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education links National Review of Nursing EducationMidwifery EducationLiterature Review and Additional Material (Revised Edition)4. International Midwifery Education4.1 Midwifery Education – United Kingdom (UK)1Introduction Midwifery education and practice is situated within clear regulatory and supportive frameworks in the UK under the jurisdiction of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and the English National Board for Nursing, Midwifery and Health Visiting (ENB). These two bodies are soon to be combined into the UK Nursing and Midwifery Council. The UKCC is the registering authority, sets standards and regulations, ensures recency of practice, handles professional misconduct enquiries and disciplinary procedures and publishes statutory documents such as The Midwife’s Rules and Code of Practice. The ENB accredits both institutions and education programs and funds research to provide guidelines for education and practice. Delegates from the ENB also visit all education institutions and hospitals providing placements on a regular basis to ensure that student/staff ratios are appropriate and that the students’ needs for experience and learning are being met. All recent studies of midwifery education programs in Britain (Kent et al 1994, Fraser et al 1998) show that the academic status, length, content and funding mechanisms of courses vary considerably throughout the country. To some extent this is identified as the result of the move into institutions of higher education, a development that is also associated with theoretical knowledge taking precedence over practical skills. The English National Board for Nursing, Midwifery and Health Visiting (ENB) argue that, in all the major reforms in midwifery education there is a need to reconsider the contribution that practice-based learning makes to an academic award so that equal value and accreditation is given to the assessment of both theory and practice (ENB 1997). Over two-thirds of graduates from education programs for entry to practise midwifery emerge from ‘direct entry’ courses (personal communication, English National Board for Nursing, Midwifery and Health). Three-year programs are available in England and Wales at degree and diploma level and in Scotland all programs are at diploma level. Midwifery education programs for nurses are of 18 months duration throughout the UK and tend to be at degree level. Only the 18-month program is available in Northern Ireland. There have been calls to finish offering the 18-month program, however, in its document Fitness for Practice (UKCC 1999a) the UKCC Commission for Nursing, Midwifery and Health has recommended that both types of education should be retained. All midwifery education programs in the UK run on a 45 weeks per annum basis and theory and practice are integrated in a 50/50 per cent ratio. Recruitment to midwifery education programs With a few minor exceptions, there is no shortage of potential recruits to midwifery programs in the UK. In England there are four to five applicants for every place although the UKCC reports that means-tested bursaries are felt to make recruitment to degree-level programs more difficult (UKCC1999b). In Scotland, recruitment problems are more prevalent for the 18-month course but there are no difficulties with the three-year course and some universities have as many as 13 applicants per place (UKCC 1999b). In the UK, a government directed system ensures that the education of midwives addresses workforce requirements. The government gives funding and directives to the ‘Trusts’ (health service providers) regarding the numbers of midwifery students who should receive practice placements. The Trusts then contract with the universities of their choice who will provide the midwifery education program. Unlike the Australian system where some universities report difficulties securing practice placements for their midwifery students (AMAP 2001), the UK system ensures that midwifery education is driven by service provision and that practice placements are assured within all programs. Student funding issues The financial difficulties associated with students of the three-year programs are the major source of attrition during midwifery education (personal communication, Glynis Mayes, English National Board, King 2001). Whereas nurses undertaking the 18-month programs are salaried at a level reflecting their previous status in nursing, students in the 3-year programs receive bursaries if studying at diploma level or means-tested grants if studying for a degree. King (2001) explains that the financial hardship is considerable, particularly for those on grants and suggests a salary for student midwives and student nurses from 18 months education to address the high cost of attrition. Preparation for autonomous practice The UKCC Commission (UKCC 1999a) identifies that the increased numbers of three-year programs has provided an opportunity to address the issue of midwives taking more responsibility for women in continuity of care models. Some concern has been expressed about the practical skills of newly qualified midwives from the 18-month programs in terms of the requirement for midwives to be autonomous practitioners on registration (UKCC 1999b). Since midwifery is seen as a separate profession to nursing in the UK, the education programs are not built onto nursing as they are in Australia. It is therefore thought by many that 18 months is too short a time to get enough experience to become an autonomous practitioner (Personal communication, Midwifery Officer ENB). UKCC Review of midwifery education The UKCC document Fitness for Practice (UKCC 1999a) resulted from extensive consultation, three research projects and 450 responses to questionnaires from individuals, professional bodies, hospitals and education institutions to illicit opinion about pre-registration nursing and midwifery. The UKCC report that the most positive responses were from students and newly qualified practitioners. Three broad themes emerged from the document: the need for more and better practice, greater flexibility, and improvements in partnerships between higher education and service providers. In relation to midwifery education and the aim to achieve fitness for practice, the following recommendations from the report are worth noting:
