Content uploaded by Marit Bovbjerg
Author content
All content in this area was uploaded by Marit Bovbjerg on Jul 22, 2016
Content may be subject to copyright.
Journal of Midwifery & Women’s Health www.jmwh.org
Original Research
Practitioner and Practice Characteristics of Certified
Professional Midwives in the United States: Results of the 2011
North American Registry of Midwives Survey
Melissa Cheyney, PhD, CPM, LDM, Christine Olsen, PhD, Marit Bovbjerg, PhD, Courtney Everson, PhD,
Ida Darragh, CPM, Brynne Potter
Introducti on: No data describing certified professional midwives (CPMs) currently exist in the literature, although CPMs attend the majority of
home births in the United States.This study addresses this gap by assessing the demographics, education levels, routes to certification, and practice
characteristics of currently practicing CPMs.
Methods: Data were collected from a survey of CPMs conducted by the North American Registry of Midwives (NARM)b etweenJuly and October
2011. In order to assess generalization to the entire population of practicing CPMs, we also completed a nonresponse bias analysis. We examined
midwives’ demographic, education, certification, and practice characteristics using descriptive and nonparametric, bivariable statistics.
Results: More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor’s degree or greater. CPMs spent a median
of 3 years (interquartile range, 2-5 years) in training before attending births as a primary midwife. However, 38.9% of currently practicing CPMs
had less than 3 years of training. Regarding pathways to certification, 48.5% utilized the portfolio evaluation process (PEP); 36.9% graduated from
a Midwifery Education and Accreditation Council (MEAC)-accredited school; 14.5% were already licensed by a state as a direct-entry midwife;
and 0.7% were already a certified nurse-midwife or certified midwife, although many CPMs reported a blended education pathway. One-fifth
(21%) of respondents identified as midwives of color. Whereas nearly one-third (31.8%) of CPM respondents reported that 95% or more of their
clients were white, 5.2% serve populations that are 90% or more nonwhite. CPMs of color are significantly more likely to serve clients of color
(P!.001).
Discussion: Training and nonmidwifery education levels of most CPMs practicing in the United States align with the Global Standards for Mid-
wifery Education established by the International Confederation of Midwives, although there are still clear areas for improvement.
JMidwiferyWomensHealth2015;00:1–12 c!2015 by the American College of Nurse-Midwives.
Keywords: accreditation, certification, demography, educational status, home childbirth, midwifery
INTRODUCTION
In 2001, the American Public Health Association called for
increased access to home and birth center births attended
by legally regulated and nationally certified midwives.1At
that time, less than 1% of all births in the United States
were occurring in homes and birth centers. However, over
the last decade, out-of-hospital births have increased by
56%,2,3 reaching 1.36% of all US births in 2012. Of these, 66%
(n =35,184 in 2012) were home births3attended primarily
by direct-entry midwives, including certified professional
midwives (CPMs).2Ye t , a l t h o ug h t h e r e e x i s t s a l a r g e b o d y
of literature on the training, credentialing, and associated
maternity care outcomes for certified nurse-midwives
(CNMs) attending births across all settings—home,4–6 birth
center,7–9 and hospital,10–12—comparatively little is known
about training, credentialing, and associated maternity care
outcomes for CPMs (for exceptions, see Cheyney et al13 and
Johnson and Daviss14). This article begins to address this gap
by reporting findings from the 2011 North American Reg-
istry of Midwives (NARM) Survey—a collaborative project
Address correspondence to Melissa Che yney, PhD, CPM, LDM, Depart-
ment of Anthropology, Oregon State University, Waldo Hall 238, Corval-
lis, OR 97331. E-mail: melissa.cheyney@oregonstate.edu
between NARM, the certifying organization for CPMs, and
researchers at Oregon State University.
In 2013, the International Confederation of Midwives
(ICM) amended their Global Standards for Midwifery
Education15 as part of their ongoing efforts to strengthen
midwifery worldwide by ensuring the preparation of highly
qualified midwives capable of providing evidence-based care
to women, newborns, and families. ICM developed these
standards with the goal of assisting 3 groups of potential users:
1) countries without basic midwifery education working to
establish programs to meet the need for qualified providers;
2) countries with basic midwifery education programs that
vary in content and quality that aim to improve and/or stan-
dardize the quality of midwifery education; and 3) countries
with standards for midwifery education that would benefit
from a clear set of minimum standards by which to evaluate
the existing programs.
In the United States today, CPMs are regulated in only 28
states, making any coordinated, national assessment of CPM
quality and preparedness challenging. The 2011 NARM Sur-
vey was designed to examine 3 research questions: 1) who are
CPMs in the United States, and how are they getting their ed-
ucation? 2) are there differences between CPMs practicing in
regulated and unregulated states in terms of training routes
or nonmidwifery education levels? and 3) who are CPMs
1526-9523/09/$36.00 doi:10.1111/jmwh.12367 c!2015 by the American College of Nurse-Midwives 1
✦More than 90% of currently practicing certified professional midwives (CPMs) attended at least some college, and 47.1%
hold a bachelor’s degree or greater.
✦CPMs spent a median of 3 years (intraquartile range, 2-5 years)intrainingbeforebeginningtoattendbirthsasaprimary
midwife; 61% met the International Confederation of Midwives-recommended 3 years of training.
✦CPM pathways to certification varied: 48.5% utilized the portfolio evaluation process (PEP); 36.9% graduated from an
accredited school; 14.5% were already licensed by a state as a direct-entry midwife; and 0.7% already were a certified
nurse-midwife or certified midwife.
✦Whereas 31.8% of CPM respondents reported that 95% or more of their clients were white, 5.2% serve populations that are
90% or more nonwhite. CPMs of color are significantly more likely to serve clients of color (P!.001).
serving and how do they practice? This article uses data from
the 2011 NARM Survey and was designed to assess the de-
gree to which US CPMs meet the ICM education standards,
which have been endorsed by both the American College of
Nurse-Midwives (ACNM) and the American College of Ob-
stetricians and Gynecologists. A concurrent, nonresearch aim
was to provide updated information about the CPM creden-
tial; such information does not currently appear in the peer-
reviewed literature.
The Certified Professional Midwife Credential in
Social and Historical Context
The United States is unique cross-culturally in having 3 cre-
dentialing routes within the profession of midwifery: the
CNM, the certified midwife (CM), and the CPM (Table 1).
Although largely distinct, these credentials do share a few key
similarities. For example, all have standards for nationally ac-
credited certification and distinguish themselves from lay or
traditional midwives who practice without having demon-
strated the ability to meet formal training and certification
requirements. The CPM, CNM, and CM credentials are ac-
credited by the National Commission for Certifying Agencies,
which is the accrediting arm of the Institute of Credentialing
Excellence.
Key differences between these credentials are tied to
the unique cultural and sociopolitical histories of obstetrics
and regional midwifery traditions in the United States (see
Craven16 for an excellent recent review). The majority of
CNMs/CMs attend births in hospitals, with a smaller number
attending home and birth center births. In addition to
maternity care, CNMs provide primary and gynecologic care.
CPMs, in contrast, provide home- and birth center-based
maternity care, with their scope of practice commonly limited
to the childbearing year.17,18 The CPM credential is also more
recent than the CNM credential. The national certification
examination to confer the CNM credential was instituted
by ACNM in 1971,19,20 whereas the first CPMs were not
credentialed until 1994.21,22 Additionally, although CNM
applicants must first hold a bachelor’s degree and registered
nurse license, NARM requires a high school diploma or the
equivalent as the basis of entry into training for the profession.
