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News From the DOR: Implementing Evidence-Informed Practice During Midwifery Care

Posted by Midwives Alliance on November 12th, 2015

We hear the terms “evidence-based practice” (EBP) or “evidence-informed practice” (EIP) used often in the healthcare world, being cited as an expected and central component of high-quality care delivery. But what do these terms really mean? There is a misconception that in EBP/EIP approaches, “research evidence” automatically equates to “what I should do in practice”. This, however, is simply not true. EBP/EIP rests in the triad intersection between the best available research with your professional expertise as the practitioner alongside the client’s individual values, needs, and context. Figure 1 (below) visually represents what we are striving for when we say EBP or EIP, in ultimate commitment to improved client care, informed choice, and shared decision-making models.

Evidence-informed Practice Triad


You may be thinking: okay, I definitely have expertise as a midwife, and I feel I have a good understanding of my client’s unique needs, but how do I integrate research into practice?  A great place to start is with a series of modules on the Principles of Evidence Informed Practice from the University of Minnesota. These modules are self-paced, free of charge, geared towards busy practitioners, and thus intended to be short and sweet, ranging from just a mere 15 minutes to 30 minutes of your time. The series includes: Section I - Overview of Evidence Informed Practice; Section II – Types of Research; Section III – Using Evidence in Practice; and Section IV – Understanding Research & Statistics; plus resources and guiding sheets to help you implement evidence-informed practice during client care. Advance your professional self and check out these modules.

Finally, how do you find research to integrate? There are many peer-reviewed journals and scholarly databases to help you in your search. A few core ones to consider (many of which are open access!) are:

Google Scholar


BioMed Central

BMC Pregnancy & Childbirth

Cochrane Reviews   

Directory of Open Access Journals


North American Journal of Medical Sciences


ERIC: Institute for Educational Sciences (collection: midwifery)

Quick Tip: for those users of handheld devices, check out the free app, PubMed for Handheld (search in the app store for “PubMed4HH”). Acknowledgements to the Consortium of Evidence-informed Practice Educators.

Pre-appraised literature options:





Courtney Everson About the author

Courtney L. Everson, PhD, is the Director of Research Education for the Midwives Alliance Division of Research, a Biocultural Medical Anthropologist and the Graduate Dean at the Midwives College of Utah (MCU). Dr. Everson is also the Vice President of the Oregon Doula Association (ODA), an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC), and serves on the Board of Directors for the Australasian Professional Doula Regulatory Association and Doulas Supporting Teens. Her research and teaching specializations are in maternal-child health; adolescent pregnancy/parenting; psychosocial stress; social support; doula care; midwifery care; research & clinical ethics; collaborative care models; health inequities; and social justice.

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.

Aviva Romm on the Impact of Midwifery Care on Lifelong Health

Posted by Midwives Alliance on August 18th, 2015

We are incredibly excited to have the honor of hosting Dr. Aviva Romm at this year's MANA conference, Shine, in Albuquerque, New Mexico. We took this opportunity to talk with her about why she thinks midwifery care can improve lifelong health, the impact of interprofessional tensions between maternity health providers, and critical opportunities for midwives to seize now.

MANA: Why have you chosen to present at Midwives Alliance of North America?

AVIVA: When I was asked to speak at MANA this year, aside from just being incredibly honored and grateful, I realized it was such a timely opportunity for me to be able to talk with midwives about something that's very important. As midwives, we are so focused on the importance of prenatal care toward birth outcome that we miss another great opportunity – the impact of pre-conception, prenatal and infancy on the lifelong health for our children.

We know that by the time a baby is born, he or she already has at least 300 environmental chemicals measurable in his or her umbilical cord. We know that early prenatal nutrition can determine a person’s predisposition to everything from eczema and allergies in young children, to believe it or not, diabetes, heart disease, stroke, and cancer, in adults. As midwives, bringing a greater awareness of this to periconception is a powerful way to bridge midwifery with lifelong public health and make a difference.

MANA: What do you believe would be the optimal relationship between families, midwives, and physicians?

AVIVA: I have long believed that the optimal relationship is a seamless one, where there's no separation between midwifery care and the medical model. I’m not saying that midwifery as a model should be subsumed by medicine or that midwifery has to emulate or become part of the way the medical model works. But there has to be a system where families don't perceive a separation in their care. This would optimize the experience of pregnancy and childbirth for women, helping them to make the best choice in where they want to have babies. One of the things I've observed as a midwife for 25 years, and also as a physician, is that women will ultimately birth where they feel the safest. For a lot of women, there's a conflict there. They don't actually feel that a hospital or a birthing center is the safest.

