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Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

Posted by Midwives Alliance on October 2nd, 2015

Questions about the education levels and routes to certification for Certified Professional Midwives often play a role in policy discussions about birth providers, but little current evidence has been available to inform these conversations. 

A new article in the Journal of Midwifery and Women’s Health takes a close look at data from the NARM 2011 Survey. We asked Melissa Cheyney, lead author of the article, to share with us this FAQ. This piece was developed to inform midwives, consumers, and policy makers on the outcomes.

Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

The demographics, education levels, routes to certification, and practice characteristics of currently practicing CPMs are assessed in a new article released September 18, 2015 in the Journal of Midwifery and Women’s Health.

The article Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey is authored by Melissa Cheyney and colleagues and uses  data collected from the 2011 North American Registry of Midwives (NARM) Survey. (Find the abstract here: Cheyney, M., Olsen, C., Bovbjerg, M., Everson, C., Darragh, I. and Potter, B. (2015), Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey. Journal of Midwifery & Women’s Health.)

What was the primary purpose of the study?

No data describing CPMs currently exist in the literature, though they attend the majority of home births in the United States. The study was designed to begin to fill this gap. Specifically, it aimed to answer three research questions: 

1) Who are CPMs in the United States, and how are they getting their educations?

2) Are there differences between CPMs practicing in regulated and unregulated states in terms of training routes or non-midwifery education levels?

3) Who are CPMs serving and how do they practice?

In addition, the project aimed to assess the degree to which US CPMs meet the ICM education standards. A concurrent, non-research goal was to provide updated information about the CPM credential, since this information does not currently appear in the peer-reviewed literature.

How about the response rate? How many currently practicing CPMs responded to the survey?

The initial invitation was sent to 1,391 CPMs, and 849 (61%) responded. Because the survey was not originally designed for research purposes, the original survey respondents were sent an email explicitly requesting consent to have their data used for research. Of the 849 initial respondents, 568 provided consent for their responses to be analyzed; 281 did not respond. The final response rate was 41%.

Is it possible to generalize to the entire population of practicing CPMs, given the response rate of 41%?

Very likely yes, because the researchers also completed something called a non-response bias analysis. This entailed calling a random 10% subsample of the initial non-respondents and asking them an abbreviated version of the survey over the phone. Because the original respondents and the non-respondent group did not differ significantly in any key characteristics or responses, the findings presented in the study very likely accurately reflect the population of currently practicing CPMs.

What did the study find regarding non-midwifery education levels for CPMs?

More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor’s degree or greater. Only 0.5% of respondents (n=3) did not have high school degrees or the equivalent in 2011.

How long do CPMs spend in training prior to taking on the role of primary midwife?

CPMs spent a median of 3 years in training before attending births as a primary midwife.  Sixty one percent met the International Confederation of Midwives (ICM)-recommended 3 years of training, however, 38.9% of currently practicing CPMs did not.

This is at least partially explained by the fact that “grand” CPMs (CPMs who have been practicing for 25 years or more) comprise 19% of currently-practicing CPMs. Midwives who began practicing this long ago, before certification was available, often began primary practice very early in their careers and sometimes with little or no 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, before formal training or credentialing opportunities existed. As the profession has matured and formal training routes have been developed, it is much less common today for CPMs to enter primary practice before the 3-year mark.

In addition, because of the variability in volume of births at training sites, the study also found that student midwives training in high-volume birth centers can easily attend more than 100 births per year during their 1 to 2-year internships, allowing them to acquiring their CPM prior to the internationally-recommended 3-year training period. Conversely, student midwives in low-volume home birth apprenticeships might take several years to qualify to sit for the NARM examination having attended fewer than 100 births. The authors conclude that within the current competency-based system of CPM education in the United States, length of time to primary practice may not always be the most useful way of estimating competency. Some combination of volume and years in training may be more helpful in this regard.

So what pathways to certification are CPMs actually using?

The study found that 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 CNM or CM. However, the researchers stress that routes to certification (that is how CPMs apply to sit for the NARM examination) should not be confused with how CPMs get trained. The study found that CPMs reported a blended education pathway that commonly involved a mixture of MEAC-accredited schooling and apprenticeship in home and birth center practices, regardless of which (MEAC- or PEP-route, for example) pathway to certification the midwives used to acquire permission to sit for the NARM examination.

