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Increasing Access to Out-of-Hospital Maternity Care Services through State-Regulated and Nationally-Certified Direct-Entry Midwives

Policy Date: 1/1/2001
Policy Number: 20013

THE AMERICAN PUBLIC HEALTH ASSOCIATION,
Reaffirming its position on credentials for health occupations, that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations1; and
Reaffirming its recognition that many women seek birthing alternatives2; and
Recognizing that pregnancy and birth are normal life events for a majority of women3,4,5; and
Reaffirming its endorsement of the philosophy of family-centered maternity care, the importance of continuity of care, and the use of a variety of licensed care-givers6; and
Recognizing that Direct-entry Midwives encompass a diverse group of midwives that have entered the profession directly through midwifery education and training, and not through a prerequisite program such as nursing7; and
Recognizing that there are alternative educational systems of selection and preparation for national certification of Direct-entry Midwives that include either the Certified Professional Midwife (CPM) credential and the Certified Midwife (CM) credential; and that both require didactic programs, written examinations and clinical experience.8,9 In the case of the Certified Professional Midwives the didactic component consists of education in a program accredited by an agency that is recognized by the US Department of Education or the Portfolio Evaluation Process program, the North American Registry of Midwives competency-based, educational portfolio evaluation, and the clinical component is equivalent to one year of experience which includes more than a thousand contact hours under the supervision of one or more preceptors, some of which must be in out-of-hospital settings, but none of which need to be in hospital settings8; and in the case of the CM credential requires education in institutions of higher learning accredited by an agency that is recognized by the US Department of Education to meet the same standards that Certified Nurse Midwives must meet, completing core science requirements similar to those required for a nurse, and fulfilling core midwifery requirements that are a part of all accredited nurse-midwifery education programs, and clinical experience that must include hospital experience, but is not required to include out-of-hospital experience.9
Recognizing that individual states interested in incorporating direct-entry midwives into their health care systems are moving toward regulatory models based on national certification5; and
Recognizing evidence that many women seek alternatives to hospital care for normal pregnancy and birth, and
Recognizing the evidence that births to healthy mothers, who are not considered at medical risk after comprehensive screening by trained professionals, can occur safely in various settings, including out-of-hospital birth centers and homes10-14; and
Noting that an epidemiological study of Certified Professional Midwives (CPMs) is ongoing in order to investigate and evaluate practice outcomes, safety, client satisfaction, and practitioner competency15; and
Recognizing that out-of-hospital settings have the potential for reducing the costs of maternity care7,12,16; and
Recognizing evidence that access to quality maternity caregivers remains an important issue, particularly for underserved urban and rural communities17; which may be addressed through out-of-hospital maternity services in some communities; and
Reaffirming that the APHA currently recognizes the value of and promotes educational opportunities for nurse-midwifery,18 and that many professionals recognize the contributions of direct-entry midwifery; and
Reaffirming that APHA has been an innovator in public health care by supporting research on alternative and complementary medicine1,19 and increased access to midwifery services in the United States,20
Recognizing that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations, including those direct-entry midwives who are nationally-certified and who have successfully completed “a recognized midwifery education process”21-23,25; and
Recognizing evidence that direct-entry midwives have multiple educational routes22,24 available to them in order to meet the entry-level requirements of knowledge, skills and experience22,24,25;
Recognizing evidence that individual states interested in incorporating direct-entry midwives into the health care system are moving toward regulatory models based on national certifications22;
Therefore, APHA
1. Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services, and further:
2. Encourages the development and implementation of guidelines for the licensing, certification and practice for direct-entry midwifery practitioners for use by state and local health agencies, health planners, maternity care providers, and professional organizations;
3. Urges that there be increased opportunities for supervised clinical learning experiences, in a variety of settings, including both high-risk and low-risk, incorporated into direct-entry midwifery education programs;
4. Encourages an increase in cost effective maternal care services for rural and underserved urban populations by advocating for increases in funding of scholarships and loan repayment programs targeted at members of these communities;
5. Urges public and private insurance plans to eliminate barriers to the reimbursement and equitable payment of direct-entry midwifery services in both public and private payment systems;
6. Encourages the National Center for Health Statistics, the US Department of Health and Human Services and State Vital Records Offices to add the CPM as a separate certifier category on birth certificates to enable routine collection of systematic data;
7. Urges HRSA, CDC and state health departments to improve the collection and quality of vital statistics and other data to enhance the monitoring of birth outcomes (e.g., infant and perinatal mortality rates, maternal mortality rates, etc.) resulting from services provided by all practitioners including specific types of midwife practitioners;
8. Urges Congress and appropriate Department of Health and Human Services agencies to increase funding and other support for ongoing research and evaluation of maternal health and birth outcomes, practice outcomes, quality of care outcomes, and safety related to the services provided by direct-entry midwives.