Unlike nurse-midwifery education programs, there is only
one university-based CPM training option (Bastyr University,
Kenmore, WA).
NARM’s approach to certif ication of CPMs relies on
highly flexible, competency-based pathways, which require
students to attain essential knowledge, skills, and experience
but allows them to do so through a variety of means, includ-
ing accredited brick-and-mortar schools, accredited distance
learning programs, self-study, apprenticeship with a senior
midwife preceptor(s), and/or internship at a birth center(s).
As a result, it is possible to acquire the CPM credential with-
out ever having attended a formal, accredited midwifery ed-
ucation program.23,24 The competency-based approach used
by NARM focuses on what has been learned, independently
of where or how it was learned, and whether a candidate
can successfully apply knowledge and skills in various clini-
cal enocunters.15,25,26 CPM credentialing is premised on this
type of competency-based education27 for both ideological
and practical reasons. It was designed to ameliorate the 3
key barriers to training described by prospective CPMs: for-
mal, accredited schools are few and far between (10 nation-
wide at the time of this writing), are very expensive relative to
the income a practicing CPM can hope to generate, and are
unavailable in regions of the United States where CPMs are
unregulated.
Routes to the Certified Professional Midwife
Credential
Prospective CPMs document the qualifications needed to sit
for the NARM examination through multiple routes; the 2
primary routes are the Portfolio Evaluation Process (PEP)
and graduation from a program accredited by the Midwifery
Education Accreditation Council (MEAC). NARM has also
evaluated requirements and set criteria for reciprocity for
midwives licensed through state established programs that
predate the CPM credential, midwives who are CNMs/CMs,
and some internationally educated midwives. In the former
case, the state criteria for licensure must meet or exceed
those set by NARM for entry-level CPMs, and the National
Assessment Institute must have deemed the state licensure
examination equivalent to the NARM examination.
2Vol u me 0 0, No. 0 , x xx 2 0 15
Table 1. Credentia ling Routes for the Midwifery P rofession in the United Sta tes
Certied Certied Professional
Nurse-Midwife Certied Midwife Midwife
Professional Association(s) ACNM ACNM MANA and NACPM
Certification Requirements 1. Graduation from an accredi-
tedanurse-midwifery educa-
tion program;
and
2. Verification of education pro-
gram completion;
and
3. Current RN license
1. Graduation from an accred-
itedamidwifery education
program;
and
2. Verification of education pro-
gram completion
1. Completion of NARM’s
Portfolio Evaluation Pro-
cess pathway;
or
2. Graduation from an
accreditedbmidwifery
education program;
or
3. AMCB-certified CNM or
CM;
or
4. Completion of state licen-
sure program
Certifying OrganizationcAMCB AMCB NARM
Legal StatusdLegally permitted to practice in
all 50 states, District of
Columbia, and US territories
Legally permitted to practice in
New Jersey, New York, Rhode
Island. Delaware, Missouri
Legally permitted to
practice in 28 states
Abbrev iation s: ACNM, A merican College of Nurse-Mi dwives; ACME, Ac credit ation C ommission for Mi dwife ry Education; AMCB, Am erican Midwi fery C ertification
Board; CNM, certified nurse-midwife; CM, certified midwife; CPM, certified professional midwife; MANA, Midwives Alliance of North America; MEAC, Midwifer y
Education Accreditation Council; NACPM, National Association of Certified Professional Midwives; NARM, North American Registry of Midwives; RN, registered nurse.
Source: American College of Nurse-Midwives.19
aThe program must be accredited by ACME. ACME is authorized by the US Department of Education to accredit midwifery education institutions and programs.
bThe program must be accredited by MEAC. MEAC is authorized by the US Department of Education to accredit midwifery education institutions and programs.
cBoth AMCB and NARM are accredited by the National Commission for Certifying Agencies.
dPractice is considered legally permitted if licensure, permit, registration, or certification is avai lable at the state level.
CPM applicants who have not completed a MEAC-
accredited midwifery program (and are not already
CNMs/CMs or state licensed) must demonstrate their
skills through the PEP, which is a comprehensive evaluation
method for documenting the skills, knowledge, and com-
petencies of the midwife candidate (Table 2). There are 3
PEP categories: entry-level, internationally educated, and
experienced midwives. The entry-level PEP requirements in-
clude documentation that the candidate has fulfilled NARM’s
general education requirements; verification from NARM-
approved preceptors that the candidate is proficient in
the skills, knowledge, and abilities required by the profes-
sion; certification in adult cardiopulmonary resuscitation
(CPR) and neonatal resuscitation; affidavits from preceptors
attesting that the candidate has developed and utilized
practice guidelines, informed disclosure documents,28 and
an emergency care plan; 3 professional letters of reference;
completion of a cultural competency course; and a passing
score on the NARM skills assessment practical examination.
Internationally educated PEP candidates must demonstrate
educational validation on approved International Credential
Associations, Inc. forms; verification of skills and experiences
as a primary midwife or primary under supervision; satis-
faction of skills verification requirements; certification in
adult CPR and neonatal resuscitation; written verification of
practice guidelines, emergency care plans, informed disclo-
sure, and informed consent documents; and completion of a
cultural competency course. Candidates applying through the
experienced midwife PEP route must demonstrate extensive
out-of-hospital birth experience; satisfaction of skills verifi-
cation requirements; certification in adult CPR and neonatal
resuscitation; written verification of their practice guidelines,
emergency care plans, informed disclosure, and informed
consent documents; and completion of a cultural competency
course. Once all requirements have been completed success-
fully and documentation verified, the candidate may sit for
the NARM written examination, which, if passed, is the final
step in the process of qualifying to earn a CPM credential.
Alternatively, aspiring midwives may establish their can-
didacy through successful completion of a MEAC-accredited
midwifery education program. All MEAC-accredited schools
in the United States incorporate NARM competency require-
ments into their curricula and are reviewed every 3 to 5
years to verify that students are provided with the necessary
learning opportunities and are being taught and evaluated
by qualified faculty. Students in MEAC-accredited schools
receive 4 benefits that students who utilize the PEP are
not necessarily guaranteed: faculty standards and oversight;
fiduciary solvency; access to Title IV federal financial aid; and
formal evaluation of curriculum adherence to the compe-
tencies outlined by NARM and the ICM. MEAC-accredited
programs vary in terms of instructional delivery and may
include classroom-based courses, online courses, hybrid
classroom/online courses, and/or independent study. In all
Journal of Midwifer y & Women’s Health !www.jmwh.org 3
Table 2. Current NARM Requirements for Entry-L evel PEP for
CPM Credentia ling
Activitya
Attend a nce at bir th sa,b
10 as an observer (in any capacity, any setting)
20 as an assistant under supervision
25 as primary midwife under supervisionc
Prenatal visitsa
25 as an assistant under supervision
75 as primary midwife under supervision
Postpartum visitsa
10 as an assistant under supervision
40 as primary midwife under supervision
Newborn exami na tionsa
20 as an assistant under supervision
20 as primary midwife under supervision
At lea st 2 y ea rs of supervi se d practi ce
Ve r i ca ti o n o f ma st e r y i n c o m pr e h e n s iv e kn o w l e d ge a n d s k i l l s
core competencies essentia l for safe midwifery practice,
includes >750 individual skills assessed through practice
examination
Completion of an approved module on cultural competency for
health professionals
Maintain a dult CPR certica tion and neonata l resuscitation
certica tion
High school diploma or e quiv alent
Abbreviations: CM, certified midwife; CNM, certified nurse-midwife; CPM,
certified professional midwife; CPR, cardiopulmonary resuscitation; LM, licensed
midwife; NARM, North American Registry of Midwives; PEP, Portfolio
Examination Process.
aAttendance of these clinical activities as either an assistant or primary must be
engaged under the supervision of a qualified preceptor who must be credentialed
as a CPM, CNM, CM, or LM. The preceptor must have an additional 3 years of
experience or 50 births, including 10 continuity of care births, beyond the
experience requirements for CPM certification. Preceptors must have attended at
least 10 births in the last 3 years and be approved by NARM. Numbers of births,
visits, and examinations represent minimal requirements.
bWithi n these bir th requirem ents, a mini mum of 5 home births mus t be atte nded
in any role, and a minimum of 2 planned hospital births must be attended in any
role in order to meet the “experience in specific settings” subrequirement.
cAt least 5 of these births must be with full continuity of care, and 10 more must be
with at least one prenatal visit under supervision. Full continuity of care is defined
as being primary midwife under supervision for 5 prenatal appointments across 2
trimesters, the labor and birth, the newborn examination, and 2 postpartum
examinations within the first 6 weeks of the birth for a given client.
