The Education of Midwives Around the World: Part 3

Welcome to part 3 in our series on the education of midwives around the world.  The research and writing presented for this part represents an important conversation between Safer Midwifery for Michigan and Judith Rooks, CNM, about the topic of education of American Midwives.    

Ms. Rooks is a certified nurse-midwife, a past-president of the American College of Nurse-Midwives, and a CDC-trained epidemiologist who has published three major studies of out-of-hospital births in this country.  She brings a wealth of knowledge and honest insight to this conversation.  We are honored to have her voice represented here. 

The United States is home to many types of midwives ranging from those educated at a graduate level to those who learn from apprenticeships alone, with everything in between.

It is vital, yet almost impossible, for consumers to be able to know who they are hiring, and how their midwife's training, education and experience will directly effect the safety and outcome of their birth.

This is especially true in a state like Michigan, which is yet to even legally define the term "midwife" let alone establish a minimum standard for their education and training. 

We contacted Ms. Rooks to ask her about what the appropriate educational standards for US midwives should be, and we're happy to share what she had to say on the subject:  

"There needs to be a way for current direct-entry midwives, including CPMs, to achieve the education they need.  A growing proportion of pregnant women in America want out-of-hospital (OOH) births with midwives, and there are not enough midwives to serve them. Some CPMs are excellent, but the PEP route to certification as a “professional” midwife isn’t deep enough educationally.   The floor is too low, some of them are dangerous, yet some of them have done extensive self-guided education and are very competent and safe.

The PEP route to becoming a CPM seemed reasonable when it was started, but I thought it would only be used to provide an opportunity for very experienced OOH birth attendants, and that new educational programs along the lines of the Seattle Midwifery School—a direct-entry professional midwifery school based on the curriculum used in The Netherlands, would be started to provide educational opportunities for young women who wanted to start preparing themselves as midwives from scratch.  

During the 1980s, a portion of the direct-entry midwifery community wanted to professionalize and developed a very few good schools.  SMS has since become the Midwifery Department at Bastyr Naturopathic University, which is located near Seattle. But many direct-entry “midwives” (I used quotes because most of them do not meet the International Definition of a Midwife) thought that the PEP route to the CPM was adequate. 

To my great disappointment, many young women who want to become midwives seem to think it is too much bother, time or money to complete an actual midwifery curriculum and think it is enough to just apprentice themselves to someone for a minimal number of births, study to pass a few tests, and become a CPM that way.


There are a lot of excellent CPMs.  I would trust some of them with a home birth of my grandchild.  But many have inadequate knowledgeable, manual skills and clinical judgment.  Some DEMs/CPMs say that it is the responsibility of a pregnant pregnant woman to choose her midwife wisely, but that is very hard to do.  

I count on the state to not license inadequately trained health care providers.  I can’t assess the skills of every professional I use.  I would not hire an electrician to change the wiring in my house without someone knowledgeable exercising due diligence to assure me that the person I hire has achieved some minimal level of relevant education and prior experience (an apprenticeship).  Attending lectures or reading some books isn't enough.  An education program that is designed to lead to the development of the core competencies is needed to provide a specific service, with objective ways to measure whether each of the myriad competencies has actually been achieved.


CNMs have a good midwifery education, but few of them have experience in OOH births. In the mid-1990s, British Columbia and Ontario knew that they needed more midwives, and they wanted them to be direct-entry instead of forcing people who want to become midwives to complete an education program in nursing first.  They wanted the graduates to be prepared to provide safe, satisfying and effective midwifery care in both hospital and OOH settings.  

Because the governments of both provinces saw the need for more midwives and safe and effective midwifery care in both settings (which also allows a  home birth midwife to go to the hospital with her patient when a transfer is necessary), the governments of both provinces had a responsibility to provide midwifery education to meet the need.  As a consequence, a leading university in each of those provinces developed a baccalaureate midwifery education program that bypasses the nursing education requirement for nurse-midwives but provides an equally deep education that is focused on midwifery.  Both provinces now have excellent outcomes of OOH births, which are in demand by increasing numbers of very happy and healthy mothers.
 