References
1. American Public Health Association Policy Statement 6805: Creden–tials for Health Occupations. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
2. American Public Health Association Position Paper 8209: Guidelines for Licensing and regulating Birth Centers. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
3. Stewart, David: The Five Standards of Safe Childbearing, NAPSAC International, 4th Edition, 1997.
4. Care in Normal Birth: a practical guide, Technical Working Group, World Health Organization. Department of Reproductive Health and Research, Section 1.1-1.6, 1999.
5. Rooks, JR: Midwifery and Childbirth in America. Temple University Press, Philadelphia, 1997.
6. American Public Health Association Position Paper 7924: Alternatives in Maternity Care. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
7. Rooks JP. Unity in Midwifery? Realities and Alternatives. J Nurse-Midwifery 1998;43:315-319.
8. North American Registry of Midwives (NARM), How to Become a Certified Professional Midwife and Candidate Information Bulletin. Revised, June 2000.
9. ACNM Issue Brief February 1999 and ACNM Position Statement on Midwifery Education 1997.
10. Durand AM. The safety of home birth: The Farm Study. Am J Public Health 1992;82:450-453.
11. MacDorman M, Singh G: Midwifery care, social and medical risk factors and birth outcomes in the USA. J Epidemiol Community Health. 1998;52:310-317.
12. Wagner M. Midwifery in the industrialized world. J Soc Obstet Gyn Canada. November 1998.
13. Mehl LE, Ramiel JR, Leininger B, Hoff B, Kroenthal K, Peterson G. Evaluation of outcomes of non-nurse midwives: matched comparison with physicians. Women & Health 1980;5:17-29.
14. Sullivan D, Weitz : Labor Pains: modern midwives and homebirth. Yale University Press, 1988.
15. Ken Johnson, PhD, and Betty Ann Daviss, MA. CPM Statistics Project 2000: A prospective study of births by certified professional midwives in North America. (Abstract #3042.0) Presented at 128th APHA Annual Meeting, Boston, MA, November 2000.
16. Blevins Medical Monopoly: Protecting Consumers or Limiting Competition? Policy Analysis by Cato Institute December 15, 1995;246:11-14. Burnette CA, Jones JA, SA.
17. Tennessee Commission on Children and Youth Report: The State of the Child in Tennessee: KIDS COUNT, 1996.
18. American Public Health Association Position Paper 9403: Increase support for education and practice opportunities for nurse-midwives. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
19. American Public Health Association Position Paper 9714: Support for Research on Alternative and Complementary Practices. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
20. American Public Health Association Position Paper 20004: Supporting Access to Midwifery Services in the United States. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
21. Charting a course for the 21st century: The future of Midwifery. A joint report of the PEW Health Commission and the University of California, San Francisco Center for the Health Professions, April 1999.
22. Myers-Ciecko J. Evolution and current status of direct-entry midwifery education, regulation, and practice in the United States, with examples from Washington State. J Nurse-Midwifery, 1999(Jul-Aug);44(4):384-392.
23. Midwifery Today. Paths to becoming a midwife: Getting an Education, Midwifery Today, Inc. 1998.
24. Haughton P, Windom KL. 1995 Job Analysis of the role of direct-entry midwives. June 1996.
25 Mahlman R. The Quality of the NARM Certification process, testimony before the Ohio Study Council on Midwifery, Associate Director of Assessment Services, Vocational Instructional Materials Laboratory, The Ohio State University, July 1997.