MEAC-accredited programs, clinical education takes place
in home or birth center settings, and students’ skills are
verified by program-approved preceptors during the provi-
sion of supervised care or by using simulation rather than
via the skills examination used by PEP-route candidates.
Graduates of MEAC-accredited programs are eligible to
take the NARM written examination, which they, like their
PEP-route counterparts, must pass in order to have the CPM
credential conferred. In addition, students in MEAC-
accredited programs may concurrently earn a certificate or
an associate’s, bachelor’s, or master’s degree in midwifery,
depending on the program.
Peterson29 has argued that a comparison of CPM certifi-
cation requirements with those of CNMs/CMs indicates that
both branches of professional midwifery in the United States
utilize similar core competencies; have established similar
clinical training requirements; and use examinations nearly
identical in terms of content, structure, and depth and breadth
of knowledge required. Yet, the CPM credential, and particu-
larly the PEP routes to certification, remains controversial.30
The main argument against use of the PEP is that it is not
an accredited education pathway because it relies primarily
on summative and not formative processes; thus, it cannot be
seen as a training program but simply as a postlearning eval-
uation process. In addition, although the CPM credential is
accredited, the PEP itself is not.
METHODS
Data Collection
The data reported here come from a survey conducted
between July and October 2011. All then-current CPMs were
sent an e-mail and postcard invitation from the NARM board
in July 2011. The invitation included an explanation of why
NARM was conducting the survey, a link to the Web-based
survey, and an incentive for participation (5.0 continuing
education units to be applied upon completion of the survey).
Aremindere-mailwassent2weeksaftertheinitialinvitation,
and a final reminder was sent 2 weeks after that. The survey
included 73 items and solicited information about practice
style, education, and routes to the credential (56 items);
demographic characteristics (5 items); and CPMs’ opinions
regarding potential changes to credentialing standards (12
items). Questions used either 4- or 5-point Likert scale
answer options or allowed semistructured, open-ended re-
sponses for descriptive replies. A copy of the survey, including
precise question wording, can be viewed online (Supporting
Information: Appendix S1).
Because of a change in study personnel and institutional
review board (IRB) requirements from Oregon State Univer-
sity, a second e-mail invitation was sent to all of the initial re-
spondents in March 2012. This invitation asked respondents
to give explicit consent for their deidentified survey responses
to be shared with external (ie, non-NARM) researchers for
analysis and possible publication.
In order to assess generalizability to the entire popula-
tion of practicing CPMs, we completed a nonresponse bias
analysis.31 This entailed calling a random 10% subsample of
the initial nonrespondents and asking them an abbreviated
version of the survey over the phone. This process was de-
veloped in conjunction with, and approved by, Oregon State
University’s IRB. C ont acting nonres ponders was allowed be-
cause NARM personnel had sole responsibility for the pro-
cess; researchers at OSU were only given aggregated data
from nonresponders. The abbreviated version of the survey
used in the nonresponse bias analysis focused on educa-
tion and routes to the credential, practice characteristics, and
demographics.
Statistical Analyses
We used d e s c ript i v e stat i s t ics to ex a m i ne midw i ves’ b a s ic
demographic, education, and certification characteristics.
We then u s e d c hi-squ a re test s , S pearma n’s c o r rela t i on
4Vol u me 0 0, No. 0 , x xx 2 0 15
coefficients, and point-biserial correlations32 for bivariable
analyses. Point-biserial correlations are mathematically
equivalent to Pearson’s correlation coefficients but com-
pare one continuous variable to one dichotomous variable;
Spearman’s and Pearson’s correlation coefficients require 2
continuous variables.32 All analyses were conducted using
IBM SPSS Statistics version 19.0 (IBM Corp., Armonk, NY).33
RESULTS
The initial invitation was sent to 1391 CPMs and 849 (61%)
responded. Two e-mail invitations bounced, indicating that
2potentialrespondentsdidnothaveaworkinge-mailad-
dress on file with NARM. Of the 849 initial respondents who
received the second e-mail invitation, 568 provided consent
for their responses to be analyzed and 281 did not respond.
Therefore, the final response rate was 41%.
Nonresponder Analysis
The original respondents and the nonrespondent (n =67)
group did not differ in terms of the number of new clients
in the last 3 years, usual fee, number of birth center births
attended in the last 3 years, or number of hospital births at-
tended in the last 3 years (P".20 for all). There were also
no significant differences in the number of home births at-
tended in the last 3 years (P=.13), whether the midwife
carries malpractice insurance (P=.12), the level of non-
midwifery education (P=.07), whether the midwife identi-
fied as a person of color (P=.08), or the certification route
(P=.09), although these might have become statistically sig-
nificant if additional nonresponders were sampled. The full
subset of nonrespondent’s questions is noted in the complete
survey (see Supporting Information: Appendix S1).
Demographic Characteristics
Nearly all respondents (99.8%) were female, although a few
male CPMs are currently practicing in the United States.
Twe nty-one pe rce nt of res pon dents i dentif ied a s per sons of
color, a category that included Native American/Alaskan
Native, Asian, black, Native Hawaiian/Pacific Islander, and
Hispanic/Latina (Table 3). The median age at which respon-
dents began attending births as a primary midwife was 31
years (intraquartile range [IQR], 27-37). More than 90% of
respondents attended at least some college; 47.1% have a
bachelor’s degree or greater; and 30.6% completed additional
formal education after receiving the CPM credential. Many
respondents (42.1%) reported being involved in midwifery
advocacy and more than half (54.6%) in midwifery education.
Survey responses came from midwives living in all states,
except for Mississippi, Rhode Island, Wyoming, and the
District of Columbia.
Training an d Certification
Survey respondents represent a wide range of training and
experience pathways leading to application for certification.
