Tuesday, October 18, 2011

Comparison of Midwifery Education in Different Developed Countries

A couple of months ago, Amber at Midwife{ology} wrote a post, Educational Standards of American Midwives: A Comparison, which compared the direct-entry midwifery education program she left to the nurse-midwifery education program she is currently pursing. She points out what she sees as a huge discrepancy in the training of these two different types of midwives, and concludes that CPM training is inadequate to prepare a midwife to be a competent birth attendant. Stephanie at Nurturing Hearts Birth Services (who I highly respect as a midwife and appreciate for the wonderful midwife's perspective on Hypnobabies she wrote) responded in her post CNM vs CPM by saying that she feels that the training of CNMs and CPMs are different because they have a different scope of practice: CPMs attend only out-of-hosptial births with low risk women who are not being medically induced or receiving drugs, while CNMs are trained to work with medical interventions in a hospital environment and do pretty much everything an OB can do except vacuum/forceps assisted births and cesareans. Training for CPMs is different because what they need to know is different. Good points on all sides.

I think that maybe comparing different midwife certifications in the U.S. is the wrong comparison, and we should be comparing American midwife training to midwife training in the rest of the developed world.

The United States: In the U.S., the types of midwives practicing fall into three basic categories:
  • Certified Nurse Midwives (CNMs): Those seeking this path must train as a Registered Nurse first and obtain a Bachelors of Science in Nursing (BSN) or the equivalent (usually through a "bridge" program), and then complete a midwifery program. CNM clinical training focuses mostly on hospital birth, and most CNMs attend hospital births, though some work in birth centers or have homebirth practices.
  • Credentialed Non-nurse Midwives: This path to midwifery is for those who do not have and are not seeking a nursing degree. These include those with the Certified Professional Midwife (CPM) credential obtained through the North American Registry of Midwives (NARM), the Certified Midwife (CM, which is only recognized in 3 states) credential from the American College of Nurse Midwives (ACNM), and various credentials bestowed by state licensing, such as Licensed Midwives (LM), Licensed Direct-Entry Midwives (LDM), or Registered Direct Entry Midwives. Different states have different requirements for their licenses. A midwife can obtain both her state license and a CPM (in some states a CPM is required to get a license, some states have requirements above what the CPM credential gives). There are multiple training paths for a CPM, including MEAC-accredited midwifery schools and apprenticeship options. All must pass the NARM exam. For more information, see the NARM website. These midwives practice almost exclusively out of the hospital and very rarely get training in hospital birth.
  • "Traditional" or Non-credentialed midwives: Licensure for non-nurse midwives is available in about half of the U.S. states. In the others, there are midwives who practice without licenses. Some do go through the training process with NARM, but they are still not legally allowed to practice. Some midwives in states that offer licenses choose to remain unlicensed, and do so illegally, except in Oregon and Utah, where it is currently legal to practice midwifery without a license. Training for these individuals varies widely.
United Kingdom: In the UK, there is one type of midwife training, done through a university. Training in nursing is not required, but those who have it have a head start in the program, so there must be overlap between basic nursing and early midwifery training. Midwives in the UK are qualified to attend births in all settings, home, hospital, and birth center. From the Nursing and Midwifery Counsel:
Education and training
In the UK midwifery education and training programmes are only run at NMC-approved educational institutions. Courses usually take a minimum of three years, unless you are already registered with the NMC as a level 1 (adult) nurse, in which case the training can be reduced to 18 months.
Midwifery training takes place at a university, with at least half of the programme based in clinical practice with direct contact with women, their babies and families. This can include the home, community and hospitals, and in other maternity services such as midwife-led units and birth centres.
Canada: Midwifery training in Canada is done through university education that prepares midwives to be able to attend both home and hospital births. From the Canadian Midwifery Registers Consortium
Midwifery education in Canada is offered at a university baccalaureate level. Education programs are “direct entry” (i.e. there is no nursing or other credential required for entry).
One example: The University of British Columbia Midwifery Education Program
The Midwifery Education Program at UBC is a four-year, direct entry, full time undergraduate program leading to a Bachelor of Midwifery degree. The curriculum combines broad-based knowledge and understanding in the humanities and the social and bio-medical sciences. . . .The first two years of study are located on the UBC campus and in the area of the Lower Mainland. The final two years, including the summer between years 3 and 4, consist of clinical courses. . . .Students are prepared for practice in both high tech and low resource settings (home, hospital, rural, international).
Australia: From the Australian College of Midwives - New South Wales
To become a midwife you need to complete either a Bachelor of Midwifery degree (direct entry) or a postgraduate program if you are already a registered nurse.
For an example of an undergraduate midwifery program in Australia, see Bachelor of Midwifery from the University of Technology, Sydney. This program takes 3 years of full time study to complete.

New Zealand: New Zealand also has a 3-year direct-entry program, where registered nurses can get advanced placement. From the New Zealand College of Midwives:

Each midwifery school offers an extended three year bachelor degree programme meaning that each year has a minimum of 45 programmed weeks rather than the more usual 36 programmed weeks. All students whether full time or part time must complete the programme within four years of commencement. This is the framework for all routes to midwifery registration. Each programme has a Recognition of Prior Learning Policy that enables those with appropriate previous qualifications and experience to receive credits or partial exemptions for aspects of the programme. Midwifery students who hold a previous nursing registration or those with other degrees or other relevant experience are likely to gain credit under these policies and complete a shorter programme. Registered nurses will usually complete at least two years of the full programme.

New Zealand midwifery training also includes mandatory hospital-based clinical experience:
Students work in a variety of settings over three years including family planning clinic, independent midwifery practices, neonatal intensive care units, maternity hospitals, laboratories, homebirth, and community. All students have a dedicated ‘block’ in base hospitals to achieve the experience necessary for competency in recognising deviations from the normal and working collaboratively with obstetricians in the provision of secondary care.
I was unable to find websites about midwifery in countries where English is not the first language, but according to reports from midwifery students on the studentmidwife.net forums, midwives in the Netherlands must complete a 4-year direct-entry program which qualifies them to attend both home and hospital births (and to allow women to choose to change her birth location up until the last minute without having to change providers), and midwifery school in Denmark takes 3 1/2 years to complete and midwives can do home or hospital births. Though it was a little difficult to decipher exactly what the French student midwife was saying with the language barrier, it appears that midwifery school in France is 4 years and may be part of medical school.

Okay, so, which one of these things is not like the others? All of these other developed countries train midwives to be qualified to attend births in both hospital and out-of-hospital environments and all of them require a university degree to practice midwifery. A class of midwives that deals exclusively with out-of-hospital births is unique to the United States. This raises some questions to me:
  • Would requiring midwives who practice out-of-hospital to receive hospital clinical experience (where they are much more likely to encounter rare complications), make them more qualified to handle rare emergencies when they occur in out-of-hospital births?
  • Would it benefit consumers for direct-entry midwives to be qualified to attend both home and hospital births and be able to obtain hospital privileges and attend the same types of hospital births certified nurse midwives currently do? Would this allow for better continuity of care when circumstances require a change in planned birth location?
  • Would standardized training and education for midwives similar to what other countries do give midwives who attend out-of-hospital births more respect in the medical community, allowing for better cooperation with obstetricians, nurses, and other hospital providers?
  • Would requiring more education for midwives, as some fear, "turn them into obstetricians"? Would training have less emphasis on skills needed to support normal birth with too much focus on pathology?
What do you think about how the training and scope of practice of midwives in the U.S. compares to the rest of the developed world?

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