They are concerned, and rightly so, that the medical model dominates there, that they'll be subjected to interventions that they don't want but really can't fend off, whereas they don't necessarily feel entirely safe at home, either. Home isn't their natural first choice. Home birth becomes a reactive choice. For some of those women, the fear factor can determine the physiology of birth. Fear at birth can interfere with the process. I've seen women with this sort of underlying, insidious fear, which may not even be conscious. Sometimes as midwives we pick it up, but don't really know exactly what to do with it, and it sort of drives a transport in some way. Maybe there's a really prolonged labor or difficulty pushing, difficulty opening up and relaxing. It's that fear. I feel like if we took that dichotomy between home or hospital out of the equation and made that seamless, it would make the choice easier for women. Of course this assumes that we're working in a culture where hospital and birthing center births are reliable for women as places where they can go and have the birth that they really want to whenever possible, barring some kind of obvious medical complication.

I also feel that the schism between home and hospital sometimes leads midwives at home to make choices that aren't always in the best interests of the birth outcome. They're afraid to transport to the hospital. Having practiced in an illegal midwifery state for about 15 of my 20+ years as a midwife, I've observed many times where a midwife stayed home a little too long and there were complications that didn't have to happen but did, out of a fear of transport. A seamless system allows for things like ease of transport and emergency services that are specifically designed for midwives practicing at home.

MANA: As more states pass midwifery legislation and more midwives become licensed and provide care at home and in birth centers, how do you see the future of midwifery? We'd especially appreciate hearing your perspective on the integration of midwifery into the mainstream maternal health care system in the US. Do you see any downsides to home birth midwifery becoming integrated into our healthcare system?

AVIVA: I am all for midwives becoming more integrated into the mainstream maternal health system. We've actually seen that already, for the most part, with certified nurse midwives. I do have concerns that the legislated midwifery runs the risk of becoming "med-wifery," so I think the question becomes, how can we preserve the valuable traditional midwifery arts of midwifery while expanding women’s access to midwives and also how can we, as midwives, inform changes in the medical model.

Good examples would be how long a mom can be in labor or how long membranes can be ruptured, or how old or young she can be, or how much weight she has or hasn't gained. All of these kinds of parameters may seem set in stone to the medical model, but in actuality they shift over time and may have some arbitrary aspects to them. Another example would be how far advanced in pregnancy a mom can be before an induction is required rather than just something that happens according to set parameters in the medical model, and is now required for midwives to participate in. I think we're still in the infancy of what this kind of dialogue all looks like.

I've met and talked with many midwives from states that have licensure and feel that they're really in a good situation, that they've got sort of the best of both worlds. I've also met midwives and moms who are frustrated with the limitations placed on them, but sort of accept it as a necessary evil, if you will, to serve the most numbers of moms in the best way knowing that some moms who could be having more natural births, or possibly home births, are getting marginalized by rules. We have to keep our fingers on the pulse of it and try not to lose too much of our art in favor of the benefits that we get. It is a necessary trade-off that I understand that we all make. I'm excited to see where it goes.

MANA: At the 2015 MANA National Conference you are speaking on Shining a Light on Midwives in PeriConception Care, As Upstream as Healthcare Gets. Can you tell us more about the concept of periconception care?

AVIVA: Peri-conception care means the care that women are getting around the time of conception. To my knowledge, most midwives aren't reaching out into their communities or being reached by their communities before pregnancy. We know that in the 3 months or so prior to pregnancy so much can happen that sets the tone for pregnancy health and for what exposures baby might get in that early prenatal period, in that first 6-8 weeks of exposures when so much of the baby's nervous system, immune system, and organ development is happening, in that embryo genesis period.

Ideally, prenatal care would start in the pre-conception period with teaching mom about environmental exposures that she can avoid, possibly even working with moms around detoxification programs if they've had significant exposures. For example, if we know that they have a high mercury level based on testing, or we know that they have elevated homocysteine, which is a serum marker of inflammation that is related to increased risk of miscarriage, preeclampsia, placental abruption, and other problems.

The weight at which a mom becomes pregnant can have an impact on her health. Whether she's obese or whether she's underweight, it can set determinative factors in the baby for how the baby uses sugar and stores fat, not just while the mom is pregnant with that baby, but actually for the baby's entire life. We can have an impact on whether that baby develops heart disease, diabetes, strokes, and Alzheimer's. This is very significant and is a well-worked out science.