Respondents reported spending a median of 3 years (IQR,
2-5 years) in training before beginning to attend births as a
Table 3. Participant a nd Prac tice Chara cteristics of 568 Certied
Professional Midwives
Characteristic
Gender, %
Female 99.83
Male 0.17
Race/ethnicity, %
Persons of Color 21
White 79
Highest level of educa tion, %
Graduate degree (MS, PhD, DNP) 12.1
Graduate-level midwifery training
(CNM/CM)
0.8
Bachelor’s degree (BA or BS) 34.2
RN degreea5.3
Some college (includes AD) 38.1
High school diploma or equivalent 8.9
Did not complete high school 0.5
Age when began attending births as a primary
midwife without supervision, median
(IQR), y
31 (27-37)
Length of tra ining before attendingbirths as
aprimarymidwifewithoutsupervision,
median ( IQR), y
3(2-5)
Route to certication used when a pplying for the CPM
credential, %
Portfolio e valuation process 48.5
Entry-level 29.8
Experienced midwife 17.5
Internationally educated midwife 1.3
Graduation from a MEAC-accredited
school
36.9
Already licensed by a state as a direct-entry
midwife
14.5
Already a CNM or CM 0.7
Tot a l c o st o f m i dw if e r y e d uc a t i o n a n d
training, median (IQR, range)
$15,000
($5,000-
$20,000,
$0-$100,000)
Reside in sta te that licenses and regula tes
CPMs, %
76.2
Participa tion, %
Midwifery advocacy 42.1
Midwifery education 54.6
Practiced within the last 3 years, % 86.2
Clients with whom care was initiated in the
preceding 3 years regardless of setting,
median ( IQR), n
40 (10-82)
(Continued.)
Journal of Midwifer y & Women’s Health !www.jmwh.org 5
Table 3. Participant a nd Prac tice Chara cteristics of 568 Certied
Professional Midwives
Characteristic
Attend h ome bir ths, % 82.4
Home births attended in the preceding
3years,median(IQR),n
31 (10.25-67)
Attend b ir th cent er bir ths, % 26.9
Birth center births a ttended in the preceding
3years,median(IQR),n
22 (5-63.75)
Attend h ospita l births, % 12
Hospita l births a ttended in the preceding
3years,median(IQR),n
3 (1.5-13)
Birth types attended, %
Vaginal birth after cesarean 86.9
Twi ns 36.4
Planned vaginal breech births 62.4
Ty pe o f p ra c t i ce , %
Solo 64.8
Partnership with another fully trained
midwife
21.4
Group practice of 3 or more midwives 13.8
Not eligible for Medica id rei mbur sement, % 72.8
Usua lly receive i nsurance reimbursement, % 25.3
Provider fee (excluding fa cility fees), media n
(IQR)
$3000 ($2200-
$3500)
Geographic area of client base, %
Urban 30. 7
Rural 32.5
Suburban 36.8
Race/ethnicity composition of client base served, %
95% or more of clients are white 31.8
90% or more are nonwhite 5.2
Abbreviations: AD, associate’s degree; BA, bachelor of arts; BS, bachelor of science;
CM, certified midwife; CNM, certified nurse-midwife; CPM, certified professional
midwife; DNP, doctor of nursing practice; IQR, intraquartile range; MEAC,
Midwifery Education Accreditation Council; MS, master of science; PhD, doctor of
philosophy; RN, registered nurse.
aThe researchers recognize that RN is a licensure and not a degree. However, this is
how the answer choice was worded on the survey. Midwives indicating RN degree
as their highest level of education were not counted as having completed a
bachelor’s degree, although it is likely that several in fact did.
primary midwife without supervision, and 38.9% of respon-
dents had less than 3 years of training prior to assuming this
role. A small number of participants (5.7%) reported zero
years in practice before operating as primary without super-
vision.
Respondents were asked which route to certification they
used when applying for the CPM credential. Nearly half
(48.5%) indicated PEP (29.8% entry level, 17.5% experienced
midwife, 1.3% internationally educated midwife); 36.9% grad-
uated from a MEAC-accredited school; 14.5% were already
licensed by a state as a direct-entry midwife; and 0.7% were
already a CNM or CM. Because the CNM/CM group consti-
tuted just 4 individuals, they were excluded from all further
analyses. The highest level of education achieved was com-
pared between the PEP, MEAC-accredited school, and state li-
censed midwife pathway groups; and no significant difference
was found (Table 4). However, there were some differences in
training and educational experiences used toward certifica-
tion among these groups (Table 5). Midwives who utilized the
MEAC-accredited school pathway more commonly reported
acquiring at least half of their training in birth centers or inter-
national clinics and via onsite and online schools. Conversely,
PEP-pathway CPMs more commonly reported acquiring at
least half of their training via home birth apprenticeship. Table
6showcasesaselectionof10differenteducationpathways,as
described by 10 individual survey participants, illustrating the
complexity and variation in how prospective CPMs acquire
their training, regardless of route to certification.
Respondents were also asked to estimate the total cost
of their midwifery education and training; the median was
$15,000 (IQR, $5,000-$20,000; range $0-$100,000). A number
of survey questions asked respondents about the mix of dif-
ferent training experiences; results are presented in Table 7.
Briefly, 71.5% of midwives (n =405) reported attending a
midwifery school of some sort (onsite, online, and/or cor-
respondence) for at least part of their training; 86.7% (n =
491) reported that a home birth apprenticeship constituted at
least part of their training; and 53.4% (n =302) received at
least some training at a birth center. In addition, 43.3% (n =
245) reported at least some hospital-based training. Almost
all midwives supplemented their formal didactic and clini-
cal skills training with self-study, formal study groups, and/or
workshops.
The regulatory status of the CPM credential in each re-
spondent’s state was also examined to determine if there was
an association with the certification pathway chosen by mid-
wives. The majority of midwives (76.2%) reported residing
in states that license and regulate CPMs. Chi-square analy-
sis showed a significant difference (P!.001) between certi-
fication pathways chosen by midwives residing in regulated
versus unregulated states. The PEP process was more likely
to be used in unregulated states, whereas MEAC-accredited
schools and the state licensed midwife pathway were more
likely to be used in states where CPMs are licensed and
regulated.
Practice Characteristics
Most mi dwives (86.2%) indicated they have been in midwifery
practice within the last 3 years. CPMs who indicated they were
not in active practice within the last 3 years (n =78) were
excluded from analyses of practice characteristics. Respon-
dents were asked to report the number of clients they have
cared for and the number of births they have attended across
all birth sites. Midwives reported initiating care, with a me-
dian of 40 (IQR, 10-82) clients total in the last 3 years. The
majority (82.4%) of CPMs attended home births during this
time frame, with a median of 31 (IQR, 10.25-67) births in
that setting over the preceding 3 years. A smaller proportion
of respondents indicated they attended births in birth centers
(26.9%) and hospitals (12.0%) in the last 3 years. The median
3-year number of birth center and hospital birt hs was 22 (IQR,
5-63.75) and 3 (IQR, 1.5-13), respectively.
6Vol u me 0 0, No. 0 , x xx 2 0 15
Table 4. Education Level by Certica tion Routea
Highest Level of Education PEP, n () MEAC-Accredited school, n () State-Licensed Midwife, n ()
Graduate degree (MS, PhD, DNP) or CNM/CM 31(12.0) 24 (12.2) 9 (11.3)
RN or bachelor’s degree (BA or BS) 93 (35.9) 87 (44.2) 31 (38.8)
Some college (includes AD) 99 (38.2) 76 (38.6) 34 (42.5)
High school diploma or equivalent 33 (12.7) 10 (5.1) 6 (7.5)
Did not complete high school 3 (1.2) 0 (0) 0 (0)
Abbreviations: AD, associate’s degree; BA, bachelor of arts; BS, bachelor of science; CM, certified midwife; CNM, certified nurse-midwife; DNP, doctor of nursing practice;
MEAC, Midwifery Education Accreditation Council; MS, master of science; PEP, Portfolio Evaluation Process; PhD, doctor of philosophy; RN, registered nurse.
aAtable-widePearsonChi-squaretestwasperformed,andnosignificantdifferenceswerefoundinhighestlevelofeducationachievedwhencomparedbyrouteto
certification (x2=12.965, P=.113).