The International educational standards should be the long term goal, but you can’t just require that in a law without providing some path by which experienced already-practicing midwives can be given reasonable time and ways to be eased into compliance.  A lot of people know that what we have now isn’t good enough and are interested in making a real investment in change.

We need a long-term solution to get where the whole country should be eventually re midwifery, with all midwives licensed under a board of midwifery, including CNMs and CMs.  I thought the CPM would be short-term; we have lived with it now for a long time.  The data from Oregon, shows that it’s not working.  The CPM credential was a stop-gap measure from the next-to-the last decade of the 20th Century.  We are now in the 2nd decade of the 21st Century.  Michigan would be a good place to start moving forward."

What options do we have in the US for University-level education for non-nurse midwives?  

MEAC accredited schools
Often we talk on this blog about concerns for the minimum standards for education.  There are multiple routes to becoming a CPM, but few choose the University education route.  There are MEAC accredited schools across the country, whereby prospective midwives can receive financial aid and attend college to become midwives.  

Another option is the CM credential (Certified Midwife).  CMs have identical scope of practice to CNMs.  The difference being that they have a four year degree in something other than nursing, then attend two years of graduate level education specific to midwifery. We currently have no CMs in Michigan, as they are not yet licensed to practice here. 

The lingering questions then become why are the minimum standards so low, especially in comparison to counterparts around the world?  Why is it acceptable for midwives to aim for the cheapest, quickest route instead of striving to be their best?  Why are the "certifying" bodies (ie NARM/MANA) keeping the bar so low...as in only requiring a high school diploma as of 2012 instead of requiring a college level education to deliver our babies?  

The vast spectrum of what defines "midwives" is confounding to consumers aiming to hire reliable, competent professionals.  We support midwifery, and hope to see the "profession" as a whole set clear standards for education that we can depend upon for safe options.  There is not excuse for anything less.  



For more on the topic of Educational Standards, Visit the links below:

Education of Midwives Around the World: Part I  Are all Midwives Created Equal?

Education of Midwives Around the World: Part II  Is the focus for US Midwives on Competency? 

Open Letter to Willow Tree Family Center

For all those living in and around the Lansing area, a new proposal is coming to town.  A group of parents is rallying and fund raising to open the Willow Tree Family Center, whose mission is:

     "Our mission at Willow Tree Family Center is to grow strong, empowered families by 
      providing support groups and educational services for pregnancy, birth and beyond. 
      By focusing on the family as a system and providing access to evidence-based 
      resources and holistic care, we will support healthy, informed, confident families. 
     Like a willow tree, our center will provide a calming atmosphere to grow strong, 
      flourishing families that support each other."

Sounds like a promising prospect, and sounds a bit familiar...especially when you read the board profiles and realize that nearly every member was affiliated with the Greenhouse Birth Center in some way.  They value "education & informed consent" and "evidence-based" care.  (I'm using quotes here because those terms are subject to definition.)  

While the notion of such a central place to support families in pregnancy, birth and beyond is exciting, it brings with it great responsibility.  It's a responsibility that was severely lacking at Greenhouse, and we sincerely hope this new project can take steps to ensure safety in the resources and care they are offering.   

An Open Letter:                                                                                                        April 24, 2013

Dear Willow Tree Family Center,

It has recently been brought to our attention that you’re aiming to open a new “Family Center” in the Lansing area, aimed at fostering community and offering families resources related to birth, pregnancy, and parenting.  While the prospect sounds enticing, we are concerned for the message you will be sending to the larger community about the safety of the care providers you intend to host at your facility.  Taking on this position demands great responsibility. 
 
We are writing to ask that you consider the necessity of implementing strict screening measures, and clear criteria for the “care providers” you intend to host at your new center.  It would not be ethical or responsible to imply that the care providers hosting appointments at your new facility are safe, or reliable without doing so.  Many, if not all, of the midwives suggested as potential staff are also those who have been reported to our advocacy group as being involved in extremely dangerous care practices, infant deaths, and injuries.  Some have multiple sanctions or pending sanctions with the state.  Others have a long reputation of dangerous practices.  Having had a good experience does not negate the possibility that others have been harmed.
 