MANA: How do you see midwifery care differing from traditional medical care in periconception?

AVIVA: The American College of Obstetrics and Gynecology has recently recognized and emphasized the need for periconception care. But most obstetricians are just not doing it; their knowledge isn't there nor is the time.

As midwives, we can take the lead on this. For example we can make nutrition, and not just calories and protein counting and what micro-nutrients a woman needs, but really true, good food, a part of our midwifery curricula. Right now, the rates of obesity in the United States are reaching about 50%. We have an enormous obesity problem in our kids that also translates to high cholesterol, increased risk for cardiovascular disease and chronic inflammation and all the diseases that are associated with that, such as autoimmune diseases and Alzheimer's.

As midwives, we have an opportunity to do what we do best, which is to do, and teach, what's natural and healthy. That includes foods and awareness of ecological issues. As a whole, our profession tends to be much more green-oriented than the medical model. If we can bring that green orientation in our personal lives into our profession, we'd be way ahead of what the mainstream model has already said is one of the pressing agendas for obstetrics and for pregnant women.


Aviva Romm About the author

Aviva Romm, MD, is a Board Certified Family Physician, midwife, herbalist and the creator of Herbal Medicine for Women, a distance course with nearly 1000 students around the world, and Healthiest Kids University, also with nearly 1000 students. Dr. Romm is a leader in the revolution to transform the current medical system into one that respects the intrinsic healing capacities of the body and nature - while helping women take their health into their own hands. Her areas of research include botanical medicine with a focus on the needs of women and children, improving maternity care models, mind-body medicine, and the impact of environment on health. She is a gardener, artist, and visionary physician, as well as the mother of 4 grown children and grandmother of two — all 6 born at home.

15 Questions To Ask Before Choosing a Midwifery Path and Program

Posted by Midwives Alliance on July 21st, 2015

What midwifery credential should I choose? How can I tell if a midwifery school is right for me? As a practicing midwife, I am asked these questions by potential students as they decide between becoming a certified nurse midwife or certified professional midwife and when trying to choose a midwifery program.

I have gathered together the 15 questions I often ask potential students to consider as they make their decisions. Give yourself a few minutes, jot down your answers, and don't think too hard about any one question! You might be surprised at some of your answers. I hope these help you find the path that is right for you.

Choosing a path

Where do you want to practice? Consider both the place of birth - home, hospital or birth center - and the state or states you want to practice in. Research the license/credential requirements for the state and place of birth you'd prefer.

Who do you want to serve? Teen mothers, low income families, a small rural community, a big city busy practice with other midwives - who do you dream of serving?

What are the laws concerning midwifery (and student midwifery) in your community? Is it legal for a CNM to attend home birth? Can CPMs practice legally? Where? Do you need to register with anyone? Do you need to be enrolled in a school program to attend births as a student midwife? Can CNM student midwives have an internship with an out of hospital midwife?

Do you want to be able to move about the country and work in a wide variety of settings? Nurse midwifery may be more flexible when moving a lot, and also has the advantage of being able to work as a nurse as well.

Choosing a program

Are you interested in a Nurse Midwifery program? a Certified Professional Midwife program? Portfolio Evaluation Process? or a MEAC (Midwifery Education Accreditation Council) approved program?

Are you able to relocate to go to midwifery school? Do you have the resources to move and attend a midwifery school in another community? Is there an at-distance or online alternative?

Are you able to organize yourself and learn independently? Would a program that offers few "extras" and where you would need to work independently be a good fit? Would you be more comfortable with a structured program, that includes a clear plan for success? Do you want to work with your local midwifery community to learn in an apprenticeship model? Do the programs you are looking at have "perks" - support groups, libraries, database search engines, writing labs, or other extras?

Do you enjoy group learning activities? Do the programs you are looking at offer an opportunity to build community with other student midwives?

Does the program you are interested in offer clinical internships in your own community? Is your local community large enough for you to find a midwife preceptor who can help you finish your clinical requirements? Do your local hospitals offer Nurse Midwife internships? Does your program help you find a preceptor?

Do you need to complete any portion of your academic program before beginning your clinical training? Some programs, and some mentor midwives require that you complete up to a year of academics before starting clinicals.

How many of the students who start the program or apprenticeship you are considering finish, and go on to pass the credential and/or licensing exams?

