by Susan Hodges

After five years of revising and refining, the resolution “Increasing Access To Out-Of-Hospital Maternity Care Services Through State-Regulated and Nationally-Certified Direct-Entry Midwives” was approved by the American Public Health Association (APHA) Governing Council at their annual conference in Atlanta, Georgia on October 24, 2001. The resolution should be a welcome and useful tool for midwifery advocates across the country!

The text of the resolution, including the footnotes, is provided below. It is also available as a PDF file at www.cfmidwifery.org/pdf/apha.pdf. In addition, it will soon be published in the APHA's regular publication Nation's Health and will be posted on their website. It will also be included in APHA Public Policy Statements, 1948 to present, cumulative, Washington, D.C. current volume.

Since its first introduction, the position statement has gone through many changes to address the concerns and requirements of many groups and professionals within the huge APHA. The intent of both the authors, as well as APHA, was to draft a resolution that supported access to out-of-hospital maternity care by qualified providers, not to support a specific credential. Currently both Certified Professional Midwives (CPM) and Certified Midwives (CM) would qualify as state-regulated and nationally certified direct-entry midwives. It is possible that in the future there might be additional national certifications available; these would also fall under the broad constructs of this resolution.

This resolution was the work of many people over a number of years. The authors include: Sharon Wells, MS, LM, CPM, a midwife who also holds a masters degree in education and is currently on staff at Draughons College in Nashville, TN; Carol Nelson, LM, CPM, a midwife who, among other pursuits, serves the Amish community near her home in Summertown, TN; Jonathan B. Kotch, MD, MPH, Professor and Associate Chair of the Maternal Child Health program at University of North Carolina, Chapel Hill and past chair of the Maternal Child Health section of APHA; Stanley H. Weiss, MD, FACP, Associate Professor, Preventive Medicine at New Jersey Medical School – UMDNJ in Newark, NJ, as well an active member of the epidemiology section of APHA; and James Gaudino, MD, MS, MPH, MCH Medical Epidemiologist at The Epidemiology Center, Northwest Portland Area Indian Health Board in Portland, OR, as well as an active member of the epidemiology section of APHA. In addition, Stanley Weiss and James Gaudino served in an advisory capacity with Ken Johnson and Betty Ann Daviss regarding the final methodology design for the CPM Statistics 2000 project.

"Increasing Access To Out-Of-Hospital Maternity Care Services Through State-Regulated and Nationally-Certified Direct-Entry Midwives"

Formally adopted by the Governing Council of the American Public Health Association (APHA)
Wednesday, October 24, 2001

THE AMERICAN PUBLIC HEALTH ASSOCIATION,
REAFFIRMING its position on credentials for health occupations, that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations (1)

REAFFIRMING its recognition that many women seek birthing alternatives (2) and,

RECOGNIZING that pregnancy and birth are normal life events for a majority of women, (3,4,5) and,

REAFFIRMING its endorsement of the philosophy of family-centered maternity care, the importance of continuity of care, and the use of a variety of licensed care-givers, (6)

RECOGNIZING that Direct-entry Midwives encompass a diverse group of midwives that have entered the profession directly through midwifery education and training, and not through a pre-requisite program such as nursing. (7) Recognizing that there are alternative educational systems of selection and preparation for national certification of Direct entry Midwives that include either the Certified Professional Midwife (CPM) credential and the Certified Midwife (CM) credential; and that both require didactic programs, written examinations and clinical experience. (8,9) In the case of the Certified Professional Midwives the didactic component consists of education in a program accredited by an agency that is recognized by the US Department of Education or the PEP Program, the North American Registry of Midwives competency-based, educational portfolio evaluation, and the clinical component is equivalent to one year of experience which includes more than a thousand contact hours under the supervision of one or more preceptors, some of which must be in out-of-hospital settings, but none of which need to be in hospital settings; (8) and in the case of the Certified Midwife (CM) credential requires education in institutions of higher learning accredited by an agency that is recognized by the US Department of Education to meet the same standards that Certified Nurse Midwives must meet, completing core science requirements similar to those required for a nurse, and fulfilling core midwifery requirements that are a part of all accredited nurse-midwifery education programs, and clinical experience that must include hospital experience, but is not required to include out-of-hospital experience. (9)

RECOGNIZING that individual states interested in incorporating direct-entry midwives into their health care systems are moving towards regulatory models based on national certification. (5)

RECOGNIZING evidence that many women seek alternatives to hospital care for normal pregnancy and birth, and,

RECOGNIZING the evidence that births to healthy mothers, who are not considered at medical risk after comprehensive screening by trained professionals, can occur safely in various settings, including out-of-hospital birth centers and homes (10,11,12,13,14) and,

NOTING that an epidemiological study of Certified Professional Midwives (CPMs) is ongoing in order to further substantiate practice outcomes, safety, client satisfaction, and practitioner competency is in progress; (15)

RECOGNIZING that out-of-hospital settings have the potential for reducing the costs of maternity care; (7,12,16)

RECOGNIZING evidence that access to quality maternity caregivers remains an important issue, particularly for underserved urban and rural communities; (17) which may be addressed through out-of-hospital maternity services in some communities; and

REAFFIRMING that the APHA currently recognizes the value of and promotes educational opportunities for nurse-midwifery, (18) and that many professionals recognize the contributions of direct-entry midwifery; and,

REAFFIRMING that APHA has been an innovator in public health care by supporting research on alternative and complementary medicine (1,19) and increased access to midwifery services in the United States, (20)

RECOGNIZING that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations, including those direct-entry midwives who are nationally-certified and who have successfully completed “a recognized midwifery education process”; (21,22,23,25) and