Debates over the CPM credential have focused on the relative merits or limitations of the two primary routes to certification: graduation from a MEAC-accredited school or successful completion of the PEP. How does this study inform that discussion?

This study found that CPM training is far more complex than this dichotomy suggests. While respondents largely cited either the PEP or MEAC route to certification, a closer look at how midwives are getting their educations showed that the vast majority of respondents combined multiple training opportunities over the course of their educations, depending on two key variables: 1) whether or not they lived in a regulated state with an accredited school and 2) whether they had sufficient funds to attend one of these schools for the entirety of their educations. Although each applicant must designate a single pathway on their NARM application, economic and legal barriers cause many to create a patchwork training trajectory that combine aspects of MEAC and PEP. As a result, the authors would argue that the "MEAC or PEP" dichotomy is a false one.

What did the study find regarding differences between CPMs living in regulated vs. unregulated states?

The regulatory status of the CPM credential in each respondent’s state was found to have an association with the certification pathway chosen by midwives. Analyses 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, while MEAC-accredited schools and the state licensed midwife pathway were more likely to be used in states where CPMs are licensed and regulated.

What about the demographic characteristics of CPMs? How diverse is the population of providers?

One-fifth (21%) of respondents identified as midwives of color. While nearly one-third (31.8%) of CPM respondents reported that 95% or more of the clients they serve are white, 5.2% serve populations that are 90% or more women of color. CPMs of color were also found to be significantly more likely to serve clients of color. Given the finding that midwives’ self-reported ethnicity/cultural group is strongly associated with the client population served, the authors identify the lack of racial, ethnic, and cultural diversity in the profession as a major concern.

Cheyney and colleagues state that while, “it is unclear from our results whether midwives of color seek clients of color or vice versa, it is clear that without more midwives of color, childbearing families of color will have limited access to culturally-matched midwifery care and particularly to home birth services. 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.” 

The same economic and legal barriers that impact all CPM education may be disproportionately impacting midwifery candidates of color. These barriers, compounded with larger issues of systemic inequality, may be sufficient to bar entry to the profession for many potential midwives of color.

Melissa CheneyAbout the author

Melissa Cheyney, PhD, CPM, LDM is the Chair of the Midwives Alliance Division of Research, and an Associate Professor of Medical Anthropology and Reproductive Biology in the Department of Anthropology at Oregon State University (OSU). She received her doctorate from the University of Oregon in 2005, where her research examined the U.S. Homebirth Movement and Midwifery Models of Care. Dr. Cheyney is a Certified Professional Midwife, Director of the Reproductive Health Laboratory at OSU, and Chair of the Board of Direct-entry Midwifery for the State of Oregon. She is also the author of the recently published ethnography, Born at Home by Wadsworth Press. Her research specializations are in midwifery care, interprofessional collaboration, reproductive biology, maternal-child health, homebirth, and medical anthropology.

Hormonal Impacts of Health Disparities on Birth Outcomes

Posted by Midwives Alliance on September 24th, 2015

The Cycle of Stress and Poor Birth Outcomes

Midwives Alliance of North America, in collaboration with ICTC, ICAN, and Elephant Circle is releasing this Executive Summary of Existing Research on Racial Disparities in Birth Outcomes and Racial Discrimination as an Independent Risk Factor Affecting Maternal, Infant, and Child Health. This infographic graphically depicts key findings and offers solutions.

New Research on Planned Home VBAC in the United States: Interview with Study Author Melissa Cheyney, PhD, CPM, LDM on the Implications for Midwives

Posted by Midwives Alliance on September 15th, 2015


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. 

To help the birth-professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Missy Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, PhD, CNM, and co-authored by Marit Bovbjerg, PhD, MS, and Lawrence M. Leeman, MD, MPH, can be found in an online-only version here

The first part of the interview is currently available in a guest blog at Science and Sensibility. In that post, which you can read here, Missy shares the findings and her recommendations for parents and policy makers. Missy shares advice specific to midwives, based on the study’s findings, here at the MANA blog. Read on to learn more.  