Finding your resources

What are your financial, emotional, spiritual resources? What is your community support like? Does your family support your chosen work? Can they manage living "on call" with you? Are they concerned about liability issues?

Do you need a midwifery program that has federal financial aid? Nurse Midwifery and some MEAC approved programs offer Federal Financial Aid. Some MEAC approved programs do not offer aid but are much less expensive than those that do.

Do you have the time necessary to commit to midwifery training? Do you have time in your life for rigorous academic and hands-on demands? Can you be on call? Part time or full time? How much flexibility do you need?

Will you need to work while you are in midwifery training? Is it realistic? What is the expectation of the midwife you are working with or the program you will be attending?


I hope these questions have helped you to become clearer about how to choose a midwifery path that is right for you. Becoming a midwife is often a winding path, challenging at times, but rewarding! Good luck to you all!


About the author

Treesa McLean, LM, is a homebirth and birth center midwife and has been involved in the birth community as a consumer, an advocate, and a birth professional for more than 30 years. She teaches a workshop "Becoming a California Licensed Midwife" and has been the preceptor for a number of student midwives.

Prison and Birth

Posted by Midwives Alliance on July 21st, 2015


Desiree Robles, a student midwife at Midwives College of Utah, shares with the MANA community the current state of maternity care for incarcerated women in the United States, along with policy recommendations for improving outcomes for mothers and babies. This post is a part of our student midwife guest post series. Are you a student? Please consider sharing a guest post with us! Contact MANA at for more information.

Pregnancy and birth have the remarkable ability to be a common process for all women, regardless of economic status, race, or culture. They can occur at any time in a woman's reproductive life, including when they are sentenced to time in jail or prison. How these instances are handled in the United States is the subject of controversy and varies greatly depending on location but, collectively, is in need of reform. In the United States, incarcerated pregnant women deal with several reproductive issues that need to be addressed, including lack of proper prenatal care and nutrition, use of restraints during transport, labor, and postpartum, and a lack of birth education and support.

Despite the importance of prenatal care and proper nutrition during pregnancy, many inmates are not guaranteed access to them. According to the Committee on Health Care for Underserved Women (CHCUW), thirty-eight states have failed to institute policies requiring that incarcerated pregnant women receive basic prenatal care. In addition, forty-one states do not require prenatal nutrition counseling or do not ensure that these women receive proper nutrition (2011). What is important to note is that, according to a study done by Martin et al. in 1997, prisons are required to provide all pregnant inmates with appropriate prenatal care. However, according to a Women's and Children's Health Policy Center publication, less than half of correctional systems require screening of new female inmates for pregnancy and STD's (2000). Even with more than half of the United States correctional facilities not providing the proper prenatal care and nutrition for these inmates, some of these same women may still be at the same high risk or may actually be better off than if they were pregnant at home. A study done by Clarke et al. points out that pregnancies among incarcerated inmates are usually unplanned, high risk, and have poor outcomes because of, among other things, lack of or failure to access prenatal care and many of these women having poor nutrition (2006). Thankfully, many studies, including one done by Martin et al., have found that incarceration allows these women to have improved maternal and fetal health thanks to access to shelter and regular meals (1997). It is important that we implement screening protocols for incoming inmates at all correctional facilities so that their reproductive health can be addressed if need be, as well as making sure these inmates receive the proper care needed if they are found to be pregnant. 

Using restraints on pregnant inmates during the process of labor is a sensitive issue that has been the subject of scrutiny for years. There have been various studies that have delved into the adverse effects of restraining women in labor both physically and psychologically. While progress has been made in stopping the use of restraints on pregnant inmates, according to the Committee on Health Care for Underserved Women, thirty-six states and the Immigration and Customs Enforcement agency of the Department of Homeland Security have failed to limit the use of restraints on pregnant women during transportation, labor and delivery, and postpartum (2011). Use of "shackling," as it is called, causes discomfort for the pregnant inmate during a time when she is most vulnerable and many times the officers present are male. In an article done by Anderson, there is implication that birth transport often results in numerous medical and mental health complications, thanks to the security precautions used, including shackling. These precautions increase instances of injury and stress while stress in itself can cause complications in labor. Also, the women have limited movement, which adds discomfort and restricts their ability to protect themselves in instances such as falling (2003). An Amnesty International article brings to attention the traumatizing experiences of shackling on the laboring inmates. These included having their legs shackled to their bed post for almost the entirety of their labor which, again, caused restricted movement and hindered their ability to position themselves in more favorable positions during labor (2000). To add to their distress, according to Codd, women in prison many times give birth to their babies who are taken away almost immediately or at discharge from maternity ward, causing the mother much distress and robbing the baby of their mother's important breast milk (2004). Laboring inmates deal with these stressful situations that, while slowly being resolved, would be helped, in part, with childbirth education and support from, at the very least, female officers during labor. 

