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.