authorized acts; rather, they govern their practice. This clarification strengthens the coherence of the hierarchy of standards. It confirms that disciplinary action by the professional body comes after the legal definition of competencies.

The French Council of State's decision of September 30, 2025 (no. 499946) helpfully clarifies this relationship. A ministerial decree had restricted the performance of diagnostic ultrasounds in prenatal diagnostic centers to physicians only. A midwives' union argued that this restriction undermined the profession's competence and created inequality among healthcare professionals.

The Council of State rejected the appeal. It ruled that the minister had the necessary authority to set the conditions for the organization of prenatal diagnosis and that reserving these diagnostic ultrasounds for doctors did not violate either the provisions of the public health code relating to the skills of midwives, or the principle of equality.

This decision confirms that recognizing the medical nature of the profession does not lead to an assimilation of its scope of practice to that of physicians. The delimitation of authorized procedures remains determined by the applicable legislative and regulatory framework. 

Furthermore, the scope of the code of ethics is clarified. The ethical rules apply to registered midwives, those performing a professional act under the conditions stipulated by law, and students mentioned in Article L. 4151-6 of the Public Health Code. Ethics thus focuses on the professional act itself.

Professional responsibility and independence as structuring principles

The reform does not simply reiterate traditional obligations. It redefines professional responsibility around a core set of principles: independence, scientific competence, and economic integrity.

Professional independence, enshrined in Article R. 4127-306 of the Public Health Code, is now given concrete form. The decree explicitly prohibits remuneration mechanisms that could influence midwives' clinical decisions, particularly those based on performance targets, bonuses linked to the number of procedures performed, or activity-based incentive schemes.

Organizational environments directly affected include those in which remuneration may be partially indexed to activity criteria, in particular:

• health centers;
• birthing centers;
• private structures or platforms implementing systems of bonuses, premiums or consultation targets.

This development necessitates increased vigilance in analyzing working conditions, particularly with regard to:

• remuneration clauses included in collaboration or employment contracts;
• internal performance objectives set by the structure;
• incentive or variable compensation mechanisms linked to clinical activity.

Once a system is capable of influencing therapeutic or referral decisions, it becomes incompatible with the ethical requirement of independence. Professional regulatory oversight can now be exercised over these mechanisms, regardless of their apparent compliance with labor or commercial law.

Responsibility also extends to the scientific field. The obligation to maintain and improve knowledge, linked to the continuing professional development stipulated in Articles L. 4021-1 et seq. of the Public Health Code, ensures the long-term sustainability of competence. Constant reference to established scientific data, the prohibition against creating unjustified risks, and the explicit ban on illusory or insufficiently tested methods give professional ethics a stabilizing function in scientific practice. 

Finally, the requirement of integrity permeates the entire system. The prohibition of practicing the profession "like a business," the ban on commissions, rebates, and benefits in kind, as well as the prohibition of collusion, structure an ethic of economic neutrality. Professional decisions must remain independent of any financial or reputational considerations. This normative choice aims to preserve patients' trust and maintain the coherence of the healthcare system in an environment marked by the proliferation of competing services and visibility strategies.

Patient autonomy and the obligation to protect: a legally intensified care relationship

The new code consolidates the legal framework of the patient-caregiver relationship by explicitly incorporating the requirements of Articles L. 1111-2 and L. 1111-4 of the Public Health Code. Information is not considered a mere formality prior to the procedure, but rather an ongoing process. It must be honest, clear, and tailored to the patient's situation and capacity for understanding. Consequently, consent is free, informed, and revocable at any time. Refusal of care, when it originates from a person capable of expressing their wishes, is binding on the practitioner after providing appropriate information about its consequences.

This incorporation of legislative principles into the code of ethics is not redundant. It represents a shift. What previously fell primarily under the purview of civil or administrative litigation also becomes a disciplinary standard. The patient's autonomy is thus doubly guaranteed: by the judge and by the professional body. The clinical relationship is no longer judged solely on the technical quality of the procedure. It is legally structured as a space for shared decision-making, where the accuracy of information determines the very validity of the intervention.

The most significant change, however, lies in the introduction, in Article R. 4127-336, of an obligation to act in the presence of a presumption of violence, abuse, or mistreatment. The text does not merely authorize reporting; it mandates a response. This obligation is linked to the criminal framework defined by Article 226-14 of the Penal Code, which allows for the lifting of professional confidentiality in certain circumstances. The decree further specifies that the midwife cannot be held liable when the report is made in good faith.

