"Certified Midwives" Examining the CM Credential

What is a Certified Midwife?

A Certified Midwife (CM) is a health care professional who holds a credential in midwifery from the American Midwifery Certification Board. Certified nurse-midwives (CNMs) are the most prevalent type of midwife in the US and are certified by this same board.

The standards for education for CMs and CNMs are identical. Both must be educated in a graduate degree program, are trained in the same competencies, and must pass the same certification examination.

By credential, certified midwives are qualified to independently manage low-risk pregnancies and deliveries, provide routine well-woman care and screenings, diagnose and treat health conditions, and prescribe medications. 

How is a certified midwife CM different than the CPM or CNM?

Educationally, the only difference between CMs and CNMs is that CMs do not have degrees in nursing. It is an equivalent credential to the CNM.

The differences between CPMs and CMs are that CMs must be trained at a graduate level, CMs are integrated healthcare providers working alongside physicians, nurses and other healthcare providers, CMs are qualified to attend births in any setting, CMs are trained in pharmacology and prescribing medications.

The differences are so important, we felt a graph would be helpful:

	CM	CPM
Graduate degree required	YES
Training in medical pharmacology required	YES
Skilled in providing care in all birth settings	YES
Providers of gynecology and well-woman care	YES
Qualified to prescribe birth control and other medications	YES
Trained with in the health care system among physicians, nurses, and other healthcare professionals	YES
Self-purported “experts” in out-of-hospital birth		YES

 
How are CMs and CPMs similar?

• Neither CPMs or CMs are required to have a degree in nursing.
• CMs and CPMs are not licensed in every state. The state of Michigan does not currently recognize either the CPM or the CM through licensing. 

But the differences between CPMs and CMs are vast and striking. Why are so many states 'pushing' for licensure of such poorly-trained midwives as CPMs, when there already is a high-quality, non-nurse credential? Why, when every state already recognizes and licenses CNMs, is it so difficult to enact licensing for the CM - an equivalent credential? Why, when it comes to midwifery licensing, should we reinvent the wheel - and an inferior wheel, at that -and license midwives with minimal training, minimal oversight, and minimal (or non-existent) standards of practice?

What we'd like to see in Michigan:

We would like to see Michigan take the lead on this very important issue, and license only the most qualified and highly-skilled midwives for women and their families, CNMs and CMs. We would like to see Michigan's nurse-midwifery programs, the University of Michigan and Wayne State, create pathways for training midwives who would become CMs in our state, and we would like to see not only the Michigan Affiliate of the ACNM but also the Michigan Midwives Association openly support improving the educational standards of midwives in our state by endorsing and promoting the CM credential.

MEAC - How to Make Accreditation Matter in Midwifery Education

The Midwifery Education Accreditation Council - also known as MEAC - is the organization that accredits programs that train midwives to become eligible to take the NARM exam and become CPMs.  (Note: The MEAC accredited route represents only one path to becoming a CPM.) 

Believe it or not, we have had numerous discussions regarding MEAC-accredited midwifery programs and creating a requirement of graduation from a MEAC-accredited program as a provision for CPM licensure in Michigan.  Florida and California already do this, and it beefs up the educational background for certified professional midwives licensed by these states. The American College of Nurse-Midwives has a position statement regarding midwifery certification in the US, and supports licensure of CPMs who have completed a formal education program. Requiring formal midwifery education goes above and beyond the paltry educational requirements set forth by NARM and perhaps even fulfills the education requirements set forth by the International Confederation of Midwives.

In our discussions we've come to the conclusion that MEAC does not do enough to ensure high-quality midwifery education, and though it is an improvement over NARM's rudimentary standards, it is not sufficient for licensing independent midwives.

Why doesn't Safer Midwifery for Michigan endorse the MEAC-graduate CPM as holding the minimum requirement for Michigan licensure?

• MEAC does not assure uniformity in education between accredited programs (some graduates hold master's degrees, others have a 'certificate' in midwifery)
• MEAC does not assure more thorough academic preparation than apprenticeship-only education
• MEAC does not strive to provide an education that is an improvement over the infamous portfolio evaluation process (PEP), but takes care to make certain there is no advantage of MEAC-graduates over apprenticeship-only trained midwives
• MEAC bows to the lowest common denominator, citing that "all pathways" to becoming a CPM are equal,  
• MEAC does not require integration into post-secondary education institutions to assure consistency with American standards for general education requirements. This means if a CPM graduates from a MEAC-accredited program, none of the credits earned will transfer to any real university or college in the US.
• MEAC programs do not require evaluation of the preceptor's teaching methods or efficacy in training student midwives.
• MEAC does not require any hospital-based clinical experience midwifery

What would it take for SMM to endorse the MEAC route to becoming a CPM?

• Regional accreditation as well as specialty accreditation.
• Requiring preceptors to have training and guidance in teaching students.
• Oversight in determining how successful completion/competence is determined by preceptor
• Require clinical experience in a US hospital setting
• Require at a minimum a Bachelor's degree
• Require specific coursework related to health care and midwifery in biology, chemistry, anatomy and physiology, microbiology, pharmacology, statistics, risk screening, assessment, the midwifery scope of practice, ethics, embryology, primary care for women's health, and prenatal, postnatal and intrapartum theory courses.
• Commit to ensuring superior education and training of midwives who are educated through MEAC accredited programs. 
• MEAC should not be branded as a 'separate but equal' pathway to becoming a CPM, but a more rigorous, more thorough, more comprehensive pathway that produces higher-quality midwives.
• MEAC must advocate for accredited programs to be the only valid route to attaining a CPM credential.

Currently, the bottom line for CPMs is that ACCREDITATION DOESN'T MATTER - because graduation from an accredited educational program is purely optional for becoming a CPM. A student midwife could drop out, not graduate or fail every single one of her classes, and as long as her 'skills were signed off on' the student midwife could still take the NARM exam and become a CPM.

A quote from Via Vita Midwifery Midwifery illustrates this point:

http://www.viavitamidwiferyschool.org/

Though this is just one example of the attitude toward accreditation of midwifery programs, we have found it to be common among CPMs. Here's another sentiment expressed in a 2011 newsletter from the National Association of Certified Professional Midwives. (Notice the glaring lack of any statement regarding assuring quality of education):

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! ~ Ellie Daniels, CPM, Past President of MEAC

So the rationale for MEAC-accreditation - from the words of a past-president of MEAC - is not to assure competent and highly-skilled midwives, but merely to gain some acceptance in mainstream America?

We believe Michigan families deserve better than this, and this is why SMM cannot support MEAC-graduates as qualified for licensure as midwives in our state.

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? 

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)