Certi Ed Professional Midwives In The United States
Certi ed Professional Midwivesin the United StatesAn Issue Brief From North AmericanRegistry ofMidwives MidwiferyEducationAccreditationCouncil “Certified Professional Midwives aretrained and credentialed to offer expertcare, education, counseling and supportto women for pregnancy, birth and thepostpartum period. ” NationalAssociationof Certi edProfessionalMidwives MidwivesAlliance ofNorth AmericaJune 2008 “Certified Professional Midwivesprovide care that is preventionoriented with particular attentionto education and support for theconsumer. This process creates anessential health care partnershipbetween the woman and her midwiferesulting in exemplary outcomes.These qualities of care are among thosemost needed to address and solve theproblems that exist in the health caresystem in the U.S. today. ”
IntroductionThe United States faces a deepening crisis in the quality, cost and availability of health care. Maternity care inparticular re ects the basic inef ciencies of the current model – on the one hand too many women receive unnecessarily expensive care due to the overuse of technology, while others cannot access even the most basic services.Midwives are poised to address this problematic distribution of care by providing essential health services thatresult in excellent outcomes at lower cost than typical care. Any plan for health reform should include support forand expansion of midwifery services.Certi ed Professional Midwives (CPMs) are a fast-growing segment of the midwifery profession in the UnitedStates today. Certi ed Professional Midwives are trained and credentialed to offer expert care, education, counseling and support to women for pregnancy, birth and the postpartum period. They have particular expertise in out-ofhospital settings. CPMs practice as autonomous health professionals working within a network of relationships withother maternity care professionals who can provide consultation and collaboration when needed.The purpose of this document is to provide information about Certi ed Professional Midwives: their quali cations,philosophy and scope of practice; the best available evidence regarding the safety and quality of their care; and abrief exploration of how increased utilization of their services will address America ’s health care needs.BackgroundMidwives played an important role historically in communities across North America. Indigenous and traditional midwives were part of community life long before the professionalization of midwifery. Immigrantpopulations included midwives educated in Europeand Asia. In fact, midwives attended the majority ofbirths well into the early 20th century, when publichealth researchers found that midwives provided care,often in the poorest neighborhoods and communities,with good outcomes. Nevertheless, as medical professions grew stronger, physicians sought to take over theprovision of maternity care, and midwifery came underattack. The percentage of births attended by midwivesdeclined as women were encouraged to have their babies in hospitals attended by physicians.This shift from midwives to physicians as the primarymaternity care providers set the stage for the medicalization of birth and has contributed to a number oftroubling and persistent problems. These include: theescalating use of birth interventions, often without evidence of bene t and with reliable evidence of harm;a cesarean rate that is nearing one-third of all births;soaring costs with no evidence of an increase in healthyoutcomes for women and infants; and, possibly mosttroubling of all, a severe erosion of women ’s belief intheir ability to give birth.2Today, in most other industrialized countries, midwivesattend the majority of births, and women experiencefewer interventions and better outcomes than in theUnited States. In fact, the World Health Organizationrecommends midwives as the most appropriate andcost-effective type of healthcare provider in the caseof normal pregnancy and birth.1 To improve birth outcomes and to better serve the health needs of womenand infants, U.S. health care policies must support midwives as the primary maternity care providers for themajority of women.The Professionalization of MidwiferyIn the United States today, the profession of midwiferyincludes direct-entry midwives and nurse-midwives.Direct-entry midwifery refers to an educational paththat does not require prior nursing training to enter theprofession. Nurse-midwifery originated in the 1920sthrough the efforts of public health nurses and otheradvocates who believed nurse-midwives could playan important role in meeting the needs of underservedpopulations. While direct-entry midwives declinedin numbers through the rst half of the 20th century,nurse-midwifery grew gradually until the 1970s whennational standards for education and certi cation wereestablished by the American College of Nurse-Midwives (ACNM), and federal funding was provided forIssue Brief —Certi ed Professional Midwives in the United States