We also ask that you gather references from families that demonstrate varied perspectives about the care they received, so that prospective families aren’t only presented with biased references, and a false sense of security.   This includes references for midwives, doulas, and childbirth educators.  Unfortunately, our advocacy group often hears only the sad stories, but they are nonetheless important.  Many of the families that report to us prefer to remain anonymous, but we’d be happy to provide any contact or reference we can that would enable new families to better know who it is they are hiring for their care. 

We absolutely appreciate the value in a community resource hub that will enable families to be “fully informed” and seek the care they choose.  Part of being fully informed includes knowing ALL sides of a care giver’s practice history.  We support what you’re aiming for, and hope that there is sincerity in your aim to provide support for genuinely balanced perspectives in pregnancy, birth, and parenthood.  Placing yourselves as a collective group, in association with questionable or dangerous care providers, will simultaneously put you in a liable position for the care you represent.  If you aim to be a credible, long term resource for this community, you will carefully consider who it is you allow to be affiliated with your group. 

We hope your future endeavors demonstrate a model of safety and integrity, and hope that you fully understand the magnitude of responsibility that comes providing truly balanced resources for a community. 

Sincerely,

The Team at Safer Midwifery for Michigan

The Education of Midwives Around the World: Part 2

Welcome to part 2 in our series on the education of midwives around the world.  The research and writing presented here was generously contributed by two special midwives in the US who want to see home birth remain an option in the care of competent care providers.  

Responsible conversations about improving the safety of out-of-hospital birth always come back to two central issues: a) education and training and b) appropriate risking out protocols to ensure those births taking place outside the hospital are indeed "low risk".  

For the purposes of this series, we're focused on the educational aspects of midwifery. Specifically we are comparing how midwives around the world are educated, in direct comparison to those in the US.   




This post examines the question, are midwives focused on competency and quality midwifery?

The State of World Midwifery Report from 2011, points to, "...competencies - the combination of knowledge, skills, attitude, and professional behavior that quality midwifery care requires." 

Competencies: The Foundation of Practice
(State of the World Midwifery Report. 2011)
     
      "Being ‘skilled’ is only one element of a more complex reality. Recent and emerging  
      evidence indicate that there is often a significant difference between the number of 
      health workers designated as skilled birth attendants and those with midwifery 
      competencies meeting evidence-based standards. Counting all individuals within 
      professional health cadres to determine the supply of skilled birth attendants may 
      therefore be misleading. The correlation between the proportion of births that are 
      attended by a so-called ‘skilled attendant’ and a country’s maternal mortality ratio 
      may be weak because quality of attendance is simply not taken into account.  As a 
      result, the focus has shifted to competencies — the combination of 
      knowledge, skills, attitude, and professional behavior that quality 
      midwifery care requires."

 
The European Union Standards for Nursing and Midwifery: Information for Accession Countries*, further illustrates the extensive coursework and education expected of midwives in the European Union. 

     "All of the countries within the European Union now enforce these  
      requirements for professional midwifery education. That education 
      takes place at the university level.  The curriculum includes the 
      following subject areas:
 
A. Theoretical and technical instruction 

a. General Subjects
– Basic anatomy and physiology
– Basic pathology
– Basic bacteriology, virology and parasitology
– Basic biophysics, biochemistry and radiology
– Pediatrics, with particular reference to new-born infants
– Hygiene, health education, preventive medicine
– Nutrition and dietetics, with particular reference to women, newborn and young babies
– Basic sociology and socio-medical 
– Basic pharmacology
– Psychology
– Principles and methods of teaching 
– Health and social legislation and health organization
– Professional ethics and professional legislation
– Sex education and family planning
– Legal protection of mother and infant
 
b. Subjects Specific to the Activities of Midwives
 – Anatomy and physiology
 – Embryology and development of the fetus
 – Pregnancy, childbirth and puerperium
 – Gynacological and obstetrical pathology
 – Preparation for childbirth and parenthood, including psychological aspects
 – Preparation for delivery (including knowledge and use of technical equipment in   
     obstetrics)
 – Analgesia, anesthesia and questions resuscitation
 – Physiology and pathology of the newborn infant
 – Care and supervision of the newborn infant
 – Psychological and social factors

