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
Introduction: 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) between July 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 Midwifery Education established by the International Confederation of Midwives, although there are still clear areas for improvement. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;00:1–12 ! Keywords: accreditation, certification, demography, educational status, home childbirth, midwifery
Address correspondence to Melissa Cheyney, PhD, CPM, LDM, Department of Anthropology, Oregon State University, Waldo Hall 238, Corvallis, OR 97331. E-mail:
[email protected]
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 standardize 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 Survey was designed to examine 3 research questions: 1) who are CPMs in the United States, and how are they getting their education? 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
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.1 At 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 births3 attended primarily by direct-entry midwives, including certified professional midwives (CPMs).2 Yet, although there exists a large body 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 Registry of Midwives (NARM) Survey—a collaborative project
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) in training before beginning to attend births as a primary 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 degree 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 Obstetricians and Gynecologists. A concurrent, nonresearch aim was to provide updated information about the CPM credential; such information does not currently appear in the peerreviewed literature. The Certified Professional Midwife Credential in Social and Historical Context
The United States is unique cross-culturally in having 3 credentialing 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 accredited certification and distinguish themselves from lay or traditional midwives who practice without having demonstrated the ability to meet formal training and certification requirements. The CPM, CNM, and CM credentials are accredited 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.
2
Unlike nurse-midwifery education programs, there is only one university-based CPM training option (Bastyr University, Kenmore, WA). NARM’s approach to certification 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, including 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 without ever having attended a formal, accredited midwifery education 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 clinical 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: formal, accredited schools are few and far between (10 nationwide 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.
Volume 00, No. 0, xxx 2015
Table 1. Credentialing Routes for the Midwifery Profession in the United States
Certified
Certified Professional
Nurse-Midwife
Certified Midwife
Midwife
Professional Association(s)
ACNM
ACNM
MANA and NACPM
Certification Requirements
1. Graduation from an accredi-
1. Graduation from an accred-
teda nurse-midwifery educa-
iteda
tion program;
program;
and 2. Verification of education program completion;
midwifery
education
1. Completion of NARM’s Portfolio Evaluation Process pathway; or
and 2. Verification of education program completion
and
2.
Graduation
accredited
b
from
an
midwifery
education program; or
3. Current RN license
3. AMCB-certified CNM or CM; or 4. Completion of state licensure program Certifying Organizationc
AMCB
AMCB
Legal Statusd
Legally permitted to practice in
Legally permitted to practice in
Legally permitted to
all 50 states, District of
New Jersey, New York, Rhode
practice in 28 states
Columbia, and US territories
Island. Delaware, Missouri
NARM
Abbreviations: ACNM, American College of Nurse-Midwives; ACME, Accreditation Commission for Midwifery Education; AMCB, American Midwifery Certification Board; CNM, certified nurse-midwife; CM, certified midwife; CPM, certified professional midwife; MANA, Midwives Alliance of North America; MEAC, Midwifery 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 a The program must be accredited by ACME. ACME is authorized by the US Department of Education to accredit midwifery education institutions and programs. b The program must be accredited by MEAC. MEAC is authorized by the US Department of Education to accredit midwifery education institutions and programs. c Both AMCB and NARM are accredited by the National Commission for Certifying Agencies. d Practice is considered legally permitted if licensure, permit, registration, or certification is available at the state level.