Birth education and support for pregnant inmates is lacking in many correctional facilities but are excellent resources that would greatly benefit these vulnerable women. According to Hotelling, with the right support and prenatal care, expectant new mothers often discard lifestyle behaviors which would compromise the health of their babies. Some programs have been initiated to provide physical and mental health care to incarcerated women. These programs depend on help from volunteers, grant money, and various organizations coming together in order to thrive (2008). The Bell et al. study noted that what is needed for incarcerated pregnant women is comprehensive programs that include enhanced prenatal care services in the community and greater transitional resources. This would be ideal, given that most women are incarcerated for smaller crimes with shorter sentences than men (2004). A great place to start would be birth education and breastfeeding workshops. In a study by Huang et al., pregnant inmates showed positive views on pregnancy and link it to a new start for them as mothers and in their life in general (2012). Childbirth education and support for pregnant inmates should be available at all correctional facilities as a way to help these women deal with the stress of pregnancy in an already stressful situation for the sake of their health and future as well as their children's.

Pregnancy during incarceration happens whether correctional facilities want it to or not. For this reason, protocols should be made mandatory at all correctional facilities to screen for pregnancy, as well as STD's, to ensure the health of their inmates. While prenatal care is required for all pregnant inmates, screening for pregnancy is not. This very important loop hole should not occur in our correctional facilities, as early prenatal care and nutrition is imperative to the health of both the mother and her infant. For those women who do experience labor during their stay, the use of restraints and shackling should be limited to actual need instead of standard protocol. Women in labor should have the ability to move freely, regardless of their situation. Maternal and fetal health is put at stake when they are put under stressful situations, and shackling only exacerbates the situation. Lastly, childbirth education and support during pregnancy and birth are a great rehabilitation tool which correctional facilities should try to make mandatory. The benefits include healthier inmates both mentally and physically and shorter births which would cut healthcare costs tremendously, considering many incarcerated women are considered high risk. Implementing these policies would help these already vulnerable women and hopefully give them the needed support to change their situations for the better.

Reference List

Amnesty International. (2000). Pregnant and imprisoned in the United States. Birth, 27(4), 266-271.

Anderson, T.L. (2003). Issues in the availability of healthcare for women in prison. In S.F. Sharp & R. Muraskin (Eds.), The incarcerated woman: Rehabilitative programming in women's prisons (pp. 49-60). Upper Saddle River, NJ: Prentice Hall.

Baldwin, K. & Jones, J. (2000) Health issues specific to incarcerated women: Information for state title v programs. Retrieved from

Bell, J. F., Zimmerman, F. J., Cawthon, M. L., Huebner, C. E., Ward, D. H., & Schroeder, C. A. (2004). Jail incarceration and birth outcomes. Journal of Urban Health, 81(4), 630-644.

Clarke, J. G., Herbert, M. R., Rosengard, C., Rose, J. S., DaSilva, K. M., & Stein, M. D. (2006). Reproductive health care and family planning needs among incarcerated women. American Journal of Public Health, 96(5), 834-839.

Codd, H. (2004). Prisoners' families: Issues in law and policy. Amicus Curiae, 55, 2-7.

Committee on Health Care for Underserved Women. (2011). Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion, 511, 1-5.

Hayes, S. L., Mann, M. K., Morgan, F. M., Kelly, M. J., & Weightman, A. L. (2012). Collaboration between local health and local government agencies for health improvement. Cochrane Database of Systemic Reviews, 10, 1-141.

Hotelling, B. A. (2008). Perinatal needs of pregnant, incarcerated women. Journal of Perinatal Education, 17(2), 37-44.

Huang, K., Atlas, R. & Parvez, F. (2012). The significance of breastfeeding to incarcerated pregnant women: An exploratory study. Birth, 39(2), 145-155.

Kitzinger, S. (1997). Sheila kitzinger's letter from Europe: How can we help pregnant women and mothers in prison? Birth, 24(3), 197-198.