In addition to supervised care of low risk, normal women and newborns, the following clinical education is required.:
 
B. Practical and Clinical Training
 
This training is to be dispensed under appropriate supervision:
– Supervision and care of 40 women at risk in pregnancy, or labour or post-natal period.
– Supervision and care (including examination) of at least 100 post-natal women and 
    healthy new-born infants.
– Observation and care of the new-born requiring special care, including those born 
    pre-term, post-term, underweight or ill.
– Care of women with pathological conditions in the fields of gynecology and obstetrics.
– Initiation into care in the field of medicine and surgery. Initiation shall include theoretical 
    instruction and clinical practice.
 
The theoretical and technical training (Part A of the training program) shall be balanced and coordinated with the clinical training."

Check out these tables for a visual glimpse at educational standards for midwives across Europe, and beyond:   

Table of Educational Requirements for Midwives Around the World

Table of Midwifery Education, Supervision, HB Rates, etc: European Countries

Table of Midwifery Education, Supervision, HB Rates, etc: Other Countries

Now consider this...

In the US we have several types of midwives with a vast range of educational training.  We have CNMs and CMs (Certified Nurse Midwives and Certified Midwives) who have graduate level training, are often licensed as advanced practice nurses, and are the most highly-educated midwives, not only in our country, but also in the world.  Most CNMs and CMs work in hospitals, and a small percentage work out-of-hospital in homes and birth centers.  

We also have CPMs (certified professional midwives) who are the ones  pushing hard across the country for licensing, and a place in the "professional" world of midwifery, yet their educational minimum is having a high school diploma and completing a rudimentary apprenticeship with no formal academic requirements.    They earn their certification by submitting documentation of completing an apprenticeship and taking an exam. The minimum standards for the education of CPMs are not only paltry when compared to CNMs and CMs, and they are also significantly below that of our European, Canadian, and Australian counterparts.  So much in fact, that they would not be credentialed to practice in ANY other first world country.  These are the midwives that largely serve the out-of-hospital population in the US, and who are rabidly seeking recognition and credibility through state licensing.

With little to no educational standards in the US for "certified professional midwives,” it is difficult for consumers to understand what type of professional they are hiring, and why it matters profoundly in terms of safety.  As stated in Part 1 of this series, not all midwives are created equal.   

Here's what NACPM (National Association of Certified Professional Midwives) has to say in their recent newsletter about the purpose behind "accreditation" for CPMs: 

      "Why does accreditation matter? It remains the first accomplishment in the midwifery  
      movement where we have fully achieved federal recognition. It is that part of the 
      movement that dips its feet into the mainstream waters. It is the portion of our 
      educational fabric that is easily understood by the mainstream, and easily accessed by 
      students who are looking for an educational experience that they can finance in the 
      mainstream and defend in the mainstream. It is a portal where the radical can 
      slip into the mainstream and stir up a change!" (Pg 10, NACPM Newsletter)

Let's reflect again on The State of World Midwifery Report from 2011: "...competencies - the combination of knowledge, skills, attitude, and professional behavior that quality midwifery care requires."    

Are midwives in the US truly focused on competency?   

Not according to NACPM:   

     "In our fervent defense of apprenticeship, have we lost sight of the whole vision our   
      professional roots dreamed of? We had the vision that gave birth to our movement, 
      that organized around a federal credential, that created a credentialing process 
     that honored multiple ways to be trained, that brainstormed what we needed to do 
     to become educational accreditors for our diverse schools, and that has led to more 
     than 1700 credentialed autonomous midwives in less than 15 years.  Some of those 
     midwives came through apprenticeships, some through schools. We created a 
     profession that offers optimal access to women with diverse learning styles, family 
     and economic limitations, and geographic realities. There is no one way that is better 
    than another; it all leads to a common denominator, which is the CPM." 
    (pg 10 NACPM Newsletter)

It would appear that the purpose behind accreditation according to NACPM has more to do with creating a name for themselves using multiple routes to a made up "certification".  Nothing about the way their non-existent standards are set up has anything to do with competency, knowledge, or adequate skills on a consistent, reliable basis.  The professional behavior and attitude demonstrated time and time again, illustrates precisely the opposite of "quality midwifery".  