Table 5. Education and TrainingExperiences by Route to Certicationa
Education or Training Experience PEP, bMEAC, bLM, bAll Respondents, b
Home birth apprenticeship 85.5 58.7 81.3 75.1
Birth center 25.1 63.2 48.4 43.3
Hospital 6.0 3.2 5.2 6.0
Onsite school 17.8 69.4 41.1 43.2
Online school 4.6 19.6 11.5 11.2
International clinic 3.0 20.0 8.7 10.8
Abbreviations: LM, licensed midwife; MEAC, Midwifery Education Accreditation Council; PEP, Portfolio Examination Process.
aA table-wide 6 ×3Chi-squaretestwasperformedandsignificantdifferenceswerefoundineducationandtrainingexperienceswhencomparedbyroutetocertification
(P!.001)
bThe percentage of midwives who reported this education or training experience comprised half or more of their educational and training path toward becoming a midwife.
Percentages t otal mo re than 100% because re spond ents answered f or each e ducation and training expe rience sepa rately.
Table 6. Education and Experience Pathways of 10 CPM Survey Participantsa
Aspiring Onsite Online Home Birth Birth International Clinic Verication of Testing and
CPMs SchoolbSchoolbApprenticeship C ente r Hospital Experience Experience and Skills Certication
1√√√ PEP (entry-level,
experienced, trained
internationally)
NARM
examination
CPM
2√√
3√
4√√
5√√
6√√ √
MEAC school graduate
7√√
8√√
9√State-licensed midwife
10 √√ CNM or CM
Abbrev iation s: CNM, c erti fied nurse-m idwife; CM, certified midwife; CP M, cer tifie d professional midwife; MEAC, Midwifery E ducation and Acc reditation Council; NARM,
North American Registr y of Midwives; PEP, Portfolio Ev aluation Process.
aOther training and experience activities included self-study, workshops, US clinics, correspondence courses, and study groups.
bThe survey did not distinguish between MEAC-accredited and non-MEAC-accredited schools.
Respondents were asked a variety of additional questions
about their practices. The majority (64.8%) reported operat-
ing as a solo practice, typically attending births with a trained
assistant, apprentice, or both. Some (21.4%) midwives work
in partnerships with another fully trained midwife, whereas a
smaller number (13.8%) reported working in a group of 3 or
more. Those in partnerships and groups also reported that as-
sistants, apprentices, and/or other midwives attend births with
them.
Most respondents (72.8%) indicated that they are not el-
igible for Medicaid reimbursement, and only one respondent
in 4 (25.3%) said that insurance reimbursement was “usually”
received. Respondents were asked how much they charge as
aproviderfee,excludingfacilityfees.ProviderfeesforCPMs
typically include all prenatal, birth, and postpartum care. The
median response was $3000 (IQR, $2200-$3500).
Respondents were also asked about attending vaginal
births after cesarean (VBACs), multiple gestation births, and
Journal of Midwifer y & Women’s Health !www.jmwh.org 7
Table 7. Ty pes o f Tra ini ng Used b y M i dw i v es in P urs u it o f the C P M Cre den tia l
Approx imate Percent of Overall Midwifery Training
Typ e of Tr ai ninga, n (), n (), n (), n (), n () Skipped by Respondent,bn()
Onsite midwifery schoolc180 (34) 69 (13.1) 108 (20.5) 9 (1.7) 32 (6.1) 128 (24.3)
Online midwifery schoolc291 (51.4) 50 (8.8) 23 (4.1) 17 (3.0) 3 (0.5) 182 (32.1)
Correspondence schoolc239 (42.2) 86 (15.2) 66 (11.7) 13 (2.3) 9 (1.6) 153 (27.0)
Self-study 31 (5.5) 167 (29.5) 202 (35.7) 89 (15.7) 15 (2.7) 62 (11.0)
Formal study group 153 (27.0) 207 (36.6) 60 (10.7) 5 (0.9) 0 (0) 141 (24.9)
Workshops 38 (6.7) 362 (64.0) 67 (11.8) 6 (1.1) 0 (0) 93 (16.4)
Home birth apprenticeship 39 (6.9) 93 (16.4) 203 (35.9) 152 (26.9) 43 (7.6) 36 (6.4)
Birth center apprenticeship 148 (26.1) 107 (18.9) 118 (20.8) 60 (10.6) 17 (3.0) 116 (20.5)
Hospital-based
apprenticeship
187 (33.0) 219 (38.7) 20 (3.5) 5 (0.9) 1 (0.2) 134 (23.7)
Short-term,ddomestic,
precepted clinical
experience
272 (48.1) 81 (14.3) 31 (5.5) 4 (0.7) 1 (0.2) 177 (31.2)
Short-term,dinternational,
precepted clinical
experience
274 (48.4) 107 (18.9) 14 (2.5) 3 (0.5) 1 (0.2) 167 (29.5)
Long-term,edomestic,
precepted clinical
experience
266 (47.0) 18 (3.2) 31 (5.5) 41 (7.2) 18 (3.2) 192 (33.9)
Long-term,einternational,
precepted clinical
experience
318 (56.2) 9 (1.6) 4 (0.7) 18 (3.2) 17 (3.0) 200 (35.3)
Abbrev iation s: MEAC, M idwifery Edu cation and Accre ditation Coun cil.
aSome types might be counted more than once. For example, a birth center preceptorship might also have been counted as either a short- or long-term, domestic or
international clinic training site. Exact wording for these and all other survey questions are available in Supporting Information: Appendix S1.
bBecause the proportion of skipped answers for any given type of training was so high, we looked closely at these data. It seems as though many respondentssimplyskipped
all that did not apply to them rather than taking the time to check every box where the answer was zero.
cThe survey did not distinguish between MEAC-accredited and non-MEAC-accredited schools.
dLess than 6 months.
eGreater than 6 months.
planned vaginal breech births. The majority of CPMs in the
sample (86.9%) reported that they attend VBACs. Of those,
83.2% had done so within the last 3 years, with a median
of 3 (IQR, 1-6; maximum 100) attempted VBACs. One-third
(36.4%) indicated that they attend births with multiple ges-
tations. Of that group, 63.4% had done so in the last 3 years,
with a median of one (IQR, 0-2; maximum 15) twin birth dur-
ing this time. One-third (34.7%) also said they attend planned
vaginal breech births. More than half (62.4%) of that group
had done so, with a median of one (IQR, 0-2; maximum 9)
vaginal breech birth in the last 3 years.
About half of the respondents (50.5%) indicated they
provide well woman care in addition to maternity services,
and 18.8% provide extended postpartum and newborn care
("6weeks).Whenaskedaboutappointmentschedulesand
length, most respondents (86.9%) follow a similar, standard-
ized prenatal schedule, with monthly appointments up to
28 weeks’ completed gestation, biweekly appointments from
28 to 36 weeks’ gestation, and weekly appointments after 36
weeks’ gestation. Most respondents (80.8%) indicated that
prenatal appointments typically last 45 minutes or longer,
with 40.6% citing 45- to 60-minute visits, and 40.2% reporting
60 or greater minutes as normative. Midwives reported more
variability in postpartum appointment schedules: 48.0%
typically have 5 appointments in the postpartum period;
35.6% have 6 visits; and the remainder provide between 7
and 12 visits between birth and 6 weeks postpartum. The
most common schedule was one visit in the first 24 hours
after birth, one visit on the second day, between one and
3visitsfrom2daysto2weeksafterthebirth,anotherone
to 3 visits between 2 and 4 weeks, and one final visit in the
fifth or sixth week. Postpartum visits are also generally 45
minutes or longer; 38.7% said visits lasted 45 to 60 min-
utes; and 43.6% indicate visits of 60 or greater minutes are
typical.