RECOGNIZING evidence that direct-entry midwives have multiple educational routes (22,24) available to them in order to meet the entry-level requirements of knowledge, skills and experience; (22,24,25)

RECOGNIZING evidence that individual states interested in incorporating direct-entry midwives into the health care system are moving towards regulatory models based on national certifications; (22)

Therefore, APHA

• Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services, and further:
• Encourages the development and implementation of guidelines for the licensing, certification and practice for direct-entry midwifery practitioners for use by state and local health agencies, health planners, maternity care providers, and professional organizations;
• Urges that there be increased opportunities, for supervised, clinical learning experiences, in a variety of settings, including both high-risk and low-risk, incorporated into direct-entry midwifery education programs;
• Encourages an increase in cost effective maternal care services for rural and underserved urban populations by advocating for increases in funding of scholarships and loan repayment programs targeted at members of these communities;
• Urges public and private insurance plans to eliminate barriers to the reimbursement and equitable payment of direct-entry midwifery services in both public and private payment systems;
• Encourages the National Center for Health Statistics, the U.S. Department of Health and Human Services and State Vital Records Offices to add the CPM as a separate certifier category on birth certificates to enable routine collection of systematic data;
• Urges HRSA, CDC and state health departments to improve the collection and quality of vital statistics and other data to enhance the monitoring of birth outcomes (e.g., infant and perinatal mortality rates, maternal mortality rates, etc.) resulting from services provided by all practitioners including specific types of midwife practitioners;
• Urges Congress and appropriate Department of Health and Human Services agencies to increase funding and other support for ongoing research and evaluation of maternal health and birth outcomes, practice outcomes, quality of care outcomes, and safety related to the services provided by direct-entry midwives;

References:

1. American Public Health Association Policy Statement 6805: Credentials for Health Occupations. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
2. American Public Health Association Position Paper 8209: Guidelines for Licensing and Regulating Birth Centers. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
3. Stewart, David: The Five Standards of Safe Childbearing, NAPSAC International, 4th Edition, 1997.
4. Care in Normal Birth: a practical guide,Technical Working Group, World Health Organization. Department of Reproductive Health and Research, Section 1.1-1.6, 1999.
5. Rooks, JR: Midwifery and Childbirth in America. Temple University Press, Philadelphia, 1997.
6. American Public Health Association Position Paper 7924: Alternatives in Maternity Care. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.
7. Rooks, JP. Unity in Midwifery? Realities and Alternatives. Journal of Nurse-Midwifery 1998; 43:315-19.
8. North American Registry of Midwives (NARM), How to Become a Certified Professional Midwife and Candidate Information Bulletin. Revised, June, 2000
9. ACNM Issue Brief February 1999 and ACNM Position Statement on Midwifery Education 1997
10. Durand AM: The safety of home birth: The Farm study. Am J Public Health 1992;82:450-453
11. MacDorman M, SinghG: Midwifery care, social and medical risk factors and birth outcomes in the USA. J. Epidemiol. Community Health 1998, 52: 310-317.
12. Wagner M: Midwifery in the Industrialized world. Journal of the Society of Obstetricians and Gynaecologists of Canada, November 1998.
13. Mehl, LE, Ramiel, JR, Leininger, B., Hoff, B, Kroenthal, K. Peterson, G: Evaluation of Outcomes of non-nurse midwives: Matched comparison with physicians. Women & Health 1980;5:17-29
14. Sullivan D & Weitz: Labor Pains: Modern Midwives and Homebirth, Yale University Press, 1988.
15. Ken Johnson, PhD and Betty Ann Daviss, MA. CPM Statistics Project 2000: A prospective study of births by Certified Professional Midwives in North America. (Abstract #3042.0) Presented at 128th APHA Annual Meeting, Boston, MA, November 2000.
16. Blevins Medical Monopoly: Protecting Consumers or Limiting Competition? Policy Analysis by Cato Institute December 15, 1995; 246: 11-14. Burnette CA, Jones JA, SA:
17. Tennessee Commission on Children and Youth Report: The State of the Child in Tennessee: KIDS COUNT, 1996.
18. American Public Health Association Position Paper 9403: Increase Support for Education and Practice Opportunities for Nurse-Midwives, 1948 to Present, Cumulative, Washington, D.C.: American Public Health Association; current volume.
19. American Public Health Association Position Paper 9714: Support for Research on Alternative and Complementary Practices, 1948 to Present, Cumulative, Washington, D.C.: American Public Health Association; current volume.
20. American Public Health Association Position Paper 20004: Supporting Access to Midwifery Services in the United States, 1948 to Present, Cumulative, Washington, D.C.: American Public Health Association; current volume.
21. Charting A Course for the 21st Century: The Future of Midwifery. A Joint Report of the PEW Health Commission and the University of California, San Francisco Center for the Health Professions, April 1999.
22. Myers-Ciecko J: Evolution and Current Status of Direct-Entry Midwifery Education, Regulation, And Practice in the United States, with Examples from Washington State. The Journal of Nurse-Midwifery, Vol. 44, No. 4, July/Aug. 1999, pp 384-392.
23. Midwifery Today. Paths To Becoming a Midwife: Getting an Education, Midwifery Today, Inc. 1998.
24. Haughton P, Windom KL: 1995 Job Analysis of the Role of Direct-Entry Midwives. June 1996.
25. Mahlman R. The Quality of the NARM Certification Process, Testimony before the Ohio Study Council on Midwifery, Associate Director of Assessment Services, Vocational Instructional Materials Laboratory, The Ohio State University, July 1997

Resolution Submitted by:

Sharon Wells, MS, LM, CPM
Carol Nelson, LM, CPM
Jonathan B. Kotch, MD, MPH
Stanley H. Weiss, MD, FACP
James Gaudino, MD, MS, MPH