Jeanette: So, what advice do you have for midwives working with a family who is considering an HBAC?

Missy: I think it is important to look very closely at the mortality and uterine rupture findings presented in the paper [the study found five deaths overall in the TOLAC sample, with three deemed unrelated to the mother having had a previous cesarean]. If we look at the two instances of confirmed uterine rupture (confirmed upon cesarean section), neither of those babies died. The midwives attending these mothers were monitoring very closely during labor and caught, early on, that something was going awry, as in decreased heart tone variability and a non-progressive labor pattern. They transferred, there was a repeat cesarean, and mother and baby were discharged in excellent condition three days after their births. In the other two cases of presumed uterine rupture (no cesarean, so no confirmation), trouble was not detected until very, very late in the process, there was no time to transfer, and both babies were born at home, but could not be resuscitated. Both of those babies died. 

The MANA Stats 2.0 form had a question that asked midwives how frequently they monitored. The midwives who said their client was attempting a TOLAC did not, in many cases, also indicate on the form that they listened more frequently. Now, part of that is because the question was not asked in an ideal way, but I will say that an overall trend in our mortality case-review process is examining the degree to which some midwives are listening and whether we are listening sufficiently. I said this last year in my presentation at the MANA 2014 conference: you have got to really be on heart tones, especially if the mother has any risk factors, including a longer than average labor or a clear plateau. What we have learned from the mortality case review - which is what we did here, we case-reviewed every one of these deaths - is that midwives who were listening very diligently (so through contractions and then for 30 seconds afterwards with increasing frequency as labor intensifies), can catch early signs of decreasing variability and respond appropriately.

The other thing that's significant is that in the cases with fatal ruptures, those mothers had plateaued, so their first or second stages were stalled for a prolonged period of time, and this can be a problem. It fits with what we know from the larger body of the literature that if you have a mother that is contracting adequately and her cervix is not changing or the baby is not moving down, the strength of those contractions will cause something to open, something to move. We're hoping it will be the cervix, but if the cervix is not opening, we need to be concerned that it might be the scar. I would advise midwives attending any woman who's attempting an HBAC to be aware that a plateau itself can be a risk factor; to listen more frequently; and to have a tighter protocol around transfer. And that means acknowledging that women attempting a TOLAC are higher risk than a multiparous woman without a previously scarred uterus. I'm not saying that they are so high risk that we can never consider them for home birth. In fact, I think that some women desiring a TOLAC are excellent candidates for HBAC. But I would say, we've got to listen more carefully and engage in very individualized, shared decision-making related to the location of the placenta, length of time to the hospital, our relationships with hospital providers in our communities once we arrive, length of time between pregnancies, etc.

I think that the vast majority of midwives attending HBACs in the United States are doing these things. Yet a study like this gives us all the invaluable opportunity to stop, turn the lens inward, and think critically about how we can make our practices as safe as possible. We all know that there is no joy, no empowerment as we typically hope for our clients in an HBAC, when there is also a loss.

Jeanette: And do you recommend any additional prenatal screening?

Missy: I do. It was concerning to us (the authors) that nearly 25 percent of women in the TOLAC group did not receive an ultrasound for placental location and diagnosis of accreta prior to attempting a TOLAC at home. Given that the rate of abnormal placentation is rising, an obstetrical ultrasound should be standard of care for any woman with a prior cesarean. Also, less than 40% of the women in the TOLAC group had GDM testing. Some of this may be reflective of the difficulty in some states of acquiring lab tests and ultrasounds, and this needs to be addressed immediately. Women are going to continue to want to attempt VBACs, and HBACs more specifically. They need access to adequate prenatal screening. If we are caring for someone who already has the known risk factor of a previously scarred uterus, we want to make sure that we have normal placentation, and we want to know that she doesn't have any other comorbidities because there can be a compounding of risk, like we see in the twin VBAC case [presented in the study]. 

This study makes me think about how important it is that all maternity care providers work together to make birth as safe and empowering for families as possible, wherever we practice, and whether or not we ourselves would ever consider having or attending a home birth after cesarean.

To read the complete interview, visit our guest post at Science and Sensibility.

About the authors


Melissa Cheyney, PhD CPM LDM, is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.


Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.

Overview of the MANA Core Competencies Revisions

Posted by Midwives Alliance on September 13th, 2015

In 2008 the International Confederation of Midwives took a serious global look at the health of mothers and babies and developed a series of core documents to support the growth and utilization of midwives throughout the world. In June 2011 the ICM Council endorsed new global midwifery standards for education, regulation, and association – the "3 pillars" for the profession. The World Health Organization uses the ICM Core Competencies to inform midwifery organizations and government agencies to improve the health of mothers and babies world-wide.

In March 2013 the MANA Document Committee prepared a side-by-side comparison document of the ICM and MANA Core Competencies to identify where these two documents were aligned and where they differed. At this time both ACNM and MEAC were engaged in similar work.

The goals for the MANA Core Competencies revision were:

  • to bring them in line with the ICM Core Competencies as they apply to US midwifery, and
  • to make our language inclusive and welcoming to all who seek midwifery care.

Bringing the Core Competencies In Line With ICM Core Competencies

Examples of changes made to the Core Competencies:

  • Inclusion of environmental concerns such as access to clean water. Although this is often a concern in developing countries, there are areas in the US where pollution makes a community water supply unsafe.
  • Including the ICM Core Competencies concerning abortion that apply to US midwifery, with sensitivity to the politically controversial nature of this topic, and that relate to providing information and support for decision making regarding timing of pregnancies and resources for counseling and referral.
  • Expanding cultural awareness and sensitivity to the needs of communities of color and the LGBTQ community: Human rights and their effects on the health of individuals, including issues such as domestic violence, genital circumcision, gender equity, gender identity and expression, and how their expression affects health outcomes.

Making Our Language Inclusive and Welcoming To All Who Seek Midwifery Care

The MANA Core Competencies is a policy-level document and should address the full scope of any midwife’s potential practice. With that in mind, MANA opted to revise the Core Competencies to reflect all of the clients MANA midwives serve. The group that worked on these Core Competencies, like all our documents, included members of the Document Committee and the Board. After moving through the various steps and being reviewed by many MANA members as well as the entire MANA board, input on the final draft was solicited from Indra Lusero, JD, genderqueer parent and former Director of the Transgender Military Initiative; from Shafia M. Monroe, MPH, DEM, CDT, Founder and President of the International Center for Traditional Childbearing; and from the other Allied Midwifery Organizations including MEAC, NARM, NACPM, AME and CfM. We received suggestions and additions which we incorporated. The revised Core Competencies were approved via consensus decision of the full MANA board.

MANA is the national midwifery organization that represents the "Big Tent" where all midwives can feel valued and find support for their work. MANA is keenly aware of the social determinants of health. There are many issues of disparities to marginalized communities, such as the disparities in pregnancy outcomes among communities of color, and culturally inclusive issues and language reflect our goal of creating a document that can speak to all the diverse communities across the nation who can benefit from midwifery care.

Whereas pregnancy, birth and breastfeeding are unique to the female sex, there are those who seek midwifery care who do not gender identify as women. Increasingly, health care providers are needing to develop a basic level competency to understand the difference between sex and gender reality and an awareness that there is not a simple binary regarding both sex and gender, that there are more than two manifestations in human reproduction and in the psychology of gender identification.

Considering the national initiatives challenging health care professionals to provide gender neutral services and gender inclusive health care materials, we committed to a document reflective of these national trends and consistent with our values. In the process of crafting these revisions to our Core Competencies, many of the midwives involved found ourselves undergoing a paradigm shift and realized that many of these issues and practices apply more broadly to include other family members. Changing to gender neutral language reaffirms the midwives’ goal with relationship to the whole family system.

Inclusion is about membership and belonging. It is a process that acknowledges and supports the meaning of equal worth and equal rights. Inclusion promotes the growth of self-esteem. Inclusive language helps us all learn to be more aware, sensitive and humble to the needs of each family system and the devastating effects of marginalization. No individual wants to be singled out or identified as "different" or less worthy. As long as a single client is excluded from the midwifery community, all clients are potentially vulnerable to discriminatory treatment.

