Monday, April 22, 2013

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   
 – 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)

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