In considering practice placements the UKCC (1999a) made the following recommendations:
Government funded research to support and resource midwifery education Although comparisons need to be mindful of context, the documents published by the ENB are a useful resource for midwifery educators, researchers, practitioners and policy makers in Australia until such day as we develop our own equivalents. Examples of recent ENB documents relating to midwifery education are listed in Appendix D. The titles of these ENB publications alone give a strong impression of the excellent resource this government-funded body provides to nursing and midwifery education. In relation to Australian midwifery education such a resource has been strongly recommended in terms of best practice guidelines in the recent Senate Inquiry Report Rocking the Cradle: A Report into Childbirth Procedures (Commonwealth of Australia 1999). Recency of Practice Programs As in Australia, there is an ongoing campaign in the UK to attract nurses and midwives back to the workforce. Midwives who have practised for less than 100 days (750 hours) during the five years preceding their point of renewal of registration have to undertake a five-day return-to-practice program to renew their registration. Return-to-practice programs have been approved by the ENB in order to facilitate this process (Gosby 2000). Midwives in the UK all have access to a Supervisor of Midwives who has a statutory duty to work in a mentoring role and ensure that midwives are supported in maintaining their skills and competency. History of midwifery education in the UK Prior to the first Midwives Act in 1902, there was no legal requirement for midwives to be registered or to undertake any programs of instruction in England. Following the Act, midwives had to provide proof of certification by an approved institution in order to be entered onto the Midwives Roll of the Central Midwives Board. Although few entered midwifery via nursing initially, after the 1920s there was an increasing trend towards post nursing education programs for midwives. By the mid-1980s only one school trained non-nurse student midwives (Radford and Thompson 1988). The re-introduction of ‘direct entry’ midwifery education in Britain A full description of the re-introduction of ‘direct entry’ midwifery education and the development and evaluation of three-year programs in the UK can be seen in Section 3.4.1. The call for a study to assess the re-introduction of ‘direct entry’ programs came from the Royal College of Midwives and was driven by concerns regarding recruitment and training and the need for midwives to undertake the full role and responsibility of the midwife. The Department of Health and Social Security (DHSS) responded by commissioning a study of ‘direct entry’ midwifery (Radford and Thompson 1988). This report investigated the factors inhibiting the development of ‘direct entry’ programs and explored the potential for their successful implementation. Midwifery education and ‘Changing Childbirth’ As in Australia, midwifery education in Britain is responding to dramatic changes in the way maternity services are offered in order to meet the identified needs of women. The Winterton Report (House of Commons 1992) and Changing Childbirth (Department of Health 1993) have challenged midwives to adopt a woman-centred approach to practice, one that enables ‘choice, control and continuity of care’ for women throughout their experience of childbirth. Studies of midwifery education in Britain following the publication of these government documents demonstrate that programs increasingly reflect a woman-centred philosophy (Fraser et al 1998; Kent et al 1994). Midwifery education in relation to nursing education in the UK ` Currently, the majority of graduates emerge from three-year midwifery programs in the UK and are not nurses. This development was unexpected and, to some extent is due to a strong articulation of midwifery as a separate profession to nursing. Arguments that have explained this separate identity are summarised in literature produced by the Association of Radical Midwives (ARM):
Such arguments were used to oppose the inclusion of midwifery as a branch of Project 2000 when it was being proposed (Radford and Thompson 1988).2 Midwifery education and primary health care in the UK In all four countries of the UK, public health is being given a high priority. There have been explicit calls for an enhanced midwifery role in maximising women’s health and contributing to public health targets The Royal College of Midwives (RCM) has responded in various positions papers by articulating the implications for midwifery education and training and making recommendations to strengthen community orientation and practice within curricula to ensure that:
Conclusion The education of midwives in the UK is supported by strong regulation and systems to ensure an evidence-based approach to maintaining high standards and an ongoing process of evaluation at every level. 4.2 Midwifery Education in New Zealand (NZ)3Background to developments in Midwifery Education Tully (1999) and Donley (1986) have described in detail the history of how consumers and midwives joined forces to enable midwifery become an autonomous, government funded profession in its own right in New Zealand. As in Canada, midwives in New Zealand implemented ‘direct entry’ midwifery education following the legal recognition of professional autonomy. In both countries, following extensive research, three and four year midwifery degree programmes were seen as the most appropriate way to prepare practitioners to meet the standards required to practise independently and provide woman-centred care. The amendments to the Nurses’ Act in 1990 (NZ Government 1990) enabled midwives in New Zealand to claim statutory equivalence to doctors providing maternity care. This meant that they would be entitled to equal pay through the public health system and to practise as self-employed practitioners in their own right, with hospital privileges, prescribing rights and laboratory access (Guilliland 1999). Changes to maternity service funding in 1993 enabled women to choose a midwife, a general practitioner or an obstetrician as their Lead Maternity Carer (LMC). This change provided access for women to a publicly funded maternity practitioner who would coordinate all maternity care in a women-centered and continuity of care model. These changes closely reflected midwifery practice and have led to dramatic changes in maternity services. By 2001 over 70 % of women were choosing a midwife as their LMC (personal communication New Zealand College of Midwives). All midwives are now prepared for initial registration through a Bachelor of Midwifery, most of them undertaking a three-year ‘direct entry’ program. The majority of midwives in New Zealand now work in independent or Lead Maternity Carer (they carry their own caseload of clients) practice in a variety of situations. Hospital-employed midwives also offer independent midwifery services and the role of the 'core' midwife in hospitals has changed to reflect the fact that most women now have their own named midwife. New Zealand women have more choice, control and continuity of care than was available in the previous doctor-led maternity services. Two large studies reviewing maternity care in New Zealand demonstrate women’s overall satisfaction with maternity care and in particular with the services offered by midwives (Health Funding Authority 1999; National Health Committee 1999). Partnership between consumers and midwives is well documented as the key to the success of all these developments in maternity service reform and midwifery’s educational and professional development (Guilliland 1999; Guilliland and Pairman 1995; Tully et al 1998, Pelvin 1992, New Zealand College of Midwives 1993). The notion of partnership between women and midwives as a political and ethical stance at both personal, professional and organisational levels was articulated by Guilliland and Pairman in 1995 and has been identified as the philosophical basis for standards for midwifery practice and education (New Zealand College of Midwives 1993). The authors explain how the idea of midwifery partnership springs from the bi-cultural nature of New Zealand society that started in 1840 with the signing of the Treaty of Waitangi and its underlying principles of the right to self determination. New Zealand midwives are justifiably proud of how the partnership model has enabled Maori women’s views of the world to be facilitated and incorporated into the maternity experience (Fox 1994) and into midwifery education programs. An education program in Cultural Safety is an essential registration requirement for all midwives and one three-year education program provides a specific stream to meet the needs of Maori students. Developments in Midwifery education The history of New Zealand midwifery in the Twentieth Century is worth consideration given its relatively similar progression to midwifery in Australia until legislative changes in New Zealand in 1990 drove radically different pathways for the education and practice of midwives in the two countries. Tully (1999) and Donley (1986) have described how midwifery education became incorporated into nursing in New Zealand through a series of legislative changes designed to govern the training and practice of both midwives and nurses. In the 1970s and 1980s, along with nurses in the United States, Britain and Australia, New Zealand nurses implemented successful professionalisation strategies to move nursing into university settings and re-define its labour as intellectual rather than manual (Tully 1999:88). In New Zealand, these developments in nursing saw midwifery education losing its separate program and being incorporated into an Advanced Diploma in Nursing (ADN) as child and maternal health nursing. Midwifery leaders protested in vain, particularly regarding the lack of clinical practice in the ADN. Many nurses went overseas in order to qualify as midwives and few enrolled in the ADN. The ensuing severe shortage of midwives and continuing pressure from midwives eventually precipitated ministerial approval for registered nurses to complete a one-year diploma of midwifery course separate to the ADN. This program was discontinued