Martin, S. L., Rieger, R. H., Kupper, L. L., Meyer, R. E., & Qaqish, B. F. (1997a). The effect of incarceration during pregnancy on birth outcomes. Public Health Reports, 112, 340-346.

Martin, S. L., Kim, H., Kupper, L. L., Meyer, R. E., & Hays, M. (1997b). Is incarceration during pregnancy associated with infant birthweight? American Journal of Public Health, 87(9), 1526-1531.

Minkler, M., Glover Blackwell, A., & Thompson, M., Tamir, H. (2003). Community-based participatory research: Implications for public health funding. American Journal of Public Health, 93(8), 1210-1213.

Walker, J. R., Hilder, L., Levy, M. H., & Sullivan, E. A. (2014). Pregnancy, prison and perinatal outcomes in New South Wales, Australia: a retrospective cohort study using linked health data. BMC Pregnancy and Childbirth, 14(214).


About the author

Desiree Robles is a student midwife, attending Midwives College of Utah. She resides in the San Francisco Bay Area and is currently beginning her clinical training with Pearl Yu, LM of Motherborn Midwifery. Desiree also works hard as a volunteer for California Families For Access to Midwives as a member of the social media team.

Albuquerque Has "Poquito de Todo"

Posted by Midwives Alliance on June 23rd, 2015

Albuquerque has "poquito de todo" - a little of everything! We enjoy great mountain views, petroglyphs, hot air balloons, art galleries and many opportunities for cultural learning. There are plenty of things to do in New Mexico no matter where your interests lie.

You might be surprised to learn that New Mexico is a great place to grow lavender, pecans, peanuts, grapes, pinto beans, and more. Of course, we are famous for producing the best chile peppers, a staple in New Mexican dishes.

The MANA Conference will be held at the Hotel Albuquerque at Old Town, right next to colorful Old Town Plaza, a favorite spot to enjoy authentic cuisine and arts. Within walking distance of the hotel are several family oriented museums: Explora, The Museum of Natural History and the Albuquerque Museum.

A short drive from the hotel will take you to the National Hispanic Cultural Center, the Indian Pueblo Cultural Center, and the Albuquerque Bio Park and Zoo.

Albuquerque boasts the world's longest aerial tramway, which runs to the top of the Sandia Mountains. The breathtaking views will give you more reasons to fall in love with New Mexico. If you're brave & into biking, you can also take the chair lift up the mountain and bike down! Beautiful hiking trails are also abundant.

You'll find lots of wineries and craft breweries in the area. There are even bus tours that will do the driving for you! The ABQ trolley will take you on a guided tour where you can see local landmarks, including Breaking Bad filming scenes.

If you're looking for a wonderful day trip, the Jemez Mountains offer gorgeous views, hot springs, canyons, waterfalls, red earth, tall pines and Aspen. Magical Santa Fe, the oldest city in New Mexico and the oldest State Capital in the U.S, is less than an hour away and is home to the Georgia O'Keefe Museum. Just an hour from Santa Fe, in Abiquiu, visit Ghost Ranch.

You can find more info about New Mexico here. For things to do in Albuquerque, visit here.

The New Mexico Midwives are proud to host SHINE MANA#15 in Albuquerque, where we can share with you our history, culture and the amazing support that our community offers midwives.

Please join us for #MANA15 in Albuquerque! Register by clicking the button below.

     SHINE MANA#15

Register for SHINE MANA#15 Now!

About the author

Kelly Camden, LM, CPM, BA, is an Albuquerque-based midwife who is thrilled to serve as the local coordinator of the 2015 MANA Conference. Following her first homebirth 16 years ago, Kelly began attending hospital births as a DONA doula and home births as a midwife's assistant. Later, she became a staff doula at Presbyterian Hospital, where she was recognized for excellent service. Kelly endeavors to empower families through education; she is founder and coordinator of the Albuquerque Birth Network, has taught breastfeeding, prenatal yoga, and childbirth classes and has published articles on pregnancy related topics. Kelly served as Consumer Advisor on the NM Certified Nurse Midwives Advisory Board and Event Coordinator for the ABQ Rally to Improve Birth. Currently, she is a Regional Coordinator for the NM Breastfeeding Task Force. Since 2011, Kelly has practiced as a Licensed and Certified Professional Midwife, offering home and birth center births. She is proud to be a midwife in New Mexico, where a blend of culture, tradition and necessity has led to a continuous history of midwifery care.

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