CPM applicants who have not completed a MEACaccredited 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 competencies of the midwife candidate (Table 2). There are 3 PEP categories: entry-level, internationally educated, and experienced midwives. The entry-level PEP requirements include documentation that the candidate has fulfilled NARM’s general education requirements; verification from NARMapproved preceptors that the candidate is proficient in the skills, knowledge, and abilities required by the profession; 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; satisfaction of skills verification requirements; certification in adult CPR and neonatal resuscitation; written verification of practice guidelines, emergency care plans, informed disclosure, and informed consent documents; and completion of a Journal of Midwifery & Women’s Health ! www.jmwh.org
cultural competency course. Candidates applying through the experienced midwife PEP route must demonstrate extensive out-of-hospital birth experience; satisfaction of skills verification 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 successfully 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 candidacy through successful completion of a MEAC-accredited midwifery education program. All MEAC-accredited schools in the United States incorporate NARM competency requirements 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 competencies 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 3
Table 2. Current NARM Requirements for Entry-Level PEP for CPM Credentialing
Activitya Attendance at birthsa,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
METHODS
40 as primary midwife under supervision
Data Collection
a
Newborn examinations
20 as an assistant under supervision 20 as primary midwife under supervision At least 2 years of supervised practice Verification of mastery in comprehensive knowledge and skills core competencies essential for safe midwifery practice, includes > 750 individual skills assessed through practice examination Completion of an approved module on cultural competency for health professionals Maintain adult CPR certification and neonatal resuscitation certification High school diploma or equivalent 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. a Attendance 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. b Within these birth requirements, a minimum of 5 home births must be attended 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. c At 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 provision 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 MEACaccredited 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 certification requirements with those of CNMs/CMs indicates that 4
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 particularly 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 evaluation process. In addition, although the CPM credential is accredited, the PEP itself is not.
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). A reminder e-mail was sent 2 weeks after the initial invitation, 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 responses 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 University, a second e-mail invitation was sent to all of the initial respondents 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 population 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 developed in conjunction with, and approved by, Oregon State University’s IRB. Contacting nonresponders was allowed because NARM personnel had sole responsibility for the process; researchers at OSU were only given aggregated data from nonresponders. The abbreviated version of the survey used in the nonresponse bias analysis focused on education and routes to the credential, practice characteristics, and demographics. Statistical Analyses
We used descriptive statistics to examine midwives’ basic demographic, education, and certification characteristics. We then used chi-square tests, Spearman’s correlation Volume 00, No. 0, xxx 2015
coefficients, and point-biserial correlations32 for bivariable analyses. Point-biserial correlations are mathematically equivalent to Pearson’s correlation coefficients but compare 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
Table 3. Participant and Practice Characteristics of 568 Certified Professional Midwives
Characteristic Gender, % Female
99.83
Male
0.17
Race/ethnicity, %
RESULTS
Persons of Color
21
The initial invitation was sent to 1391 CPMs and 849 (61%) responded. Two e-mail invitations bounced, indicating that 2 potential respondents did not have a working e-mail address 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%.
White
79
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 attended in the last 3 years (P " .20 for all). There were also no significant differences in the number of home births attended in the last 3 years (P = .13), whether the midwife carries malpractice insurance (P = .12), the level of nonmidwifery education (P = .07), whether the midwife identified as a person of color (P = .08), or the certification route (P = .09), although these might have become statistically significant 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. Twenty-one percent of respondents identified as persons 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 respondents 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 and 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 Journal of Midwifery & Women’s Health ! www.jmwh.org
Highest level of education, % Graduate degree (MS, PhD, DNP)
12.1
Graduate-level midwifery training
0.8
(CNM/CM) Bachelor’s degree (BA or BS)
34.2
RN degreea
5.3
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
31 (27-37)
midwife without supervision, median (IQR), y Length of training before attending births as
3 (2-5)
a primary midwife without supervision, median (IQR), y Route to certification used when applying for the CPM credential, % Portfolio evaluation process
48.5
Entry-level
29.8
Experienced midwife
17.5
Internationally educated midwife
1.3
Graduation from a MEAC-accredited
36.9
school Already licensed by a state as a direct-entry
14.5
midwife Already a CNM or CM Total cost of midwifery education and training, median (IQR, range)
0.7 $15,000 ($5,000$20,000, $0-$100,000)
Reside in state that licenses and regulates
76.2
CPMs, % Participation, % Midwifery advocacy
42.1
Midwifery education
54.6
Practiced within the last 3 years, %
86.2
Clients with whom care was initiated in the
40 (10-82)
preceding 3 years regardless of setting, median (IQR), n (Continued.)
