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?

Tempering Extremism in the Natural Birth Community

The online world of natural childbirth is often heavily influenced by extremism. People claiming things like "Birth is safe. Interventions are risky" sometimes leads women to believe that as long as there is minimal intervention in their birth and they listen to their intuition, there will be a good outcome. Worse yet is the belief that a bad outcome occured because the woman didn't "trust birth" enough or the ridiculous logic that anything makes a baby's preventable death okay.

Most people who promote natural childbirth also promote that women educate themselves, but as I have said before, the problem with not knowing is we don't know what we don't know. Many women may think that they are educated about birth when they really aren't. And if you really believe that "birth is safe," then what do you really need to know? The same is true of under-trained women who act as "midwives"--many of them follow this same mentality and are unaware of the information out there that they don't have. To be clear, I do not mean all direct-entry midwives. Some are well educated. Some are not. And having the CPM credential doesn't mean anything. Having a state license may mean something, depending on the individual state's requirements--they range from having a CPM (which, as I understand, at minimum, can be achieved by doing an apprenticeship involving at least 40 births, getting CPR and NRC certified, and passing the NARM exam) and being required to graduate from a three-year program at an accredited midwifery school, attend at least 100 births, and pass the NARM exam (Washington State).

I mentioned the homebirth midwifery laws in Oregon in a previous post. A recent tragedy in Oregon has opened debate about these laws, and many are calling for mandatory licensing. I think that this unfortunate event may be a consequence of extremism--untrained midwives thinking they were qualified enough to attend births and a poor mom who didn't know or believe that looking into their training was important.

There will always be extremists in every movement. The internet, with its power to bring people together, sometimes gives the illusion of normalcy to the extreme. Sometimes it is necessary to push back against the influence of extreme ideas--to nudge the proverbial pendulum back the other way a little. Those who do so will often be accused of being "from the other side" or "causing division." I think voices of reason are essential. I have recently come across a circle of bloggers who fight to temper extremism in natural childbirth and homebirth, and to raise standards for midwifery in the U.S. They promote Certified Nurse Midwives as the optimal caregiver for a homebirth and believe that the Certified Professional Midwife credential should be changed to match the CNM standard of education or be done away with. Amber and Jessie are both former CPM students who have now chosen to pursue CNM education. Deb ("The Sensible Midwife") is a CNM with a homebirth practice. While I may not agree with everything these women have to say, I do believe the natural birth movement needs voices like theirs to help keep it in check.

Temper (verb): to dilute, qualify, or soften by the addition or influence of something else: moderate (merriam-webster.com)

Licensing vs Decriminalization

Hope everyone is enjoying their Independence Day weekend. This post seems appropriate for this holiday, as it addresses freedom and law in the U.S.

One commenter on my post, How Homebirth Benefits Babies, said that she feels decriminalization of midwives would be a better way to legalize midwifery than licensing. I am aware of the division within the midwifery support community on the issue of licensing. Here is the issue, as I see it.

The arguments for decriminalization
Licensing puts restrictions on midwifery practice. States that license midwives have laws governing direct-entry midwifery that determine the criteria for acceptance as a midwifery client and conditions that require transfer to hospital-based care. These criteria may categorize a woman as "high risk" who is not really very high risk at all. For example, Arkansas law states that licensed midwives may not treat women who have previous cesarean sections, multiple gestation, maternal age greater than 40, or previous infant weighing more than 10 pounds. It also requires transfer for non-vertex positions and gives a set number of hours a woman can be in labor before she has to transfer. Here, in the state of Washington, transfer is required for women who pass 42 weeks gestation. I most definitely do not believe that all women that fit into these categories are only safe birthing in a hospital. These kinds of restrictions put many women and their midwives in tough situations, where the midwife could risk losing her ability to practice legally if she choses to help a woman have the homebirth they may both feel is optimal for her.

In theory, decriminalization would give midwives the freedom to set their own standards without the fear of prosecution for practicing medicine without a license (something underground midwives in states where homebirth midwifery is not legalized in any way have to deal with) and without having to worry about being punished for not following the terms of the state that gives them a license.

The arguments for licensing
The Unnecessarean reposted a discussion from their facebook wall on a status update that they shared from Big Push for Midwives'. It is an interesting conversation between midwives, consumers, lawyers, and advocates that I recommend reading if you want a good grasp of the different points of view on the issue. Here are a couple of quotes that address why licensing appears to be the best course:

Just “make midwifery legal”? How? By pushing for a blanket “midwifery is legal” law? How do you define midwifery? How do you define a midwife? How do you define what is NOT covered? All of these things would have to be done in order to “make midwifery legal.” All of these things are the same exact things done with licensure.-Tara ANaturalAdvocate

[A]s a practical matter, simply legalizing midwifery — that is, decriminalizing the practice of midwifery by statute and/or getting the legislature to pass a law to officially declare that midwifery will no longer be considered unauthorized practice of medicine or nursing — would be politically impossible. Organized medicine, and often organized brainy, fight tooth and nail against efforts by consumer groups to regulate midwifery. They win over many legislators by claiming that licensed certified professional midwives are unsafe. Can you imagine the field day the OBs and medical society would have, or how skeptical the legislators would be, if the legislation simply allowed midwives to practice without any state oversight? Even if this legislative option may have worked ever in the past, it would be truly impossible today. Really truly impossible. Our state groups are there “in the trenches” and know how difficult it is already to get licensed regulated midwives.-Susan M. Jenkins

Why push for the licensing of midwives? Because licensing legislation actually happens. Because states have the right to regulate health care providers who practice there. Because the majority of professions require some sort of license/certification/official credential to do their job. Because in order to legally recognize midwifery, you have to define it, and by defining it, you necessarily have to determine what it is not, which by definition will "limit" midwifery.

Oregon is the one state I know of were there is "decriminalized" midwifery--midwives have two options--they can choose to obtain a license from the state (which allows them to file for reimbursement from the medicaid system) or they may legally practice midwifery without a license. However, practicing without a license means it is a felony for these midwives to use oxygen and pitocin, as the use of such drugs falls under the category of "practicing medicine." I believe that women and babies benefit when midwives have the ability to legally use life-saving medications in the home in the event of an emergency. It appears to me that there is definitely a trade-off. Either midwifery involves the occasional practice of medicine, or it does not. You can’t have it both ways.

Beyond the ability to have pitocin and oxygen available, licensing also ensures consumers a minimum standard for licensed midwives. No, being licensed does not guarantee that someone is a competent midwife, but it gives consumers some indication of the midwife's qualifications. When anyone can claim to be a midwife, it creates a confusing and unsafe environment for consumers.

Licensure also strengthens the credibility of midwives, both to consumers and to medical professionals. Knowing that licensed midwives have completed certain requirements may make physicians and hospitals more respectful of them, allowing for better collaboration, which also benefits mothers and babies.

Many states do have mostly good, evidence-based guidelines for the scope of practice of midwifery. It is not necessarily licensing that limits homebirth options, but rather certain state’s licensing laws. Those who are unhappy with their state’s licensing regulations are free to organize consumer efforts to change those laws.

I, personally, am quite convinced that licensing is the most feasible way to legalize midwifery and that it helps make homebirth safer for consumers. What do you think?