Evolution and current status of direct-entry midwifery education, regulation, and practice in the United States, with examples from Washington State☆

Background 

After the dramatic decline in the number of direct-entry midwives in the United States in the first half of this century 4, 5, direct-entry midwifery re-emerged during the 1960s and 1970s as a grassroots movement among women seeking home births (6). This movement built upon the earlier prepared childbirth and natural birth movements, yet it was a localized phenomenon among specific feminist women’s health activists, holistic health care providers, back-to-nature enthusiasts, and religious or spiritual communities. Since very few physicians or nurse-midwives were either willing or able to attend home births, women who distrusted the overmedicalization of birth and wanted more personalized care turned to each other for support. Some formed study groups and read the medical literature on childbirth while sharing what they were learning from practical experience. The Birth Book written by Raven Lang in 1972, was the first publication to describe the home birth movement, including stories about women having home births in Santa Cruz, California 7, 8. In 1975, Ina May Gaskin published Spiritual Midwifery, a book that described her apprenticeship with a family physician and the births she and other lay midwives were attending in their community, The Farm, in Summertown, Tennessee (9). Other midwives organized home-study courses or taught basic midwifery skills in intensive workshops (10).

A group of young women in Seattle organized themselves as the Fremont Women’s Clinic Birth Collective and began attending home births, supported by several like-minded young physicians (11). In 1978, these midwives founded the Seattle Midwifery School, one of several small independent schools launched during that period. Birth centers run by direct-entry midwives, including The Maternity Center in El Paso, Texas, and the Northern New Mexico Birth Center in Taos, New Mexico, also began to accept students who traveled from across North America to obtain short, intensive clinical training (10). Women who had experienced home births with midwives formed consumer organizations or joined with midwives to organize state midwifery associations. These state associations typically established their own standards for training and practice within the context of political concerns and the legal status of midwifery in each specific state.

Midwives alliance of North America 

Midwives and their supporters across the country soon realized the importance of developing a more unified body, and several unsuccessful attempts at national organization were made. Finally, in 1982 the Midwives Alliance of North America (MANA) was established to “honor diversity in midwifery educational background and practice styles while fostering unity among all midwives.” The creation of MANA followed a meeting of direct-entry midwives and nurse-midwives convened by Sister Angela Murdaugh, CNM, then President of the American College of Nurse-Midwives (ACNM) (12). Membership in MANA has never been limited to midwives with specific credentials and all midwives are encouraged to participate. In February 1999, MANA had over 1,000 members, two-thirds of whom were midwives and one-third of whom were associate members. MANA has always had a fairly significant non-midwife membership comprised of consumers, aspiring midwives, and other health care professionals who support midwifery (Kelly Daniels, MANA Membership Chair, personal correspondence, 1999). Despite ongoing internal debate about the pros and cons of professionalization, MANA adopted standards of practice in 1985, created a board to test basic midwifery knowledge through a written examination in 1987, adopted core competencies in 1989, and issued a statement of values and ethics in 1991 (13).

What had begun as a grassroots movement responding to consumer demand for home births has gradually taken form as a professional body. Starr asserts that the “legitimization of professional authority involves three distinctive claims: first, that the knowledge and competence of the professional have been validated by a community of peers; second that this consensually validated knowledge and competence rest on rational, scientific grounds; and third, that the professional’s judgement and advice are oriented toward a set of substantive values, such as health” (14). All three elements are now present among professional direct-entry midwives in the United States.

Midwifery values and ethics 

Direct-entry midwives are oriented to a set of substantive values that have been informed by serving women who choose to give birth at home or in birth centers—a choice that suggests a commitment to assume or share responsibility for decisions about their own health care. The Statement of Values and Ethics adopted by MANA in 1991 affirms the midwives’ view of women as individuals with unique value and worth (15): “We value women and their creative, life-affirming and life-giving powers which find expressions in a diversity of ways. We value a woman’s right to make choices regarding all aspects of her life.” The mother and baby as a whole, the importance of relationships, personal responsibility, informed choice, the sharing of information and diversity among midwives are also stated as values. Social scientists who have studied direct-entry midwifery practice describe the distinctive nature of midwifery care and out-of-hospital birth, as well as beliefs and practices that are consistent with MANA’s statement of values and ethics.