5
Table 3. Participant and Practice Characteristics of 568 Certified Professional Midwives
Characteristic Attend home births, %
82.4
Home births attended in the preceding
31 (10.25-67)
3 years, median (IQR), n Attend birth center births, %
26.9
Birth center births attended in the preceding
22 (5-63.75)
3 years, median (IQR), n Attend hospital births, %
12
Hospital births attended in the preceding
3 (1.5-13)
3 years, median (IQR), n Birth types attended, % Vaginal birth after cesarean
86.9
Twins
36.4
Planned vaginal breech births
62.4
Type of practice, % Solo
64.8
Partnership with another fully trained
21.4
midwife Group practice of 3 or more midwives
13.8
Not eligible for Medicaid reimbursement, %
72.8
Usually receive insurance reimbursement, %
25.3
Provider fee (excluding facility fees), median
$3000 ($2200-
(IQR)
$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. a The 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 respondents 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 supervision. 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% graduated 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 constituted just 4 individuals, they were excluded from all further 6
analyses. The highest level of education achieved was compared between the PEP, MEAC-accredited school, and state licensed midwife pathway groups; and no significant difference was found (Table 4). However, there were some differences in training and educational experiences used toward certification 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 international 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 6 showcases a selection of 10 different education pathways, 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 different 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 correspondence) 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 clinical skills training with self-study, formal study groups, and/or workshops. The regulatory status of the CPM credential in each respondent’s state was also examined to determine if there was an association with the certification pathway chosen by midwives. The majority of midwives (76.2%) reported residing in states that license and regulate CPMs. Chi-square analysis showed a significant difference (P ! .001) between certification 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 midwives (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. Respondents 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 median 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 births was 22 (IQR, 5-63.75) and 3 (IQR, 1.5-13), respectively. Volume 00, No. 0, xxx 2015
Table 4. Education Level by Certification 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)
3 (1.2)
0 (0)
Did not complete high school
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. a A table-wide Pearson Chi-square test was performed, and no significant differences were found in highest level of education achieved when compared by route to certification (x2 = 12.965, P = .113).
Table 5. Education and Training Experiences by Route to Certificationa
PEP, b
MEAC, b
LM, b
All Respondents, b
Home birth apprenticeship
85.5
58.7
81.3
75.1
Birth center
25.1
63.2
48.4
43.3
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
Education or Training Experience
Hospital
Abbreviations: LM, licensed midwife; MEAC, Midwifery Education Accreditation Council; PEP, Portfolio Examination Process. a A table-wide 6 × 3 Chi-square test was performed and significant differences were found in education and training experiences when compared by route to certification (P ! .001) b The 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 total more than 100% because respondents answered for each education and training experience separately.
Table 6. Education and Experience Pathways of 10 CPM Survey Participantsa
Aspiring Onsite CPMs 1
Online
Home Birth
Birth
International Clinic Verification of
Schoolb Schoolb Apprenticeship Center Hospital √ √ √
Experience
Certification
PEP (entry-level,
NARM
experienced, trained √
2 3 4 5 6 7 8 9
√ √ √
√
√
√
Testing and
Experience and Skills
CPM
examination
internationally)
√
√
√ √
√ √
10
√
MEAC school graduate
√ √
√
State-licensed midwife CNM or CM
Abbreviations: CNM, certified nurse-midwife; CM, certified midwife; CPM, certified professional midwife; MEAC, Midwifery Education and Accreditation Council; NARM, North American Registry of Midwives; PEP, Portfolio Evaluation Process. a Other training and experience activities included self-study, workshops, US clinics, correspondence courses, and study groups. b The 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 operating 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 assistants, apprentices, and/or other midwives attend births with them. Journal of Midwifery & Women’s Health ! www.jmwh.org
Most respondents (72.8%) indicated that they are not eligible 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 a provider fee, excluding facility fees. Provider fees for CPMs 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 7
Table 7. Types of Training Used by Midwives in Pursuit of the CPM Credential
Approximate Percent of Overall Midwifery Training Type of Traininga Onsite midwifery school
, n () c
, n ()
, n ()
, n ()
, n ()
Skipped by Respondent,b n ()
180 (34)
69 (13.1)
108 (20.5)
9 (1.7)
32 (6.1)
128 (24.3)
Online midwifery schoolc
291 (51.4)
50 (8.8)
23 (4.1)
17 (3.0)
3 (0.5)