in 2000 once the three-year degree programme became the foundation route to midwifery registration. All nurses wishing to become midwives in New Zealand can now apply for an individualised assessment of recognition of prior learning in order to undertake a shortened version of the undergraduate program. Thus, all graduates emerge from the same programs regardless of whether they were nurses before undertaking midwifery. Continuing education and professional development Apart from providing the opportunity for the introduction of pilot ‘direct entry’ programs, the amendments to the Nurses Act in 1990 precipitated a range of ongoing professional development activities. The five Polytechnic Midwifery Schools worked with the NZ College of Midwives (NZCOM) to provide education programs for qualified midwives to update and expand their practice in order to fulfill the full role and scope of practice that they were now legally able to undertake as self-employed practitioners. Guilliland (1999: 17) describes how midwives ‘ responded positively to the faith in their abilities enrolling in sources of ongoing education in numbers unprecedented in the history of nursing and midwifery’. New Zealand maternity hospitals developed in-service education based on or adapted from the New Zealand College of Midwives professional standards set out in the Midwives Handbook for Practice (New Zealand College of Midwives 1993). The College has also set up a system for peer review that enables midwives to reflect on their practice and learning needs in a supportive environment with a small group of midwives and consumers. Three-year midwifery education programs in New Zealand The initial impetus for getting 3-year ‘direct entry’ midwifery education established in New Zealand grew out of the consumer movement, initially the Homebirth Association in Auckland and subsequently the pressure group, ‘Save the Midwife’ (Donley 1986). A 13-member Taskforce was formed in 1986 and a year later this group was joined by the New Zealand College of Midwives in a series of campaigning strategies to raise the profile of midwifery and promote the ‘direct entry’ option. Their efforts were rewarded when Helen Clark became Minister for Health in 1988 and supported the introduction of government funding for 3-year pilot programs (Tully 1999). Tully (1998) has explored how the development of undergraduate programs in New Zealand gave midwifery the opportunity to bring together educators and practitioners in order to define midwifery’s knowledge base and framework of practical judgement:
As in other countries faced with the task of developing an appropriate curriculum for autonomous midwifery practice, claims to expertise in providing individualised continuity of care for women throughout their experience of ‘normal’ childbirth were the foundations of the particular knowledge and skills that were identified as learning outcomes. The notion of ‘partnership between a woman and her midwife in their shared experience of childbirth’ (Guilliland and Pairman 1995) formed the philosophical stance of the new programs. Following The Nurses Amendment Act (1990), four polytechnics in New Zealand applied to run three-year midwifery education programs and the Minister of Health approved pilot funding for two programs with an evaluation to assess whether the programs would produce the desired outcomes at an acceptable cost. In 1992, the Auckland Institute of Technology (AIT) commenced a three-year diploma program and Otago Polytechnic, Dunedin commenced a three-year degree program. The interim report of the evaluation process in 1993 identified trends and issues:
The second Interim Report of the evaluation process (Ministry of Health 1995) was conducted as graduates emerged from the programs stated that there were many benefits to support continuation of ‘direct entry’ education. They noted that:
Eventually all five polytechnics throughout New Zealand offered undergraduate degrees in midwifery, Waikato and Wellington commencing in 1996, and Christchurch in 1997. The Waikato Polytechnic offers a parallel program for Maori midwifery students. Postgraduate studies in midwifery are now offered at several universities. These include a Masters and PhD program at Victoria University, a Masters of Midwifery based at Otago Polytechnic and available throughout the South Island, and a Masters and PhD program at Massey University offered at the Palmerston North and Albany campuses. In New Zealand, most students will qualify having attended 30 – 60 births, with some managing over 100. All of these students will have followed at least 40 women through from early pregnancy to 6 weeks following birth, approximately 30 of them in their final year. Since nurses who wish to become midwives now enter the same programs, they also have to meet these requirements for repeated practice even though they may be undertaking a shortened course as a result of recognition of prior learning. Midwifery education in New Zealand continues to produce graduates who are ‘fit to practise’ (Nursing Council of New Zealand, 1999) according to the international definition of the midwife. In reporting on her impressions of midwifery in New Zealand, Professor Lesley Page (1997) noted the strong relevance of education for practice, the high profile of the discipline of midwifery alongside the discipline of nursing, and the emphasis that is placed on teachers having current knowledge of contemporary practice. 