Sullivan and Weitz, for instance, interviewed midwives in both Arizona and Massachusetts during the early 1980s (16). They found a striking congruence in the midwives’ beliefs about pregnancy and childbirth, despite considerable divergence in their educational backgrounds and in the legal status of midwifery in these two states. The researchers attributed this to a shared philosophy that emphasizes a wellness orientation, holistic and individualized care, and shared responsibility between the midwife and the mother. Sakala, who conducted in-depth interviews with midwives attending home births in Utah in 1985, found that they were motivated by a desire to avoid the iatrogenic consequences of conventional obstetric interventions (17). They also emphasized individualization of technique and providing care for the mother in the context of her overall life circumstances. They defined continuity of care as an approach that includes long prenatal visits to build trusting relationships and intrapartum support that began early in labor. These midwives also emphasized respect for the knowledge, resources, and capability of the mother and her close family and friends, thus employing prenatal and intrapartum empowerment as a fundamental therapeutic technique.

Development of a national certification process for direct-entry midwives 

In addition to their orientation to these values, direct-entry midwives are now able to claim legitimate professional authority through the validation of knowledge and competence by a community of peers—knowledge and competence that rest on rational, scientific grounds. MANA’s Interim Registry Board began to administer a written test to validate knowledge of individual midwives in 1989, however, candidates were not required to provide evidence of their qualifications and skills were not evaluated. In 1991, the board incorporated separately as the North American Registry of Midwives (NARM) and work was begun to set standards for the qualification of professional midwives and the comprehensive evaluation of competency (18). NARM is committed to “identifying standards and practices that preserve the unique, woman-centered forms of practice that are common to midwives attending out-of-hospital births.”

A Certification Task Force was convened in 1992 to oversee the establishment of standards, policies and procedures for the certification of midwives. The Task Force met periodically over the next 6 years while NARM initiated a pilot project aimed first at the certification of experienced midwives and later, at entry-level midwives. Completing the certification process entitles a midwife to use the title “Certified Professional Midwife” or “CPM.” The first group of experienced midwives became CPMs in 1995. Although certification remains entirely voluntary, over 400 experienced and entry-level midwives elected to complete the process in order to become CPMs between 1995 and April 1999 (Sharon Evans, NARM, personal correspondence).

In early 1996, NARM performed a comprehensive job analysis and translated the results into new specifications for both the written examination and a clinical skills assessment (18). Citizens for Midwifery commissioned an independent review of the NARM certification process in 1997. Experts in competency-based education and assessment from the Ohio State University Vocational Instructional Laboratory examined the processes used to develop the certification tests and testing procedures and reported that NARM’s process represented “best practice” within certification industry standards: “The development of the content specifications based on the job analysis information was focused on the primary purpose of certification—the protection of public health and safety. The procedures used for test item writing, content validation, setting pass/fail scores, and the development of the overall certification process represent a system explicitly designed to optimize fairness and accuracy in certification testing” (19).

During the pilot project, entry-level midwives were required to establish eligibility by providing extensive documentation that a supervisor or preceptor had assessed specific skills, knowledge, and abilities. They were not required to have completed a formal educational program. Applicants had to provide evidence of a minimum number of clinical experiences encompassing prenatal, intrapartum, newborn, and postpartum care. This included attending a minimum of 20 births as an active participant and another 20 births in the role of primary midwife, while working under supervision. Ten of these had to be births in homes or other out-of-hospital settings, and at least 3 of the total of 40 births had to be with women for whom the applicant had provided primary care during at least 4 prenatal visits, the birth, a newborn exam, and a postpartum exam. In addition, the applicant had to have conducted 75 prenatal exams, including 20 initial exams; 20 newborn exams; and 40 postpartum exams. Once eligibility was established, entry-level applicants were required to pass the written examination as well as an assessment of clinical skills conducted by a specially trained CPM (20).