182 (32.1)
Correspondence schoolc
239 (42.2)
86 (15.2)
66 (11.7)
13 (2.3)
9 (1.6)
153 (27.0)
31 (5.5)
167 (29.5)
202 (35.7)
89 (15.7)
15 (2.7)
62 (11.0)
153 (27.0)
207 (36.6)
60 (10.7)
5 (0.9)
0 (0)
141 (24.9)
38 (6.7)
362 (64.0)
67 (11.8)
6 (1.1)
0 (0)
93 (16.4)
Self-study Formal study group Workshops 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
187 (33.0)
219 (38.7)
20 (3.5)
5 (0.9)
1 (0.2)
134 (23.7)
272 (48.1)
81 (14.3)
31 (5.5)
4 (0.7)
1 (0.2)
177 (31.2)
274 (48.4)
107 (18.9)
14 (2.5)
3 (0.5)
1 (0.2)
167 (29.5)
266 (47.0)
18 (3.2)
31 (5.5)
41 (7.2)
18 (3.2)
192 (33.9)
318 (56.2)
9 (1.6)
4 (0.7)
18 (3.2)
17 (3.0)
200 (35.3)
apprenticeship Short-term,d domestic, precepted clinical experience Short-term,d international, precepted clinical experience Long-term,e domestic, precepted clinical experience Long-term,e international, precepted clinical experience Abbreviations: MEAC, Midwifery Education and Accreditation Council. a Some 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. b Because 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 respondents simply skipped all that did not apply to them rather than taking the time to check every box where the answer was zero. c The survey did not distinguish between MEAC-accredited and non-MEAC-accredited schools. d Less than 6 months. e Greater 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 gestations. 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 during 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 ("6 weeks). When asked about appointment schedules and length, most respondents (86.9%) follow a similar, standardized 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 8
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 3 visits from 2 days to 2 weeks after the birth, another one 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 minutes; 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. Volume 00, No. 0, xxx 2015
Using a point-biserial correlation, we found that midwives of color are significantly more likely to have a higher proportion 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% attended 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 a 4-year degree—meaning that 47.1% is likely an underestimate. 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 grand CPMs, 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 variability in training sites, student midwives training in highvolume 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 training 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 system 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 requires 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 under 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 Journal of Midwifery & Women’s Health ! www.jmwh.org
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, timeintensive, 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 characteristics, 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 additional 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 dichotomy 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 regulated 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 MEACaccredited midwifery school but then drops out citing financial hardship. She relocates to another state where she moves in and out of apprenticeship depending on her own childbearing 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 oversimplifies 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 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%).3 As ACNM has observed: “Representation of diverse groups in [midwifery] ranks strengthens opportunities for providing midwifery care to otherwise underserved 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 States, as well as in other traditionally marginalized 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
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 addition to the need to expand access to midwifery training and services for families of color, we see a critical need for universal state licensure and regulation of CPMs in accordance with the guidelines and next steps delineated by the US Midwifery Education Regulation and Association (MERA) working group.45 Licensure of CPMs is important because it allows for greater quality assurance, as well as mechanisms for oversight and review of CPM practice.46,47
STUDY LIMITATIONS
Christine Olsen, PhD, is Research Social Scientist in the Department of Forest Ecosystems and Society at Oregon State University in Corvallis, Oregon. She also consults on maternity care-related social science research and has worked for several years as a certified childbirth educator and birth doula.
43
This study has 3 primary limitations. First and foremost, it relies on participant recall and is thus vulnerable to all of the known weaknesses of this approach, including the introduction of systematic error caused by differences in the accuracy or completeness of recollections reported by study participants. Second, there is some evidence of digit preference for a few of the survey questions. For example, more midwives 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 estimate when acquiring a precise value might be time consuming. 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 importance 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 nonrespondents 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 completed the survey.