Is midwifery care, particularly in the out-of-hospital sector, truly as "high-quality" as it could be?  Is it on par with our foreign counterparts?  Should states be issuing licenses to individuals with such skimpy education and training of those who attend births outside hospital walls?  Why should we settle for any less than the best, most skilled, and highly trained midwives to be attending childbirth in out-of-hospital settings?  

It's time for the US to establish higher standards for "professionals" so we can have reliable options on par with our foreign counterparts.  We are a nation full of resources, educational opportunity, schools, libraries, etc.  There is no excuse for not expecting more in terms of educational standards of our midwives. 

More on this topic:
The Education of Midwives Around the World: Part 3 (Coming Next Week)

(*Second edition Revised and updated by: Thomas Keighley, 2nd edition, 2009)

Disaster in the Making: Senate Bill 292

Last week Senator Green introduced a new bill in the Senate, SB 292.  It looks much like last year's HB 5070, and its sister bill SB 1310, all of which propose to license CPMs in the State of MI.  

In summary, this bill is a disaster in the making. 

According to Kate Mazzara, CPM and President for the Michigan Midwives Association:
 
     “The purpose of licensure is to protect the public's safety by providing a mechanism 
      for consumers to verify that their midwives have appropriate training, proficiency 
      and accountability, as determined by the state,” said Kate Mazzara, president of the 
      Michigan Midwives Association.  "Licensed health care providers are subject to 
      oversight by state boards that are responsible for determining standards of practice 
      as well as hearing consumer grievances and carrying out disciplinary measures 
      when necessary.” ~ Quoted from recent LSJ Article

All sounds good right?  "Appropriate Training ~ Proficiency ~ Accountability ~ Oversight ~ and Standards of Practice"... so what's the problem?  Isn't this precisely what Safer Midwifery for Michigan is all about? 

The problem is that Ms. Mazzara's statement is a carefully crafted PR move, with absolutely no meaning or intention behind it.  Anyone who takes the time to read this bill will see glaring discrepancies between what she claims to support, and what is actually being proposed in this bill.  It's almost as if the small number of midwives supporting this bill are counting on the fact that the public won't read it for themselves. 

Well, we did read it, and in a nutshell here is what this bill proposes for MI families: 

• A body of licensed midwives whose minimum standard for education is a high school diploma or a GED, hold a CPM certification, and pass the NARM exam.  

• Just a reminder here that the minimum standard for education in every other first world country is 3-5 years of UNIVERSITY education.  The educational standards for CPMs in the US would not qualify them to be employable in any other first world country.  Is this "appropriate training and proficiency?"  Not by anyone's standards but their own.   This level of educational training is no where near a university level education, in fact there is literally NO university level training required whatsoever to earn a "CPM" credential. 

• Midwives who carry prescription medications and administer IV fluids with NO MEDICAL TRAINING or even so much as a course in Pharmacology.  

• No, they don't want to bother with jumping through the hoops of earning prescriptive authority, instead they propose to work under the prescriptive authority of other "health care providers".   Other "health care providers" is purposefully defined as Physicians, Nurse Midwives, or any other licensed, registered, or authorized health care professional. 

• The bill further states:

                        "The department shall not promulgate any rules that limit the  
                         authority of a midwife to administer prescription drugs or 
                         medication or prohibit the administration of medication." 

• A strategically biased board of "midwifery" that consists of 5 midwives and 2 members of the public.   

• Note that this bill also defines "midwifery" as being completely separate from Nurse Midwifery.  Therefore, there are no Nurse Midwives that will participate on this board, no physicians, no balance.  It's a sneaky little way to avoid accountability by protecting the sisterhood, just as is done now with "peer review".  

 

•  A "board" that promises to promulgate rules about regulating, limiting, prohibiting, the tasks, acts, or functions of midwives, yet in the same bill states:   
  

                          "The department shall NOT promulgate any rules under this 
                          section that limit or restrict the scope of practice of midwifery 
                          as established under this article." 