nurse-midwifery training. Nurse-midwives are now recognized in every state. The majority of nurse-midwivesare employed by physicians or medical centers. Whilenurse-midwives may attend births in home settings orfreestanding birth centers, approximately 95% of allbirths attended by nurse-midwives occur in hospitals.2A new generation of direct-entry midwives emerged inthe 1970s to serve those women who were rediscovering normal birth and choosing to give birth at home.What began as a grassroots movement almost fortyyears ago has evolved into a body of professionals witha national identity. This professionalization began in1982 with the founding of the Midwives Alliance ofNorth America (MANA), an organization that broughttogether midwives from all backgrounds who werecommitted to unifying and strengthening midwifery.MANA ’s role was central to the development andevolving philosophy of contemporary direct-entry midwifery. From the beginning, its leaders and memberswere committed to envisioning an innovative midwifery model that could meet the needs of contemporarywomen of reproductive age who desired an alternativeto the prevailing maternity care that would provide access to physiologic, woman- and family-focused care.MANA developed the rst national certifying examination for direct-entry midwives and in 1986 launcheda national registry of midwives, thereby laying thegroundwork for the establishment of the Certi edProfessional Midwife (CPM) credential. In the early1990s, MANA developed the Statement of Values andEthics, providing guidance for professional conduct inthe practice of midwifery with a unique focus on experience and competencies of childbearing women. Atthe same time, MANA ’s Core Competencies describedthe clinical skills and judgment needed for the practiceof midwifery and became the foundational documentfor the professsionalization of direct-entry midwifery.In the early 1990s, MANA began collecting data onout-of-hospital births to assess the practice of directentry midwives which contributed to one of the largestprospective studies of midwifery practice conducted inNorth America. In 2004, MANA implemented a stateof-the-art on-line data collection system.By the early 1990s, several states actively regulatedthe practice of direct-entry midwifery. Many morestates were interested in licensing laws, and there was agrowing consensus among midwives that national standards for the education and certi cation of direct-entryIssue Brief —Certi ed Professional Midwives in the United Statesmidwives would serve as useful tools for de ning theirparticular expertise for the public and increase women ’saccess to their services. The North American Registryof Midwives (NARM) created an innovative and credible new mechanism for certi cation. The MidwiferyEducation Accreditation Council (MEAC) establishedrequirements for the accreditation of schools and wasrecognized by the U.S. Department of Education as anational accrediting agency for direct-entry midwiferyeducation programs and institutions. In 2001, the National Association of Certi ed Professional Midwives(NACPM) was created to articulate the philosophyand principles of practice and to establish standards ofpractice speci c to CPMs.In 2000 all CPMs were required to participate in a yearlong prospective study undertaken by a team of independent researchers to evaluate the practice of CPMs.The researchers analyzed over 5400 home births involving CPMs, comparing outcomes and medicalinterventions with low risk hospital births. The datarevealed far lower rates of expensive medical interventions among planned home births attended by CPMswith outcomes that were comparable to low risk birthsin the hospital. This landmark study was published inthe BMJ in 2005.3It should be noted that direct-entry midwifery is alsorecognized within the American College of NurseMidwives which established the Certi ed Midwife(CM) credential in 1997. CMs are not nurses and mustmeet quali cations established by the ACNM. They arecurrently licensed to practice in three states.Current Status of the ProfessionCerti ed Professional Midwives are trained and credentialed professionals who offer primary maternitycare to women and families across the United States.The number of Certi ed Professional Midwives isgrowing rapidly – from 500 in early 2000 to more than1400 in 2008. At least 1 in 9 of all nationally-certi edmidwives in the United States today is a CPM.Twenty-six states now recognize direct-entry midwivesin statute, 24 through licensure. Before the advent ofthe CPM credential in 1994, individual states that licensed midwives each had their own requirements andstandards. Since the availability of the CPM credential, the trend has been to use the CPM as the basis for3