At the final meeting of the Certification Task Force in 1998, it was decided that NARM should separate the two processes of educational evaluation and certification while keeping essentially the same clinical experience requirements in place (21). Entry-level midwives who are graduates of educational programs accredited by the Midwifery Education Accreditation Council (MEAC) and midwives certified by the ACNM Certification Council (ACC) are now only required to pass the NARM written examination to become CPMs. All other midwives, including those who have not completed formal educational programs and those who have graduated from nonaccredited programs, must establish that their educational preparation has met the requisite knowledge and skills by submitting a portfolio that documents their experience and includes a comprehensive assessment by a supervising midwife. Portfolio applicants are then required to complete both the written examination and a NARM-administered skills assessment.

Development of an evaluation process for direct-entry education programs 

The Midwifery Education Accreditation Council (MEAC) was founded in 1991 by a coalition of midwifery educators to create a mechanism for evaluation of direct-entry midwifery education programs (22). Each school is required to articulate the philosophy and purpose of its program, to provide a curriculum based on MANA’s core competencies and NARM’s knowledge and skills requirements, and to meet other standards. The core competencies identified by MANA include skills and knowledge in the following areas: general social and health sciences; antepartum, intrapartum, postpartum, and neonatal care; family planning/well woman care; and professional and legal aspects of midwifery practice. The accreditation process includes preparation of a self-evaluation report by faculty and staff of the program and site visits conducted by representatives of MEAC. The agency’s standards and procedures follow guidelines established by Congress in the Higher Education Act (23).

Maternidad la Luz, in El Paso, Texas, was the first direct-entry midwifery education program accredited by MEAC. By April 1999, three programs had received full accreditation and six had been pre-accredited (23). A program that is pre-accredited has not yet graduated students, but has met all other criteria for accreditation. By the end of 1999, MEAC will have completed one full cycle of re-accreditation, having reviewed all of the programs previously accredited or pre-accredited for two or more years. The agency will conduct a complete self-evaluation process before seeking formal recognition by the U.S. Department of Education.

In addition to the 9 MEAC-accredited or pre-accredited programs, 16 other direct-entry midwifery schools have reported that their programs address all of the MANA core competencies and include the clinical experiences required for NARM certification (24). Six of these have stated their intention to seek MEAC accreditation or pre-accreditation status in 1999 (23). Two other schools offer comprehensive programs that are not linked to national standards and 11 offer short courses, workshops, or clinical experiences that are not part of a complete midwifery program. Most of the latter are located in states that do not recognize or regulate direct-entry midwifery.

UCSF center for the health professions taskforce on midwifery 

In early 1998, the University of California at San Francisco Center for the Health Professions convened a Taskforce on Midwifery to explore the impact of health care system developments on midwifery and identify issues facing the profession and the role midwives play in the health care system 1, 40. The Taskforce presented 14 recommendations on midwifery practice, regulation, education, research, and policy, all incorporating the vision that the “midwifery model of care should be embraced by and incorporated into the health care system in order to make it available to all women and their families” (1). Midwives, educators, collaborators, and policy makers were urged by the Taskforce to use the recommendations to develop curricula, practice sites, and laws that fully include midwives and the midwifery model of care with the goal of improving the health care system.

The following is an assessment of several Taskforce on Midwifery recommendations as they relate to the status of regulation, education, practice and credentialing, research, and policy for direct-entry midwifery in the United States:

Recommendation 1. Midwives should be recognized as independent and collaborative practitioners with the rights and responsibilities regarding scope of practice authority and accountability that all independent professionals share.

Recommendation 2. Every health care system should integrate midwifery services into the continuum of care for women by contracting with or employing midwives and informing women of their options (1). As health care systems consider introducing or expanding the use of direct-entry midwives, they should examine the successes and the challenges experienced by licensed midwives in states that recognize the independent and collaborative practice of midwifery. Licensed midwives in Washington state provide an example that might be useful in developing guidelines for the integration of midwifery services.