• In other words, there will be no risking out criteria, no defined scope of practice that ensures families will be properly assessed and appropriately limited to low-risk births.  The bill specifically states that no one can limit a midwife's scope of practice except for themselves.  
 

• Collaborative care will be determined by the "board" with the "appropriate health care providers".  

• So an unbalanced board will determine when, if ever, a client would need to consult with a "health care provider."  For example, a woman with a breech presenting baby might be referred to a local chiropractor in lieu of consulting with an actual OBGYN.  (Yep, that happened.)  We all know that high risk birth is considered, "just a variation of normal" anyway.  

 

Licensing alone will not improve the safety of out-of-hospital birth!  Time and time again, experts have said that the factors that contribute to the safety of home birth (or OOH birth) are:
          a) Highly educated care providers (In the US that means a CNM or a CM)
          b) Clear screening guidelines and risking out criteria that ensure homebirth is an 
               option for only low-risk women
          c) Truly collaborative care between midwives and medical personnel
 
ACOG has issued a statement on Planned Homebirth explaining the critical factors in achieving favorable outcomes:

     "Importantly, women should be informed that the appropriate selection of candidates 
      for home birth; the availability of a certified nurse–midwife, certified midwife, or 
      physician practicing within an integrated and regulated health system; ready access 
      to consultation; and assurance of safe and timely transport to nearby hospitals are  
      critical to reducing perinatal mortality rates and achieving favorable home birth 
      outcomes.

Licensing CPMs wouldn't come close to meeting educational standards for "highly educated care providers", and dangerous bills like SB 292 work intentionally against appropriately defining a scope of practice as being for low-risk pregnancies in the OOH sector.   The notion that this bill is about accountability, proficiency, oversight, or safety is an absolute lie.   

There is no doubt that our options in MI are limited, and that licensing is part of a bigger picture that can potentially offer safer options, but it MUST be done responsibly, including all of the factors that impact safety.  Handing out a license to those who haven't earned them according to educational & safety standards, will undoubtedly cause more harm than good.  Women in MI deserve to have safe, reliable options, and this bill will not provide them with that. 

Please read the bill for yourself and contact your Senator and State Representative immediately to share your concerns for the safety and well being of mothers and babies in MI.  

* Tell them that people with a high school diploma, & no medical or university level training, have NO business administering drugs or IVs, let alone delivering babies.  

* Let them know you value options surrounding birth, but that MI women deserve for those options to be safe and reliable...this bill won't get them there.


What would improve the safety of OOH birth?  

• Licensing only the most educated to serve as midwives, those with a university level education 
• A clearly defined scope of practice and risking out protocols that ensure only low-risk births are taken on outside the hospital
• Appropriate transfer of care and Collaborative Care guidelines 
• A balanced board of midwifery, including a majority of highly educated midwives, doctors, and citizens

Check out this link for more reading about Educational Standards for Midwives Around the World.  


(Part II in the 3 part series on Education of Midwives Around the world, coming on Monday.) 

The Education of Midwives Around the World: Part 1

We'd like to invite you to follow our 3 part series on the education of midwives around the world.  The research and writing presented here was generously contributed by two special midwives in the US who want to see home birth remain an option in the care of competent care providers.  

"Out of hospital birth is only safe if your midwife practices safely!"

Part 1: A midwife is a midwife is a midwife...or maybe not.  Are all midwives created equal?

There is a long list of studies (Homebirth: An Annotated Guide to the Literature, May 2011. Saraswathi Vedam, Laura Schummers & Colleen Fulton.) which show that birth out of hospital is safe. These studies are frequently quoted by advocates, parents, and midwives when discussing the safety of out of hospital birth, and specifically home birth.  Birth out of hospital is safe in the studies cited, but the common thread that makes them safe is the educated, knowledgeable, licensed and regulated midwife responsible for the care of the mother and baby. The studies discuss the outcomes, but they don’t discuss the training, education and experience of the midwives providing the care. Nor do they examine the supervisory role of a more experienced midwife, or collaboration with a physician in the larger medical system.
 