Some questions were asked to better understand the
women who CPMs typically serve. Midwives reported 30.7%
urban, 32.5% rural, and 36.8% suburban residency for the
majority of their clients. Respondents were also asked to
estimate what percentage of their client base was white, black,
Hispanic or Latino, Native American/Alaskan Native, Asian,
or Native Hawaiian/Pacific Islander. Whereas 31.8% of CPM
respondents said that 95% or more of their clients were white,
5.2% serve populations that are 90% or more nonwhite.
8Vol u me 0 0, No. 0 , x xx 2 0 15
Using a point-biserial correlat ion, we fou nd t hat midwives
of color are significantly more likely to have a higher pro-
portion of clients of color (P!.001). In a separate question,
midwives were also asked to estimate what percentage of
their client base is Amish, Mennonite, Mormon, Muslim, or
Hassidic Jew. Whereas some midwives (1.6%) serve almost
exclusively (95%-100%) within these populations, most work
primarily outside of these groups.
DISCUSSION
Higher education was common among CPMs: 90.6% at-
tended some college, and 47.1% completed a bachelor’s
degree or higher. An additional 5.3% reported that they had
earned RN licensure, which may or may not have included
a4-yeardegree—meaningthat47.1%islikelyanunderesti-
mate. Although much has been made of the fact that, until
recently (2012), NARM did not require successful completion
of secondary education, only 0.5% of respondents (n =3)
did not have high school degrees or the equivalent in 2011.
These 3 CPMs were likely members of Plain communities,
where formal education beyond eighth grade is uncommon,
because each reported serving a high proportion of Amish
and Mennonite clientele.
With regard to length of training prior to assuming the
role of primary midwife, the median for this sample is 3 years
as recommended by ICM; however, nearly 40% of currently
practicing CPMs did not meet this standard. This is at least
partially explained and mediated by the fact that grandCPMs,
who have been practicing for 25 years or more and comprise
19% of currently practicing CPMs (I. Darragh, CPM, LM,
written communication, August 2014), often began primary
practice very early in their careers and sometimes without
any formal training. These CPMs describe “being taught by
birth”, other midwives, and home birth-friendly physicians as
they pieced together their training in the 1970s and 1980s.34
It is much less common today for CPMs to enter primary
practice before the 3-year mark. In addition, because of vari-
ability in training sites, student midwives training in high-
volume birth centers can easily attend more than 100 births
per year during their 1- to 2-year internships, acquiring their
CPM prior to the internationally recommended 3-year train-
ing period; whereas student midwives in low-volume home
birth apprenticeships might take several years and qualify to
sit for the NARM examination, having attended fewer than
100 births. Thus, within the current competency-based sys-
tem of CPM education in the United States, the length of time
to primary practice may not always be the most useful way of
estimating competency. Because of this, NARM currently re-
quires CPM candidates to document a minimum number of
births attended (see Table 2) and a minimum of 2 years in
supervised practice. Although 5.7% of CPMs reported never
practicing under supervision, this would not be permitted un-
der NARM’s current standards.
Our findings also indicate that CPMs tend to work in
solo practice, attending births with assisting midwives or
students/apprentices; that medical and private insurance
reimbursement rates are low; and that costs of home birth
care are minimal relative to those of hospital births, largely
due to low rates of intervention and the absence of a facility
fee. CPMs also spend more time with clients during prenatal
visits and provide substantially more postpartum care within
the home than is common in mainstream obstetrics.21,35,36
CPM models of low-volume, highly individualized, time-
intensive, and largely in-home prenatal and postpartum care
may help explain the high rates of normal physiologic birth
and successful breastfeeding and the low rates of intervention
and surgical birth reported for CPM-attended home and birth
center births,8,13 although selection bias favoring low-risk
pregnancies clearly also plays a role. These practice charac-
teristics, when combined with sociopolitical marginalization,
may also help to explain why attrition rates (ie, the number
of CPMs who leave active practice, sometimes permanently
and sometimes cyclically as they temporarily engage more
sustainable employment) are reportedly high among CPMs.21
The relatively low volume of CPM practice raises an addi-
tional concern, particularly given that some respondents
report attending higher-risk vaginal births, including breech
presentation and multiple gestations. How are CPMs able to
acquire and maintain the unique competencies required to
attend these higher-risk births when they attend, on average,
only one to 2 twin and/or breech pregnancies in a 3-year
period?
Additionally, debates over the CPM credential have
focused on the relative merits or limitations of the 2 primary
routes to certification: graduation from a MEAC-accredited
school or successful completion of the PEP. We found that
routes to certification are far more complex than this di-
chotomy suggests. Although respondents largely cited either
the PEP or MEAC route to certification, a closer look at how
midwives’ educations were actually obtained was informative.
The vast majority of respondents patched together multiple
training opportunities over the course of their education,
depending on 2 key variables: whether they lived in a regu-
lated state with an accredited school and whether they had
sufficient funds to attend one of these schools for the entirety
of their education. Consider this common pattern: A student
midwife completes some of her didactic training at a MEAC-
accredited midwifery school but then drops out citing finan-
cial hardship. She relocates to another state where she moves
in and out of apprenticeship depending on her own childbear-
ing and intermittent need to leave apprenticeship for a paying
job. After a few years, she relocates temporarily to a state with
a busy birth center where she completes her required clinical
activities via a 6- to 8-week long, high-volume internship.
She then utilizes the PEP route to certification. This midwife
identifies as a PEP-route CPM, yet her actual academic path
is far more complicated and included at least some terms, and
perhaps several, as a student at a MEAC-accredited school.
Given the prevalence of these piecemeal training trajectories,
the MEAC or PEP dichotomy is a false one that oversim-
plifies a diverse and largely reactive, rather than optimal,
process of training that is riddled with economic and legal
barriers.
Finally, given our finding that midwives’ self-reported
ethnicity/cultural group (eg, Amish, black) is associated with
the client population served, the lack of racial, ethnic, and
cultural diversity in the profession is a major concern.37
Although it is unclear from our results whether midwives of
color seek clients of color or vice versa, it is clear that without
Journal of Midwifer y & Women’s Health !www.jmwh.org 9
more midwives of color, childbearing families of color will
have limited access to culturally matched midwifery care,
and particularly to home birth services. The proportion
of home and birth center births for non-Hispanic white
women (2.05%) in the United States is about 3 times that for
non-Hispanic black, American Indian, and Asian or Pacific
Islander women (0.49-0.81%)—and about 4 times that for
Hispanic women (0.46%).3As ACNM has observed: “Repre-
sentation of diverse groups in [midwifery] ranks strengthens
opportunities for providing midwifery care to otherwise un-
derserved communities.”38 Access to midwifery care has the
potential to redress some of the disparities in outcomes that
have been well documented in communities of color in the
United St ates, as well as in other traditionally marg inalized
groups such as adolescent or queer-identified parents.24, 39–41
Indeed, 26% of non-Hispanic, black women surveyed for the
Listening to Mothers III study42 said they would select a home
birth for their next birth. Home and birth center birth may
currently be a white middle-class phenomenon in the United
States, not because women of color prefer hospital birth but
because they have been systematically excluded from choice
in childbearing by larger structures of inequality.41,42
STUDY LIMITATIONS
This study has 3 primary limitations.43 First and foremost,
it relies on participant recall and is thus vulnerable to all of
the known weaknesses of this approach, including the intro-
duction of systematic error caused by differences in the accu-
racy or completeness of recollections reported by study par-
ticipants. Second, there is some evidence of digit preference
for a few of the survey questions. For example, more mid-
wives than expected answered round numbers in multiples of
10 for number of births in the last 3 years, reflecting both a
tendency to round larger numbers, as well as a tendency to es-
timate when acquiring a precise value might be time consum-
ing. Even given these limitations, however, estimates provided
by CPMs for the key variables analyzed here—like number of
years in training and highest degree earned—are likely to be
remembered with some degree of accuracy given their impor-
tance in individual midwives’ lives. Lastly, whereas the final
response rate of 41% and sample size (N =568)—together
with the results of the nonresponse bias analysis indicating no
significant differences between respondents and nonrespon-
dents for key variables—suggest that we may be justified in
generalizing to the CPM population,31,44 it is possible that our
findings would have varied had closer to 100% of CPMs com-
pleted the survey.