Recommendation 4. Midwives and physicians should ensure that their systems of consultation, collaboration, and referral provide integrated and uninterrupted care to women, which requires active engagement and participation by members of both professions (1). Since most physicians have never worked with direct-entry midwives, they have little direct knowledge of their qualifications or practice. Misinformation and bias regarding the safety of home and birth center practices are commonly encountered when midwives seek to establish consulting relationships. Even though most licensed midwives in Washington state have not considered physician consultation and referral to be a major barrier to practice, their options for physician consultation are often limited by the fact that most physicians have not made themselves available to midwives (38).

Recommendation 5. State legislatures should enact laws that base entry-to-practice standards on successful completion of accredited education programs, or the equivalent, and national certification and that do not require midwives to be directed or supervised by other health care practitioners (1). The North American Registry of Midwives standards for certification as a CPM, which require completion of an accredited program, or the equivalent documentation and evaluation of knowledge and skills (20), are consistent with this recommendation. Policymakers in various states are already beginning to recognize the utility of employing NARM certification and MEAC accreditation mechanisms in regulatory activities; specifically, 14 states now use the NARM written examination while Florida requires that educational programs be MEAC accredited.

Recommendation 6. Hospitals, health systems, and public programs, including Medicare and Medicaid, should ensure that enrollees have access to midwives and the midwifery model of care by eliminating barriers to access and inequitable reimbursement rates that discriminate against midwives.

Recommendation 7. Health care systems develop hospital privileging and credentialing mechanisms for midwives that are consistent with the profession’s standards, recognize midwifery as distinct from other professions, and recognize established processes that permit midwives to build upon their entry-level competencies within their statutory scope of practice (1). Group Health Cooperative of Puget Sound (described previously) provides a model for accomplishing this recommendation, providing access to midwives and the midwifery model of care in hospital and home settings. Obtaining hospital privileges for direct-entry midwives, however, represents a considerable challenge. Although direct-entry midwives have historically based their practice in the out-of-hospital setting, a few have sought hospital employment or independent admitting privileges. It is plausible that many women would appreciate the option of choosing a direct-entry midwife to attend a planned hospital birth or the opportunity to have their midwives follow them into the hospital when change of location from a planned birth-center or homebirth is indicated. Privileging and credentialing mechanisms that recognize direct-entry midwives would make this possible.

Recommendation 8. Education programs should provide opportunities for interprofessional education, multiple points of entry, and collaboration and/or affiliation with colleges and universities (1). Many direct-entry midwifery education programs have provided informal opportunities for physicians, nurses, childbirth educators, and doulas to participate in didactic courses or clinical experiences that expose them to the midwifery model of care and some have actively sought and built relationships with colleges and universities. There is, however, a deep, abiding desire among direct-entry midwives and consumers for midwifery education to remain autonomous in order to preserve the model of education, as well as the model of practice, that developed specifically in response to the needs of women seeking home and birth-center options. These concerns will best be addressed when colleges and universities recognize the value of direct-entry midwifery programs and seek to enter into partnerships for mutual benefit.

Recommendations 9 and 11. Midwifery education programs should include content related to practice management, the impact of health care policy on midwifery practice, and cultural competence (1). These topics, already addressed in some programs, will become increasingly significant as more direct-entry midwives enter the mainstream as health care providers with managed care contracts or with jobs in formal health care systems.

Recommendation 10. The midwifery profession should recognize the benefits of teaching midwifery in a variety of education programs and affirm the value of competency-based education in all midwifery programs (1). The standards set by MEAC for accreditation of a range of midwifery programs based on MANA Core Competencies are consistent with this recommendation. MEAC recognizes degree and nondegree granting programs. MEAC provides mechanisms for the accreditation of institutions solely devoted to midwifery education, as well as midwifery education programs based in institutions that are accredited by nationally recognized agencies that do not specialize in assessment of midwifery education programs.