The scope of this provision is fundamental. Professional ethics are no longer limited to regulating the quality of care. They establish a protective responsibility. Midwives are required to assess situations of vulnerability and determine the appropriate means to prevent or stop the abuse. The obligation is formulated in general terms, which allows for professional discretion, but also exposes them to disciplinary action in the event of unjustified inaction. In cases of suspected violence, midwives can no longer simply refrain from taking action: a professional response is expected.

The lack of reaction, when a situation of violence was identifiable, could now be examined not only from the perspective of civil or criminal fault, but also with regard to a positive ethical obligation expressly enshrined.

The freedom to consent is accompanied by a heightened duty of care on the part of the practitioner. The patient-care relationship is thus imbued with a more demanding ethical and legal dimension, where professional responsibility extends beyond the technical act to encompass the prevention of harm to the patient's integrity.

Modernizing the practice and regulating digital technology

The reform acknowledges the structural transformations of professional practice. It establishes a controlled opening up of communication for midwives, who are now authorized to present their skills and practice methods, including digitally. This right does not entail any deregulation. It remains strictly subject to the requirements of fairness, dignity, and the absence of any comparative or promotional intent. The prohibition of priority listing in exchange for payment reflects an explicit desire to prevent the commodification of visibility and to preserve equal access to information.

The organization of practice is also being streamlined. The replacement of prior authorization for practicing at separate sites with a declaration system reflects a reduction in procedures, without abandoning regulatory oversight. The use of freelance or salaried associates is permitted within a formalized contractual framework, subject to submission to the regulatory body. 

The management of personal data is explicitly integrated into the code of ethics, in accordance with Regulation (EU) 2016/679 and the French Law of 6 January 1978. The distinction made between patient records and personal observations provides a normative basis for a practice that was previously debated. The protection of health information is no longer solely a matter of external law; it is now central to the professional discipline.

The reform significantly alters the conditions under which midwives can communicate and organize their activity.

Professional communication is now expressly permitted, including online. Midwives may present their skills, experience, and practice methods. However, this right remains strictly regulated. The following are prohibited:

• comparisons with other professionals or establishments;
• third-party testimonies;
• any presentation likely to mislead or encourage unnecessary recourse to care;
• obtaining priority listing in exchange for payment.

Websites, professional pages, and digital materials must therefore be reviewed in light of these requirements. Visibility cannot be bought. It must remain fair and informative.

The organization of practice is also affected. Operating at a separate site now requires prior notification rather than authorization. This change simplifies the procedure but does not eliminate regulatory oversight. Departmental councils retain the right to object to the practice if it fails to meet quality, safety, or continuity of care requirements.

The use of collaborators, whether freelance or salaried, is permitted within a formalized contractual framework. Contracts must be in writing and submitted to the professional body. Clauses relating to remuneration, independence, and the organization of care must be carefully examined, as the professional body may review their compliance with ethical principles.

Finally, the management of personal data is a major area of ​​concern. The code explicitly incorporates the requirements of Regulation (EU) 2016/679 and the French Data Protection Act of 6 January 1978. This implies:

• effective security of patient records;
• control over the conditions of access to data;
• a clear distinction between medical records that can be communicated and personal notes that cannot be transmitted.

The protection of health information is no longer solely a matter of external obligation under data law. It is becoming an element of ethical oversight. Any failure to comply may be assessed in light of both the GDPR and professional regulations.

Professional ethics as a standard of regulation and responsibility

The reform enacted by the decree of December 30, 2025, significantly alters the conditions under which midwives practice. It goes beyond mere formal harmonization with European law or with other medical professions. It redefines the parameters within which professional responsibility is assessed.

Professional ethics now constitute a directly enforceable framework in many everyday practice situations. It influences:

• drafting and negotiating collaboration or employment contracts;
• the internal organization of the practice structures;
• the methods of professional communication, particularly digital;
• health data management;
• the identification and handling of situations of violence or vulnerability.

The explicit reference to EU law and Regulation (EU) 2016/679 on data protection means that certain practices previously tolerated or loosely regulated may now be subject to dual oversight, both disciplinary and administrative. Ethical compliance is no longer assessed in isolation; it is part of a broader legal framework.

Affirming the medical nature of the profession also has practical consequences. It implies a level of expectation equivalent to that of other medical professions in terms of independence, scientific rigor, and accountability for decisions. The standards applicable to physicians now explicitly inform the assessment of midwives' professional conduct. Their responsibility will be assessed in light of this strengthened regulatory framework.