About the author

Justine Clegg, MS, LM, CPM, is Association of Midwifery Educators Board President. A Florida Licensed Midwife since 1987, she is Academic Director and Faculty for Commonsense Childbirth School of Midwifery since 2009 and Miami-Dade Community College Midwifery Director/faculty emeritus (1993-2008). Former Florida Council of Licensed Midwifery Chair (1993-2001) and Miami FIMR committee chair (2004-2009), she is also a licensed Mental Health Counselor and Certified Lactation Counselor. She graduated from the South Florida School of Midwifery and earned her MS from Florida International University. She served on the MEAC and NACPM Boards.

MANA's Access and Equity Committee

Posted by Midwives Alliance on September 1st, 2015

The Access and Equity Committee is a new MANA initiative to address systemic issues impacting midwifery and those seeking midwifery care. "Access" and "equity" are both words that capture the essence of this work: access = the right or opportunity to use or benefit from something; equity = the quality of being fair and impartial. As a midwife, you know that the right or opportunity to use or benefit from midwifery has not been fair or impartial. This is true for many, layered reasons:

  • state laws criminalize some forms of midwifery;
  • state scope of practice laws make it hard to practice the midwifery model of care;
  • insurance companies don’t include midwives as covered providers;
  • insurance commissions interpret "adequate networks" without considering midwives or place of birth;
  • state agencies regulate midwives using an obstetric model not made for midwifery;
  • federal grants and loans for education aren’t available for all midwifery educational paths.

The list could certainly go on, and each of these issues is compounded by how the right or opportunity to use or benefit from a wide range of things has not been fair or impartial when it comes to race, class, gender, sexual orientation, national origin, gender expression, region, language, and more. This is the intersection where the Division of Access and Equity works.

One strategy we will use in this effort is to increase the capacity of midwives to connect with their clients about these issues. To this end MANA has established a strategic partnership with Elephant Circle with the goal of charting a course for a stronger and more diverse political base for physiologic birth and access to the midwifery model. This partnership deliberately combines a professional association (MANA) with a grassroots, consumer-based, non-profit (Elephant Circle).

Elephant Circle has found, in organizing and legislative work for maternity care, that consumers are most effectively mobilized by their midwives. Consumers often feel a strong loyalty and commitment to their midwives, and when that passion is channeled into advocacy efforts it can be very effective. Connecting consumers and midwives in coalition as policy-collaborators is a deliberate strategy to increase political power. Midwives don’t hold as much political power as medical providers in existing health systems for a variety of reasons, not the least of which is sheer numbers (less midwives, less consumers of midwifery care).

The dominant model of political advocacy among healthcare providers is professional associations, and it is essential that midwives have healthy professional associations as a result. However, as minority providers, that advocacy model (professional associations) reinforces the power imbalance, keeping the "voice" for midwifery and physiologic birth small. Building an alliance between midwives and consumers adds sheer numbers, increases political strength, and moves the forum from a place where medical providers have an advantage (professional associations) to one where midwives have an advantage (consumer loyalty and passion).

Make sure to connect with the Access and Equity Committee this fall in New Mexico to learn more and get involved. Look for more articles and updates including the infographic on Physiologic Birth for African American Women, and the "Executive Summary of Existing Research on Racial Disparities in Birth Outcomes" created by ICTC, ICAN, MANA and Elephant Circle coming out soon. Share your resources with us at, and we will share resources with you! Here are a few:

  1. Take a short test at Project Implicit.
  2. Watch a video at BeyondWhiteness.
  3. Learn more about health care licensing boards in this Tool Kit from the Citizen Advocacy Center.
  4. Learn about The Speaking Race to Power Fellowship, which will connect and support leaders who want to develop generative ways of breaking through the current bottlenecks of race and power in the reproductive health, rights, and justice movement.
About the author

Indra Lusero, Esq., works as an organizer, trainer, and lawyer practicing family formation and regulatory law in Colorado. Indra’s publications include “Challenging Hospital VBAC Bans Through Tort Liability” and “Making the Midwife Impossible: How the Structure of Maternity Care Harms the Practice of Home Birth Midwifery.” Indra went to law school after attending a MANA conference in 2005 where folks lamented not having a “hot shot team of lawyers” who could help defend midwives. Indra has endeavored to develop just such a team.