Recommendation 12. Midwifery research should be strengthened and funded in a wide range of areas from the analyses of how midwives complement and broaden the woman’s choice of provider, setting; and model of care to studies of normal pregnancy, normal labor and birth, health parent-infant relationships, and breastfeeding; and satisfaction with maternity and midwifery care (1). Most research activities concerning direct-entry midwives have been conducted at the state level or through private initiative. MANA began collecting data from members on a voluntary basis in 1993 and now has detailed information on the care provided to more than 11,000 women who were initiated as planned home or birth center births under the care of a midwife; this figure includes clients of both direct-entry and CNM members of MANA (41). Several descriptive reports drawn from the data have appeared in the organization’s newsletter, including basic demographics, transfer rates and reasons for transfer from intended home and birth center births, medical intervention rates, breastfeeding success, and the perinatal mortality rates for Manitoba and Minnesota.

The homebirth movement and the re-emergence of direct-entry midwifery have drawn the attention of a wide array of researchers, including sociologists, political scientists, anthropologists, historians, lawyers, and public health researchers 42, 43, 44, 45, 46, 47, 48. Their work includes analyses of the content of care provided by direct-entry midwives, descriptions of the historical development of the movement, case studies of regulatory issues, and so on. Additionally, a considerable amount of unpublished work has been done by graduate students in academic programs 49, 50, 51, 52. Despite the attention given to midwifery in some circles, policy-relevant research involving midwives in the United States are limited by the midwifery profession’s own limited resources, a lack of outside funding, and the lack of uniform data collection. These gaps are particularly true of direct-entry midwives.

The Taskforce recommendations for research priorities are comprehensive and far-reaching. Direct-entry midwifery should be included in each of the areas suggested for research. Direct-entry midwives have much to contribute, especially to research on normal pregnancy, labor and birth; and satisfaction with maternity and midwifery care (41).

Recommendation 14. Federal and state agencies should broaden systematic data collection, which has traditionally focused on medicine and physicians, to include midwifery and midwives (1). Birth certificate data, a widely used research resource with well-acknowledged limitations, have been used to assess direct-entry midwifery practice in some states, including the comparative study of licensed midwives in Washington described previously (36). In 1995, Declercq examined birth certificate data to determine the demographic and medical risk profiles of the population served by midwives, including women served by direct-entry midwives (53). But, because direct-entry midwives do not complete birth certificate information in some states, there is underreporting of the actual number of births attended by direct-entry midwives.

Some states, like Arizona and New Mexico, require licensed midwives to report specific procedures and outcomes within the context of regulation. Sullivan and Beeman used this data to review 4 years’ experience with licensed midwives in the early 1980s (54). Similarly, state midwifery associations and other private entities, including third-party payors and malpractice insurance providers, often require data collection. However, retrieval of this proprietary information for analysis and public review has proven problematic.

Recommendation 15. A research and policy body, such as the Institute of Medicine, should be asked to study and offer guidance on significant aspects of the midwifery profession (1). More than half of all states have explored legislation or public policy changes related to direct-entry midwifery regulation, education, and/or practice in recent years. Florida, which had earlier set aside a direct-entry midwifery statute, reauthorized licensure in 1993. Then Governor Lawton Chiles subsequently called for a dramatic increase in the proportion of midwife-attended deliveries. Florida state law now mandates managed care plan contracting/reimbursement for licensed midwives 55, 56. Several direct-entry midwifery education programs have been started, including a publicly funded program at Miami-Dade County Community College. The California Bureau of Health Professions called for the legalization of midwifery as early as 1986, though legislation setting standards for licensure was not adopted until 1993. California law also mandates insurance reimbursement for licensed midwives 57, 58.

Even though direct-entry midwifery has been on the agendas of various state legislators for many years, there has been a dearth of public policy discussions, and initiatives programs, related to the goal of recognizing and expanding the use of direct-entry midwives nationally. At least 10% of all midwives in the United States today are direct-entry midwives who are licensed to practice in their state and/or certified by NARM. These midwives represent a valuable resource and their representatives should be included in any group assigned to examine public policies as they relate to the midwifery profession and/or maternal health care.