4.3 Midwifery Education in the Netherlands4The Netherlands has a long tradition of midwifery education, the first midwifery schools being set up in Maastricht in 1779 and Amsterdam in 1861. Midwives have been recognised by society as autonomous practitioners in their own right since the 18th century. Various Acts that have clearly identified the separate roles and responsibilities of midwives and medical practitioners have reinforced this. In 1865, the Act Governing the Practice of Medicine authorised midwives to advise and assist women in childbirth, providing that labour was proceeding normally and there was no requirement for the use of instruments. In 1878 the Act Governing the Powers of Doctors, Dentists, Pharmacist, Midwives and Pharmacists’ Assistants gave those who had passed midwifery examinations the authority to practise. The description of a midwife’s duties in the Instructions for Midwives in the Kingdom of the Netherlands, written in 1818 served as a guideline for this legislation. In 1941, the Medical Insurance Funds Act set up a system for maternity payments that exists to this day. Women with uncomplicated pregnancies and births are under the care of a self-employed midwife and obstetricians are funded for the care of women with complications. No family doctor can claim reimbursement for maternity care if a midwife practises in the same geographical area and there is strong support and funding for the provision of home birth services by midwives. Approximately a third of all babies are born at home in the Netherlands, home birth is encouraged and funded by the government and students have ample opportunities to be involved in home births. Interestingly, a study to determine the effect of workload on ‘burnout’ and work capacity among Dutch midwives concluded that the chance of ‘burnout’ are considerably lower when a large percentage of the midwife’s time involves attending women who give birth at home (Bakker et al 1996). The majority (80%) of midwives in the Netherlands are in independent practice attending women who give birth at home or in short-stay maternity units (Hingstman 1994). In 1992, community midwives supervised 45% of all births in the Netherlands and over half of these occurred at home (Netherlands Central Bureau of Statistics 1994). In the Netherlands, ‘physiology’ and ‘pathology’ are "recognised as two autonomous specialisations" within medicine (Committee for the Revision of the Curriculum of Midwifery Schools in the Netherlands 1991: 24). The midwife’s domain is firmly within ‘physiology’ and this clear delineation of roles, reflected in funding arrangements, has been a major contributor to collegiality between midwives and obstetricians:
There are now three midwifery schools in the Netherlands – in Amsterdam, Rotterdam and Kerkrade. Candidates have to have an advanced high school diploma and need to have taken additional biology and chemistry courses in the last two years of high school. Competition for places is more acute than for entry to any other profession with only 20 – 25 places a year in each of the three schools. Many candidates spend years re-attempting to gain a place. Crebas (1991: 21) describes a process where 100 applicants are selected for interview by means of a ‘lottery. Candidates are interviewed at least once to ‘evaluate the applicant’s aptitude for the profession as well as her/his motivation’ (Crebas 1991:21). The midwifery schools are independent of universities ‘although the training is considered equal to an education in an institute of Higher Vocational Education’ (Committee for the Revision of the Curriculum of Midwifery Schools in the Netherlands 1991: 20). In 1993 the curriculum was extended to a four-year program in order to address the need for midwives to have experience and understanding of research and to maintain the quality of the programs. It was felt that the academic standard achieved by this would enable graduates to undertake doctoral studies. The education comprises 1,680 hours per year to include contact time and home study, divided over 40 weeks of 40 hours each. Placements are in clinics, maternity wards, theatre and gynaecology departments as well as with independently practising midwives in order to learn about setting up and running a practice and home births. Students attend many more births than the 40 required by EEC regulation and each year they have to reach specified educational objectives. The programs move through modules with central themes incorporating theory and skills acquisition, with an increasing emphasis on internship by the third year. The government meets all costs of the education and students receive a grant throughout their the four-years. Midwifery education is enshrined in legislation under the Midwifery Schools Act 1988 and the Act Governing Midwifery Examinations. In 1991, the curriculum was reviewed by a Committee set up by the Department of Welfare, Health and Cultural Affairs of the Netherlands who identified that revision of the curriculum needed to be made based on:
The Midwife Profile designed by the Netherlands Organisation of Midwives and educational objectives defined by the government guide curriculum content and the revision of midwifery education programs (Committee for the Revision of the Curriculum of Midwifery Schools in the Netherlands 1991). Government directives are specific and extremely detailed regarding curriculum content. These are centred on clear responsibilities for care and detailed procedures linked to three categories reflecting different stages of the antenatal, intrapartum and postnatal periods. In 1991 the following sub-categories were added to each of these categories:
According to the Committee for the Revision of the Curriculum of Midwifery Schools in the Netherlands (1991:20): The expertise of the midwife has five components:
Students are assessed according to these components and this includes written and oral examinations. Teachers also ‘determine whether the student has the personality traits necessary to practise midwifery’ (Crebas 1991: 21). Students who fail the final exam have one opportunity to repeat the exam. As in medicine, on graduation all students take the Hippocratic oath. . On completion of their midwifery training, midwives are authorised to practise independently with per capita payments through the government’s insurance scheme for each woman for whom they undertake care. Over 70% of graduates will enter private practice, most of them with a partner or in group practices. Some may also take up hospital employment. 4.4 Midwifery Education in Canada5Throughout most of the 20th century, Canada was the only western industrialised country with no legal provision for the practice and profession of midwifery. In spite of a tradition of midwifery in indigenous communities and the existence of thousands of trained midwives from other countries, across the ten provinces and two territories the profession of midwifery was eliminated as medicine claimed sole professional rights over maternity care. The majority of midwives who had trained in other countries were forced to work as obstetric nurses in maternity units. A few British trained nurse-midwives were employed to work in remote areas where doctors did not wish to reside. Elsewhere, birth care moved almost universally into hospital where women were cared for by doctors and ‘obstetric nurses’. A small number of home births continued to be attended by General Practitioners. Midwives could not officially offer services to women giving birth at home as they had no legal status but some ‘neighbourly help’ continued. (Tyson 2001). The 1970s and 1980s saw the emergence of an organised childbirth activist movement in some provinces. Women and midwives joined forces in a successful campaign to legalise midwifery and promote woman-centred care and choice regarding place of birth (Burtch 1994). With the Regulated Health Professions Act of 1991, Ontario became the first province in Canada to grant midwives a distinctive legal status. Subsequent provincial legislation enabled the same process in Alberta, British Columbia, Quebec, Manitoba, Saskatchewan and the North West Territories and Nunavut. This legislation has moved midwives from having what Burtch (1994:4) refers to as an ‘alegal’ status, to having fully fledged professional recognition. Over the last decade, in all of these provinces except Alberta and Manitoba where midwifery has not yet been funded, (McKendry and Langford 2001), midwifery services became incorporated into the public health care system. Increasingly, women would be able to access free midwifery continuity of care, with some choice of birthplace from self-employed, community-based midwives. However, homebirth was restricted in British Columbia for a while and remains illegal in Quebec where midwifery was set up as a ten-year ‘pilot project’. To begin to meet the projected demand for such services, steps were taken in most provinces to increase the supply of midwives. In those provinces where midwives from varying backgrounds had already been practicing before legislation, a "grandmothering" assessment and upgrading program was put in place, in order not to deprive midwives of their livelihood during a transition period of integration, and to ensure that they would be able to meet the high standards of the newly designated Canadian midwifery practice. Preparations were made for launching new midwifery educational programs. In Ontario and Quebec, one-year assessment courses were set up for midwives who had previously completed training in other jurisdictions to ensure that they would be able to meet the high standards of Canadian midwifery practice. In most provinces, a legal ‘grand mothering’ clause was enacted, in order not to deprive existing midwives of their livelihood during the transition period of ‘integration’, and the development of midwifery education programs. Over the next years, several provinces have put in place processes to assess the qualifications and experience of midwives from other countries wishing to work in Canada. Midwifery education in Ontario Review For the purposes of this Inquiry, the situation in Ontario will be given priority consideration since a midwifery education program has been running at a consortium of three universities there since 1993. Quebec, the only other province currently offering midwifery education for entry to practice, started a four-year midwifery bachelor’s (baccalaureate) program in 1999. British Columbia expects to launch its degree program this year and Manitoba is in the planning stages of a university program. The College of Midwives of Ontario was established under the Regulated Health Professions Act, 1991 as the governing body of midwifery. Its major function is to administer the related Midwifery Act in the public interest. This includes all aspects of regulation and registration including processing complaints, professional misconduct and developing, establishing and maintaining standards for practice and education. The Government-initiated Taskforce on the Implementation of Midwifery in Ontario reported in 1987, after extensive research into midwifery education in other countries, that direct entry midwifery education programs