CONCLUSION
The training and nonmidwifery education levels of the ma-
jority of CPMs practicing in the United States today align
with the ICM’s Global Standards for Midwifery Education, al-
though there are still clear areas for improvement. The ICM
standards of completion of secondary education and a 3-year
minimum length of direct-entry midwifery training are met
by 99.5% and 61% of CPMs, respectively. Further evaluation
of the minimum-time versus minimum-numbers criteria in
terms of practice outcomes would be a useful addition to the
literature on this topic.
Findings from this survey indicate several significant
challenges facing the profession that will need to be addressed
if CPMs are to contribute more substantially to the mitigation
of inequities in our nation’s maternity care system. In addi-
tion to the need to expand access to midwifery training and
services for families of color, we see a critical need for uni-
versal state licensure and regulation of CPMs in accordance
with the guidelines and next steps delineated by the US Mid-
wifery Education Regulation and Association (MERA) work-
ing group.45 Licensure of CPMs is important because it allows
for greater quality assurance, as well as mechanisms for over-
sight and review of CPM practice.46,47
AUTHORS
Melissa Cheyney, PhD, CPM, LDM, is Associate Professor of
medical anthropology and reproductive biology in the De-
partment of Anthropology at Oregon State University in Cor-
vallis, Oregon. She is also a certified professional midwife,
licensed in the State of Oregon, and Chair of the Division
of Research for the Midwives Alliance of North America
(MANA).
Christine Olsen, PhD, is Research Social Scientist in the De-
partment of Forest Ecosystems and Society at Oregon State
University in Corvallis, Oregon. She also consults on mater-
nity care-related social science research and has worked for
several years as a certified childbirth educator and birth doula.
Marit Bovbjerg, PhD, MS, Instructor in the College of Pub-
lic Health and Human Sciences at Oregon State University in
Corvallis, Oregon. She is also Director of Data Quality for the
MANA Division of Research.
Courtney Everson, MA, PhD, is a Medical Anthropologist and
the Graduate Dean at the Midwives College of Utah in Salt
Lake City, Utah. She is alsothe Director of Research Education
for the MANA Division of Research.
Ida Darragh, CPM, LM, BA, is a certified professional mid-
wife and Chair of the North American Registry of Midwives
(NARM). She has been a licensed midwife in the state of
Arkansas since 1985. She has a bachelor’s degree in psychol-
ogy.
Brynne Potter is Chief Executive Officer of Maternity Neigh-
borhood, a digital health platform for maternity care. She is
also a midwife and a former member of NARM.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
We would like to acknowledge respondents to the 2011
NARM Survey for their time and effort. We are grateful
for your participation. In addition, we would like to thank
members of the NARM Board of Directors, who provided
expert consultation and support for this project.
10 Vol u me 0 0, No. 0 , x xx 2 0 15
SUPPORTING INFORMATION
Additional Supporting Information may be found in the on-
line version of this article at the publisher’s Web site:
Appendi x S1 . Questionnaire used for: Practitioner and
Practice Characteristics of Certified Professional Midwives in
the United States: Results of the 2011 North American Reg-
istry of Midwives Survey.
REFERENCES
1.American Public Health Association. Increasing access to out-
of-hospital maternity care services through state-regulated and
nationally-certified direct-entry midwives (policy statement). Am J
Public Health. 2002;92(3):453-455.
2.MacDorman MF, Declercq E, Mathews TJ. Recent trends in out-of-
hospital births in the United States. JMidwiferyWomensHealth.
2013;58(5):494-501. doi:10.1111/jmwh.12092.
3.MacDorman MF, Matthews TJ, Declercq E. Trends in out-of-
hospital births in the United States, 1990-2012. NCHS Data Brief.
2014;(144):1-8.
4.Cook E, Avery M, Frisvold M. Formulating evidence-based guide-
lines for certified nurse-midwives and certified midwives attend-
ing home births. JMidwiferyWomensHealth. 2014;59(2):153-159.
doi:10.1111/jmwh.12142.
5.Malloy MH. Infantoutcomes of certified nurse midwife attended home
births: United States 2000 to 2004. JPerinatolOJCalifPerinatAs-
soc.2010;30(9):622-627.doi:10.1038/jp.2010.12.
6.Cox KJ, Schlegel R, Payne P, Teaf D, Albers L. Outcomes of
planned home births attended by certified nurse-midwives in south-
eastern Pennsylvania, 1983-2008. JMidwiferyWomensHealth.
2013;58(2):145-149. doi:10.1111/j.1542-2011.2012.00217.x.
7.Jackson DJ, Lang JM, Swartz WH, et al. Outcomes, safety, and re-
source utilization in a collaborative care birth center program com-
pared with traditional physician-based perinatal care. Am J Public
Health. 2003;93(6):999-1006.
8.Stapleton SR, Osborne C, Illuzzi J. Outcomes of care in birth cen-
ters: Demonstration of a durablemodel. JMidwiferyWomensHealth.
2013;58(1):3-14. doi:10.1111/jmwh.12003.
9.American College of Nurse-Midwives. Issue Brief: Where Mid-
wives Work.SilverSpring,MD:AmericanCollegeofNurse-
Midwives; 2012. Available at: http://www.midwife.org/ACNM/files/
ACNMLibrar yData/UPLOADFILENAME/000000000277/Where%
20Midwives%20Work%20June2012.pdf. Accessed April 28, 2014.
10.Johantgen M, Fountain L, Zangaro G, Newhouse R, Stanik-Hutt J,
White K. Comparison of labor and delivery care provided by cer-
tified nurse-midwives and physicians: A systematic review, 1990 to
2008. Women s Hea lt h I ssu e s O P ub l Jac obs I n s t Wom e n s He alt h .
2012;22(1):e73-e81. doi:10.1016/j.whi.2011.06.005.
11.Schuiling KD, Sipe TA, Fullerton J. Findings from the analysis
of the American College of Nurse-Midwives’ membership surveys:
2009 to 2011. JMidwiferyWomensHealth.2013;58(4):404-415.
doi:10.1111/jmwh.12064.
12.Declercq E. Trends in midwife-attended births in the United
States, 1989-2009. JMidwiferyWomensHealth.2012;57(4):321-326.
doi:10.1111/j.1542-2011.2012.00198.x.
13.Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D,
Veda m S. Ou t com es of c a re f o r 16 , 924 p l ann e d ho m e bi r t hs i n t h e
United States: The Midwives A lli ance of North America Statis tic s
Project, 2004 to 2009. JMidwiferyWomensHealth.2014;59(1):17-
27. doi:10.1111/jmwh.12172.
14.Johnson KC,Daviss B-A. Outcomes of planned home births with certi-
fied professional midwives: Largeprospective study in North America.