state licensure. Twenty-four states now recognize theCPM credential or use the NARM written examinationin their state regulatory process. The use of the CPMcredential as the basis for licensure preserves the Midwives Model of Care , which emphasizes individualized care, continuity of care and minimization of risk4by de ning the knowledge and skills necessary for entry to midwifery practice.Currently there are legislative initiatives in numerousstates, all with the goal of licensing CPMs. The National Birth Policy Coalition, a broad-based group ofconsumers, midwives and state and national midwiferyorganizations, has launched a campaign to increasewomen ’s access to the Midwives Model of Care byencouraging and supporting the licensing of CPMs inall 50 states. The CPM credential provides a processfor licensing midwives that saves states the work andexpense of developing and implementing their ownprogram of evaluating and assessing the competencyof midwives. The credential also establishes a nationalstandard for quality assurance within the professionand minimizes confusion about the profession of midwifery among consumers and policy makers.NARM: The Credentialing Agencyfor CPMsThe CPM credential was developed by NARM in collaboration with MANA, MEAC, Citizens for Midwifery (a consumer-based group) and diverse stakeholdersfrom across the United States.5 The credential validatesthe knowledge, skills and abilities vital to responsiblemidwifery practice and re ects and preserves the essential nature of midwifery care. The CPM credentialis unique among maternity care providers in the UnitedStates as it requires training and experience in out-ofhospital birth. The CPM credential allows multipleroutes of entry to the profession in order to encourageinnovation in education, adaptability to evolving bestpractices of the profession, diversity in the pool of credentialed midwives and broad accessibility to the profession. The competency-based model for certi cationassures well-educated, skilled and competent providersin a way that also mitigates the costs of education.The CPM credential requires that all candidates demonstrate successful mastery of both didactic information and clinical experience components, whichincludes either education in a program accredited by4the Midwifery Education Accreditation Council or theACNM Division of Accreditation or completion of aPortfolio Evaluation Process (PEP), a competencybased education process. Other routes to the credentialare current legal recognition to practice in the UnitedKingdom, legal recognition in a state previously evaluated for educational equivalency and comparable international training. All CPM candidates are requiredto demonstrate acquisition of the required knowledgeand skills and to have performed competently as aprimary midwife under supervision. Certi cation isrenewed every three years, and all CPMs must obtaincontinuing education and participate in peer review forrecerti cation.Competency-based credentialing is based on documentation of comprehensive training and testing ofknowledge and skills that are relevant to real-life jobconditions, as determined by psychometric researchwithin the profession. The current CPM requirementsare based on a national job analysis that surveyed thelargest number of professionals ever examined in anystudy of midwives. The credential has been evaluatedby independent researchers at Ohio State Universityand was determined to be a credential that exempli es the established standards for educational testing asdetermined by the American Educational Research Association and the National Council of Measurement inEducation.The Certi ed Professional Midwife credential, issuedby NARM, is accredited by the National Commissionfor Certifying Agencies (NCCA), the accrediting bodyof the National Organization for Competency Assurance (NOCA). The mission of NOCA is to promoteexcellence in competency assurance for practitionersin all occupations and professions. The NCCA accredits many healthcare credentials, including the Certi edNurse-Midwife. NCCA encourages their accreditedcerti cation programs to have an education evaluationprocess so candidates who have been educated outside of established pathways may have their quali cations evaluated for credentialing. The NARM PortfolioEvaluation Process (PEP) meets this recommendation.The CPM is the only NCCA-accredited midwifery credential that includes a requirement for out-of-hospitalexperience.Issue Brief —Certi ed Professional Midwives in the United States
MEAC: An Accrediting Agency forMidwifery EducationMidwifery institutions and programs accredited by theMidwifery Education Accreditation Council currentlyproduce almost one-half of all new CPMs annually. In2008, eight free-standing institutions and two programswithin other institutions had combined enrollments ofmore than 500 midwifery students. These institutionsand programs are located in eight different states. Fouroffer distance education courses that allow students tocombine local clinical preceptorships with their didacticstudies, thereby making midwifery education availableto students in virtually every state in the country. Threeare degree-granting institutions offering entry-leveland/or advanced degrees in midwifery. Three institutions are certi ed by the U.S. Department of Educationto participate in Title IV student nancial assistanceprograms. At least ve newly-established or proposedinstitutions/programs in four additional states have expressed their intent to apply for pre-accreditation in thecoming year, and several more schools are reportedlyin the formative stages.MEAC is recognized by the U.S. Secretary