The three studies listed in the Meta Analysis and Systemic Review are the best available evidence (Section 1:A) of the safety of out of hospital birth. However, included within those analyses were large studies that included home births in British Columbia, Canada, the US and the Netherlands. One of the US studies cited was the National Birth Center study from 1992. As has been shown in the National Birth Center Study of 2013 the great majority of women receiving care at birth centers receive care provided by Certified Nurse-Midwives (CNMs).  CNMs are licensed in all 50 states and their educational requirements are much different than CPMs and non-certified non-nurse midwives (those that provide the majority care in the home birth setting). 

CNMs usually are graduates of university based midwifery programs and at a minimum posses a bachelor’s degree with the standard for newer graduates of these programs being a Master’s degree.  The midwifery education programs are similar to the one offered through Wayne State University in Detroit, MI.  Students must complete 48 college credits which includes over 600 clinical hours and completed in 2 years. Most states require a Master’s degree in nursing for CNMs to be licensed in that state.  

Of the 4 studies that Vedam (2011) cites in the North American Cohort Studies section of her paper, three of them examined a Canadian population. Midwives in Canada are Registered Midwives (RM).  Midwifery education in Canada leads to a baccalaureate level degree in midwifery. It is currently offered only through universities.  Admission and Graduation Requirements for Canadian midwifery education programs are direct entry and do not require a prior nursing degree or diploma.  Admission is based on secondary school eligibility and completion of prerequisite sciences and other courses with minimum grades or an overall average. Most midwifery programs recommend at least one year of university studies and/or related work or volunteer experience before applying. The admissions process usually includes a personal interview as well as assessment of academic eligibility.

In addition, the four-year Canadian curriculum includes required courses in health, social and biological sciences (anatomy and physiology, biochemistry, reproductive physiology, pharmacotherapy) and a series of midwifery care courses that integrate academic studies with clinical experience. Clinical courses taught by program faculty are combined with placements in midwifery practice settings, during which students develop clinical skills in prenatal, intrapartum, postnatal and newborn care under the supervision of midwife preceptors. The equivalent of at least 2400 clinical hours and 850 academic hours over a minimum of 18 months of midwifery education.  Placements extend over five to six semesters with electives in interdisciplinary and international settings and a clerkship (internship) in the final year. Graduation requirements include successful completion of academic courses and examinations, demonstration of competencies in all levels of the program, and attendance at a minimum of 60 births (40 as the primary care provider) in hospital and out-of-hospital settings.  Most provincial/territorial regulatory authorities also require new graduates of midwifery education programs to write the national Canadian Midwifery Registration Examination (CMRE) before registration.

The profession of midwifery in Canada includes significant emphasis on medico-legal issues and risk management. Canada has a single, regulated model of care which includes informed choice and continuous on–call care of clients by fully autonomous midwives. As of 2011, nearly all the Canadian provinces required that midwives be registered in order to practice.

There are 6 studies listed in the International Cohort Section of Vedam’s paper. The studies detailed were two each from the Netherlands and the United Kingdom, and one each from Australia and Switzerland. Midwives in the Netherlands are educated at institutions of higher learning (colleges) in a program that lasts four years. A high school diploma with courses in biology and chemistry is a prerequisite. The educational program includes 3560 hours of practical classes and 3160 hours of theoretical classes. In the Netherlands women are only allowed the option of home birth if they live within 15 minutes of the hospital.

In the United Kingdom (UK), midwifery education takes place at a university and is 3 years in length.  Prerequisites include science and English. Each of the midwifery programs include 2500 hours of practical classes and 2500 hours of theoretical classes. Although there are midwives in the UK that choose to practice independently (less than 1% of all midwives), most are employed by the National Health Service. All midwives are required to be licensed and to carry liability insurance.  All midwives whether independent, or NHS, have a supervisor who ensures their practice is of a satisfactory standard. The home birth rate is less than 2.5%. 