AUTHORS
Melissa Cheyney, PhD, CPM, LDM, is Associate Professor of medical anthropology and reproductive biology in the Department of Anthropology at Oregon State University in Corvallis, 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).
Marit Bovbjerg, PhD, MS, Instructor in the College of Public 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 also the Director of Research Education for the MANA Division of Research. Ida Darragh, CPM, LM, BA, is a certified professional midwife 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 psychology. Brynne Potter is Chief Executive Officer of Maternity Neighborhood, a digital health platform for maternity care. She is also a midwife and a former member of NARM.
CONCLUSION
CONFLICT OF INTEREST
The training and nonmidwifery education levels of the majority of CPMs practicing in the United States today align with the ICM’s Global Standards for Midwifery Education, although 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.
The authors have no conflicts of interest to disclose.
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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. Volume 00, No. 0, xxx 2015
SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article at the publisher’s Web site: Appendix S1. Questionnaire used for: Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey. REFERENCES 1.American Public Health Association. Increasing access to outof-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-ofhospital births in the United States. J Midwifery Womens Health. 2013;58(5):494-501. doi:10.1111/jmwh.12092. 3.MacDorman MF, Matthews TJ, Declercq E. Trends in out-ofhospital births in the United States, 1990-2012. NCHS Data Brief. 2014;(144):1-8. 4.Cook E, Avery M, Frisvold M. Formulating evidence-based guidelines for certified nurse-midwives and certified midwives attending home births. J Midwifery Womens Health. 2014;59(2):153-159. doi:10.1111/jmwh.12142. 5.Malloy MH. Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol Off J Calif Perinat Assoc. 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 southeastern Pennsylvania, 1983-2008. J Midwifery Womens Health. 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 resource utilization in a collaborative care birth center program compared 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 centers: Demonstration of a durable model. J Midwifery Womens Health. 2013;58(1):3-14. doi:10.1111/jmwh.12003. 9.American College of Nurse-Midwives. Issue Brief: Where Midwives Work. Silver Spring, MD: American College of NurseMidwives; 2012. Available at: http://www.midwife.org/ACNM/files/ ACNMLibraryData/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 certified nurse-midwives and physicians: A systematic review, 1990 to 2008. Womens Health Issues Off Publ Jacobs Inst Womens Health. 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. J Midwifery Womens Health. 2013;58(4):404-415. doi:10.1111/jmwh.12064. 12.Declercq E. Trends in midwife-attended births in the United States, 1989-2009. J Midwifery Womens Health. 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, Vedam S. Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014;59(1):1727. doi:10.1111/jmwh.12172. 14.Johnson KC, Daviss B-A. Outcomes of planned home births with certified professional midwives: Large prospective 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. The Hague, Netherlands: International Confederation of Midwives; 2013. Available at: Journal of Midwifery & Women’s Health ! www.jmwh.org
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36.Gaskin IM. Ina May’s Guide to Childbirth. 1st ed. New York, NY: Bantam; 2003. 37.Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwifeled continuity models versus other models of care for childbearing 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 NurseMidwives; 2007. Available at: http://www.midwife.org/ACNM/files/ ACNMLibraryData/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 Childbirth Educ. 2012;27(4):37-40. 40.Allen J, Gamble J, Stapleton H, Kildea S. Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature. Women Birth J Aust Coll Midwives. 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. Winter Garden, Florida: Commonsense Childbirth; 2009. Available at: http://www.commonsensechildbirth. org/files/Commonsense Childbirth Evaluation Final Data Aug 09 3 0.pdf.
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42.Declercq E, Sakala C, Corry M, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York, NY: Childbirth Connection; 2013. 43.Tarrant MA, Manfredo MJ. Digit preference, recall bias, and nonresponse 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 MixedMode Surveys: The Tailored Design Method. 3rd ed. Hoboken, NJ: JohnWiley & Sons; 2008. 45.US MERA Representatives. 2014. US MERA Meeting: A Summary Report. 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). The Hague, Netherlands: International 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.
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