of Education as a national accrediting agency for direct-entrymidwifery education programs and institutions. Thestandards for accreditation address curriculum requirements, faculty quali cations, facilities and student services, scal responsibility and administrative capacity.MEAC accreditation requires that midwifery schoolsincorporate the Core Competencies adopted by MANAand the clinical experience requirements and essentialknowledge and skills identi ed by NARM. They mustalso provide evidence that graduates are capable ofpassing the NARM written examination and becoming CPMs and/or meeting the requirements for statelicensure.Building on a decade of experience in various modelsof community-based education, the founders of MEACwere deeply committed to the principles of midwiferycare and to the preservation of creative, exible educational pathways that include apprenticeship as the basisfor clinical training and are based on core competenciesWhile developing the standards for accreditation in the1990s, MEAC also participated in the national Certi cation Task Force that established the basic requirements for the Certi ed Professional Midwife. MEACtoday stands by the commitment made by the TaskIssue Brief —Certi ed Professional Midwives in the United StatesForce to recognize diverse routes to midwifery, af rmsthe valuable role that apprenticeship training plays inmidwifery and supports the Portfolio Evaluation Process administered by NARM as another method of establishing the quali cations and competencies requiredof entry-level midwives. At the same time, MEAC believes in the value of accreditation as a measure of aneducational program ’s adherence to established standards, commitment to self-evaluation and willingnessto be held accountable to peers, state requirements andother third parties. Accreditation is useful to students,childbearing families, policy makers and others interested in determining the legitimacy of a program or institution offering a course of study leading to nationalcerti cation.In 2005, MEAC launched a project to reach out to midwifery educators across the U.S., regardless of theirinstitutional af liation, with the aim of sharing usefulinformation and building a network of mutual support.That project resulted in the establishment of the Association of Midwifery Educators, which now hosts awebsite, produces a quarterly newsletter and providestraining and support to teachers, preceptors and administrators. Again, the commitment is to develop and sustain a cadre of educators, working in a wide array of institutional and community settings, in order to preserveand promote diversity and accessibility in midwiferyeducation.NACPM: A Professional AssociationRepresenting CPMsThe National Association of Certi ed ProfessionalMidwives aims to increase women ’s access to careprovided by CPMs by removing barriers to this careand supporting the legal recognition of the CPM onthe federal and state levels. In 2004, NACPM adoptedthe Essential Documents of the NACPM. These documents outline the philosophy and principles of practice, the CPM scope of practice and standards for practice. They provide a tool for measuring and assessingCPM practice as well as a mechanism for professionalaccountability.The NACPM Standards for Practice provide guidanceto states in the regulation of Certi ed Professional Midwives. In several states, the licensing legislation refersdirectly to the NACPM Standards of Practice as thereference for developing state rules for practice. This5
speci c inclusion in legislation is becoming the normas more states take up licensing initiatives. Using theNACPM Standards as the guide to developing rules ensures that the Midwives Model of Care will be preserved and that accountability for midwifery practicewill be consistent from state to state.In 2008, NACPM is implementing a comprehensiveplan to train advocates and support CPM participation in national and state health care reform initiatives.NACPM continues to develop strategic alliances withleading professional and women ’s organizations witha shared commitment to improving maternity care forall women.MANA: An Alliance for the Profession of MidwiferyThe Midwives Alliance of North America is a broadbased alliance representing the breadth and diversity ofthe profession of midwifery in the United States today.MANA was created for midwives from diverse educational backgrounds to work for the advancement ofmidwifery as a viable choice in materni
Certi ed Professional Midwives are trained and cre-dentialed professionals who offer primary maternity care to women and families across the United States. The number of Certi ed Professional Midwives is growing rapidly from 500 in early 2000 to more than 1400 in 2008. At
6 The role of a clinical supervisor for midwives 10 7 Preparation for the role of a clinical supervisor for midwives 12 8 Governance 12 8.1 Selection criteria 13 8.2 Workforce Numbers 13 8.3 Clinical Supervision For Midwives 14 8.4 Management and Support 15 8.5 Continuous Professional Development (CPD) for Clinical Supervisors for Midwives 15
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