BMJ. 2005;330(7505):1416. doi:10.1136/bmj.330.7505.1416.
15.International Confederation of Midwives. Global Standards for
Midwifery Education (2010) Amended 2013.TheHague,Nether-
lands: International Confederation of Midwives; 2013. Available at:
http://www.internationalmidwives.org/assets/uploads/documents/
CoreDocuments/ICM%20Standards%20Guidelines ammended2013.
pdf. Accessed May 4, 2014.
16.Craven C. Pushing for Midwives: Homebirth Mothers and the Re-
productive Rights Movement.Philadelphia,PA:TempleUniversity
Press; 2010.
17.American College of Nurse-Midwives. Comparison of Certied
Nurse-Midwives, Certie d Midwives, and C ertied Pro fessional
Midwives: Clarif ying the Distinctions Among Professional
Midwifery Credentials in the U.S. Silver Spring, MD: Ameri-
can College of Nurse-Midwives; 2011. Available at: http://www.
midwife.org/acnm/files/cclibraryfiles/filename/000000001031/cnm%
20cm%20cpm%20comparison%20chart%20march%202011.pdf.
Accessed May 4, 2014.
18.Midwives Alliance of North America. State By State Comparison.
Availableat: http://mana.org/about-midwives/state-by-state. Accessed
May 5, 2014.
19.American College of Nurse-Midwives. The Credential CNM and CM.
ACNM. Available at: http://www.midwife.org/The-Credential-CNM-
and-CM. Accessed May 5, 2014.
20.American College of Nurse-Midwives. Position Statem ent: Mid -
wifery C ertication in the United States.SilverSpring,MD:
American College of Nurse-Midwives; 2009. Available at: http://www.
midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/
000000000077/Midwifery%20Certification in the United States 3
31 09.pdf. Accessed May 4, 2014.
21.Cheyney M. Born at Home: e Biological, Cultural and Political
Dimensions of Maternity Care in the United States.CengageLearn-
ing; 2010.
22.North American Registry of Midwives. History of the development
of the CPM. Available at: http://narm.org/certification/history-of-the-
development-of-the-cpm/. Accessed May 5, 2014.
23.Midwifery Task Force. Midwives model of care, 2008. Available at:
http://cfmidwifery.org/mmoc/define.aspx. Accessed May 5, 2014.
24.Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led
versus other models of care for childbearing women. Cochrane
Database Syst Rev. 2008;(4):CD004667. doi:10.1002/14651858.
CD004667.pub2.
25.Thompson JB, Kershbaumer RM, Krisman-Scott MA. Educating Ad-
vanced Practice Nurses and Midwives: From Practice to Teaching.
New York, NY: Springer Publishing Company ; 2001.
26.International Confederation of Midwives. Essential Competencies
for BasicMidwifery Practice 2010 Revised 2013.TheHague,Nether-
lands: International Confederation of Midwives; 2013. Available at:
http://www.internationalmidwives.org/assets/uploads/documents/
CoreDocuments/ICM%20Essential%20Competencies%20for%20
Basic%20Midwifery%20Practice%202010,%20revised%202013.pdf.
27.Klein-Collins R. Competency-Based Degree Programs in the U.S.:
Postsecondary Credentials f or Measur able Stud ent Learning and
Performance. Chicago, IL: Council for Adult and Experiential Learn-
ing; 2012. Available at: http://hdl.voced.edu.au/10707/299172.
28.North American Registry of Midwives. Shared decision making
and informed consent. Available at: http://narm.org/accountability/
informed-consent/. Accessed May 5, 2014.
29.Peterson C. Midwifery and the crowning of health care reform.
JMidwiferyWomensHealth. 2010;55(1):5-8. doi:10.1016/j.jmwh.
2009.10.006.
30.DiVenere L. Lay midwives and the ObGyn: Is collaboration risky?
OBG Manag.2012;24(5):21-26.
31.Leedy PD, Ormrod JE. Practical Research: Planning and Design.10
ed. Boston, MA: Pearson; 2012.
32.Measured Porgress. Discovering the Point Biserial. Available at:
http://www.measuredprogress.org/learning-tools-statistical-analysis-
the-point-biserial. Accessed March 15, 2015.
33.IBM Corporation. SPSS Statistics. Armonk, NY: IBM Corp.
34.Gaskin IM. Spiritual Midwifery.4ed.Summertown,TN:BookPub-
lishing Company; 2002.
35.Davis-Floyd RE. Birth as an AmericanR iteof Passage.2nded.Berke-
ley, CA: University of California Press; 2004.
Journal of Midwifer y & Women’s Health !www.jmwh.org 11
36.Gaskin IM. Ina May’s Guide to Childbirth.1sted.NewYork,NY:
Bantam; 2003.
37.Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-
led continuity models versus other models of care for child-
bearing women. Cochrane Database Syst Rev. 2013;8:CD004667.
doi:10.1002/14651858.CD004667.pub3.
38.American College of Nurse-Midwives. Issue Brief: Reducing
Health Disparities. Silver Spring, MD: American College of Nurse-
Midwives; 2007. Available at: http://www.midwife.org/ACNM/files/
ACNMLibrar yData/UPLOADFILENAME/000000000112/Health
Care Disparities Issue Brief 10 07.pdf. Accessed May 4, 2014.
39.Singer RB. Improving prenatal care for pregnant lesbians. Int J Child-
birth Educ.2012;27(4):37-40.
40.Allen J, Gamble J, StapletonH, Kildea S. D oes the waymaternity care is
provided affect maternal and neonatal outcomes for young women? A
review of the research literature. Wom e n Bi r t h J Au s t Co l l M id w iv e s .
2012;25(2):54-63. doi:10.1016/j.wombi.2011.03.002.
41.Commonsense Childbirth, Inc. Program Evaluation: Study Results
of the JJ Way In Action.WinterGarden,Florida:Commonsense
Childbirth; 2009. Available at: http://www.commonsensechildbirth.
org/files/Commonsense Childbirth Evaluation Final Data Aug 09
30.pdf.
42.Declercq E, Sakala C, Corry M, Applebaum S, Herrlich A. Listening to
Moth ers III: Pre gnancy and Birth . New York, NY: Childbirth Con-
nection; 2013.
43.Tarrant MA, Manfredo MJ. Digit preference, recall bias, and non-
response bias in self reports of angling participation. Leis Sci.
1993;15(3):231-238. doi:10.1080/01490409309513202.
44.Dillman DA, Smyth JD, Christian LM. Internet, Mail, and Mixed-
Mod e Sur veys: e Tailo red D esign Method.3rded.Hoboken,NJ:
JohnWiley & Sons; 2008.
45.US MERA Representatives. 2014. US MERA Meeting: A Summary Re-
port. 2014. Available at: http://mana.org/us-midwifery-era-us-mera.
Accessed September 25, 2014.
46.International Confederation of Midwives. ICM Global Standards
for Midwifery Regulation (2011).TheHague,Netherlands:In-
ternational Confederation of Midwives; 2011. Available at: http://
internationalmidwives.org/assets/uploads/documents/Global%20
Standards%20Comptencies%20Tools/English/GLOBAL%20
STANDARDS%20FOR%20MIDWIFERY%20REGULATION%20
ENG.pdf. Accessed September 1, 2014.
47.Cheyney M, Everson C, Burcher P. Homebirth transfers in the United
States: narratives of risk, fear, and mutual accommodation. Qual
Health Res.2014;24(4):443-456.doi:10.1177/1049732314524028.
12 Vol u me 0 0, No. 0 , x xx 2 0 15
