Monday, April 29, 2013

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 cons
umers 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 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? 


  1. Thanks for sharing Ms. Rook's comments -- I found them really interesting and well-reasoned.

    One thing I'm a little confused about is SMFM's position on CPMs. At the end of the post, you seem to imply that SMFM is okay with the CPM credential if the CPM has completed her education at a MEAC-accredited institution. But in the section of the website devoted to SB 1208, you state that SB 1208 would "[define] a 'Licensed Midwife' as a registered professional nurse who is licensed as a midwife. The bill further states that anyone who does not hold a license would not be allowed to refer to, or advertise herself as a 'midwife' in the state of Michigan." The latter position indicates that SMFM does not support allowing anyone with the CPM credential (regardless of where she received her education) to practice as a midwife in MI. Can you clarify which position accurately reflects that of SMFM?

    Also, just curious -- has SB 1208 been reintroduced this year?

    1. Excellent questions, and I can see where the confusion comes into play. I don't think MEAC accreditation is sufficient, but it is a college level training. We have a post coming up soon addressing the issues with this accreditation. We don't have any CPMs in our state (that I am aware of) who have the CPM credential by attending an MEAC accredited program, so I suppose the point we're making is that even though it's available, few are choosing to educate themselves in that way. We don't endorse it as being sufficient.

      1208 is being considered for revision and reintroduction. Significant changes have been recommended, including the minimum standard for education being set at a much higher level, w/o the nursing component, and removing any language that limits the scope of practice for CNMs. We're hoping the new bill will aim efforts at setting the standards of both practice and education for midwives practicing OOH. As part of the bill, "midwife" would be defined. That doesn't mean your Aunt Sally, couldn't deliver your baby, it just would mean that she can't advertise herself as a licensed, educated, midwife. You can be sure we'll post the minute we have a new bill to share!