The same educational standards are true of midwives certified by the American Midwifery Certification Board, which certifies nurse midwives (CNMs) and certified midwives (CMs) in the US.  (Note: Not all CNMs and CMs carry insurance if they are practicing outside a hospital in the US.)  These two types of midwives have educational standards and competencies consistent with the International Confederation of Midwives (ICM) and the World Health Organization (WHO). CNMs are licensed and regulated in all 50 US states.

However, the standard of being licensed, educated, and insured is not true for the majority of midwives serving the home birth sector.   

In the US, there exist other types of midwives which include certified professional midwives (CPMs), Direct Entry (apprentice style) Midwives (DEMs), Lay/Licensed Midwives (LMs), community midwives, and practical midwives. CPMs are "certified" by the North American Registry of Midwives (NARM), but only recently (2012) has NARM required a minimum educational prerequisite of a high school education.  A university midwifery education program is not required to become a CPM.   Currently 26 states license CPMs but the licensing regulations vary greatly by state.  

Please see the attached pdf for details comparing CNMs, CMs, and CPMs.

Non-certified, non-nurse midwives are not licensed in any of the 50 states, although they may be licensed as licensed midwives (LMs) in a few states. They may be known as lay midwives, or direct entry midwives (DEMs), community midwives, practical midwives, or traditional birth attendants (TBAs).  They have no minimum educational requirements. Their experience, knowledge and skills may vary greatly. Because they are not certified, a midwifery education program is not required to become a non-nurse, non-certified midwife.

The educational requirements among the non-CPM, unlicensed midwives is similar, if not the same, to the traditional birth attendants in developing countries. Even the governments in those countries recognize that TBAs do not have the knowledge or skills to care for even some of the more common complications. They may be knowledgeable when all is going well, but cannot save mothers or babies lives when things aren't going well.  The countries with high maternal and infant mortality rates also have a high proportion of TBAs. These countries are training midwives at the university level to go out into the rural areas and train the TBAs to be better midwives. It is the same thing that happened in the US early in the 20th century.

Although CNMs may provide care to women planning births in hospitals, birth centers, or at home, CPMs and uncertified and unlicensed midwives only provide care to childbearing women desiring to give birth at home and sometimes at birth centers.

The United Nations Family Planning Association has this to say about regulation and education:

     "The purpose of regulation and the process of regulating combine first
      and foremost to serve and protect the public. Regulation is a way to
     oversee whether health professionals are competent to practice. It is
     an essential accountability function for a government to fulfill its
     responsibility t0 protect its citizens, and ensure their right to
     health, including the obligation to grant special care and attention to
     women during a reasonable period before and after childbirth.
     Conversely a health care system that relies on midwives or other 
     cadres who are less than competent to provide care through their
     professional careers is dangerous to women, newborns, families, and
     communities.”

The United Nations Family Planning Association (UNFPA) in 2011 published a comprehensive study, The State of World's Midwifery 2011: Delivering Health, Saving Lives that detailed the state of midwifery worldwide. They looked at how midwifery is saving the lives of mothers and babies around the world. In order to continue and improve the services that midwives provide, the UNFPA recommends additional education and continuing competencies.

The best OOH birth outcomes result from attendance by a trained and skilled midwife who collaborates with physicians and medical facilities and has clear risk-out criteria for eligibility for home birth.  Unfortunately we do not have an ideal system for assuring this type of safety and high-quality care in the US. Even licensed midwives can have difficulty assuring smooth referral or transfer of care to the hospital or collaboration with physicians when needed. I've found that unlicensed midwives have an even harder time assuring these safety measures.

I believe that low-risk mothers experiencing healthy pregnancies with no discernible risk factors attended by a licensed certified midwife who practices in accordance with safe standards of care can provide care that is pretty darn good - and probably comparable to hospital birth. But removing any of these factors (risk-out criteria, practice standards, qualified midwife), the outcomes will be poorer, as we've seen demonstrated time and time again across the US. 

Thus, to say that home birth in the US with an undereducated, possibly unlicensed, and definitely unregulated midwife is as safe as with educated, knowledgeable, licensed, and regulated midwives in the US (CNMs and CMs), Canada (RM), Europe, or Australia is a disingenuous, false and dangerous comparison. 

Midwives are not all created equal. Knowing the difference may save you or your baby’s life.