were the most appropriate use of resources for educating midwives to fulfil the role of primary caregiver in maternity care (TFIMO 1987). The work of the Curriculum Design Committee of the Ontario college of Midwives resulted in Ontario’s four-year Bachelor of Health Sciences in Midwifery (baccalaureate) program, which commenced in 1993. In Ontario, The Registrant’s Booklet (College of Midwives of Ontario 1994) defines core competencies as the foundation for these midwifery education programs. The fundamental knowledge and skills expected of a new graduate are linked to the international Definition of a Midwife (ICM 1972) and to a comprehensive list of the ‘Components of Midwifery Care’. A new graduate is expected to be capable of taking responsibility for providing midwifery continuity of care in all settings, with appropriate consultation, referral and collaboration when appropriate. In Ontario, the population of 65 midwives registered in 1994 grew to 220 in the year 2000 and is increasing at approximately 30 per year. There are not enough midwives to meet the increasing demand for midwifery services. Midwives currently provide care for 4% of Ontario’s childbearing women and it is expected that this figure will rise to 10% in the next four years (Tyson 2001). This compares with 6.6% of all births in British Columbia being attended by midwives. Midwifery education across Canada There are currently 200 midwives practicing outside of Ontario:
Canadian midwifery education programs prepare practitioners to fulfil a role outlined here in the Canadian Association of Midwives Newsletter:
Midwifery education aims to ensure that the guiding principles of Canadian midwifery care are maintained:
Graduates of midwifery programs are required to have:
Graduates are required to be competent to work in both home and hospital settings. Therefore, of the 60 births attended, 10 must be hospital births with 5 as primary midwife and 10 must be home births with 5 as primary midwife. Universities in Ontario are currently educating approximately 30 new students per year. Similar intakes occur in universities in Quebec and comparable numbers are anticipated in British Columbia when programs commence there in the near future. As with any other university education in Canada, students fund their own education and some loans are available. In other words, there are big financial barriers but this is no different for students undertaking nursing or medicine. Attrition rates from the programs are "low" so far but it is not clear how this will translate into graduates practising. Anecdotal evidence suggests that some finish their degree B.A. and subsequently choose not to practise midwifery Programs for indigenous women Ontario has a separate stream with reserved spaces for First Nations women. Also, traditional midwifery education is now available in one First Nations Community, although it does not lead to formal credentials. Indigenous midwives working on First Nations lands in Ontario are exempted from prosecution. Practice placements Practice placements occur wherever midwives practise and this could include rural and remote areas, hospitals, community organisations and placements with an obstetrician, paediatrician and/or GP. Some preference is given to Northern students having a northern placement (ie. in rural and remote areas). Students organise their own 6 to 8 week optional placement and this means they could go somewhere very remote if this experience was what wanted/needed. 4.5 Midwifery Education in the United States of America (USA)6Midwifery development in the USA At the beginning of the twentieth century most women in the USA gave birth at home attended by midwives. By the 1950s this figure had fallen to only 4.5% of all births. Philips (1999) has described this process, as well as the swing back to family-centred care in the latter part of the century as alternative and freestanding birth centres began to appear and hospitals were forced to rethink their policies and see midwifery as a potentially important contribution to maternity service provision. During the twentieth century in the USA, two distinct and polarised routes of entry to midwifery practice emerged following the demise of traditional midwifery. On the one hand, apprenticeship style training for midwives gained momentum through the homebirth movement and on the other hand, nurse-midwifery developed as a speciality of nursing aligned with obstetrics. It is important to understand that, in the USA, the nomenclature ‘direct entry’ is the term used to describe midwives who are not nurses who have been educated through apprenticeship style or private schemes rather than through the three or four year mainstream formal education programs that were developed in other countries. Bourgeault and Fynes (1997) explain this difference when comparing the integration of midwifery into the health care systems in the USA and Canada. They note the gains that the profession of midwifery has made in both countries, but highlight interesting differences in how midwifery is organised and practised in these two settings. They summarise their findings in the following terms:
Capitulo (1998) has also described the historical, social, political, economic, and philosophical forces that have shaped the role of midwives in the USA, summarised here:
As in Australia, state governments in the USA play a central role in determining the extent to which midwives can provide care to women and babies. State laws and regulations establish midwives' scope of practice, set licensure requirements, and frequently determine their ability to get paid and obtain access to health care facilities. For certified nurse-midwives (CNMs), state regulation has evolved from a haphazard patchwork of highly variable regulatory models into a fairly uniform set of rules and requirements from one state to the next. For direct entry midwives (DEMs), there is much less uniformity, with some states outlawing practice by any midwife who is not a CNM, whereas other states have established rigorous standards and requirements for the licensure of DEMs. Reed and Roberts (2000) provide a broad overview of these state regulatory variables for both CNMs and DEMs, and explore issues and options that both state regulators and midwives should consider when developing or amending state laws and regulations governing their practice. In particular, the role of the state in regulating the practice of the certified midwife (CM) is examined in the context of existing regulatory frameworks for CNMs and DEMs (Reed & Roberts 2000). Figures published by the National Centre for Health Statistics have demonstrated a consistent trend and a tenfold increase in the use of CNMs in maternity care over the past 20 years. In 1996, CNMs attended 229,855 hospital births in the United States, an 11% increase on the previous year. CNMs also attended 8,884 births outside of hospitals, including home births and those in freestanding birth centres. This means that CNMs attended 6.5% of total births in 1996. Although physicians attended more than nine out of every ten births in 1997, the percentage of births attended by midwives increased and accounted for 7% of all births. In 1998, the number of births attended by CNMs rose to 277,811 in spite of an overall decline in the number of births in the USA. Although approximately 99% of births are in hospitals, a situation basically unchanged over the last ten years, the percentage of home births has increased over the period, while births in freestanding birthing centres has declined (Curtin 1999). Brucker and Reedy (2000) describe how the consumer demand for certified nurse-midwives continues to rise, spurring the preparation for more professionals. However, the average woman in the United States still does not have access to midwifery services. Nurse-midwifery and ‘direct-entry’ midwifery In the USA, the American College of Nurse-Midwives (ACNM) represents CNMs and the Midwives Alliance of North America (MANA) represents DEMs. In recent years efforts have been made to address the polarisation that exists between the two organisations. In suggesting strategies for continued efforts to work together, Rooks (1998) discusses the development of these differences and the problems in removing the barriers between the two organisations. Disagreements over the years have revolved around nurse-midwifery being seen as aligned with a medical model of childbirth and direct entry being aligned with counter-culture efforts to promote normal birth and birth at home (Rooks 1998). This was obvious recently in a debate between the ACNM and MANA over whether professional midwifery requires university education and a degree program (Gaskin 1997). Scoggin (1997) highlights the struggles that American nurse-midwifery has undergone in defining itself in relation to the medical profession. She suggests that because nurse-midwifery came into existence following the demise of traditional midwifery, it has had many prejudices to overcome and describes how nurse-midwifery allied itself with nursing to gain power and acceptance from physicians. Scoggin (1997) describes a move toward independence as nurse-midwives are more visible and the effectiveness and safety of their practice have been established. A study by Curtin (1999) reporting on changes in birth attendant and the use of obstetric interventions between the years 1989 – 1997 supports suggestions that CNMs are more likely to practise within an obstetric mould. Midwives as well as physicians increased the use of obstetric procedures over the period studied, and the use of many procedures by CNMs was as high, or nearly as high, as use by physicians. The findings of the 1993 and 1994 American College of Nurse-Midwives Membership Surveys elicited data from 3,600 respondents. The mean age was 43 years, and most members were female and Caucasian. Two-thirds of the certified nurse-midwives (CNMs) who responded had earned master's degrees. Approximately one-half of the respondents were employed by physicians or hospitals, and 71% reported that their primary employment involved clinical care with attendance at births. More than 90% of CNM respondents who reported site of birth attended births in hospitals (Walsh & Boggess 1996). By contrast, between November 1992 and March 1993 a survey was conducted to study midwives in the USA who began their careers as lay midwives and later decided to become certified nurse-midwives (Ventre et al 1995). Questions addressed their demographic and socio-economic characteristics to compile a profile that could be compared with other midwife populations. The survey elicited information regarding what motivated the decisions to change status and how these decisions have made an impact upon respondents' personal lives, family life styles, and income. It identified how becoming a nurse-midwife changed the respondents' work in regard to their own community, the clientele they serve, and their style and site of practice, and how the change in identity affected their self-perceptions as midwives as well as their relationship to the health care system, the legal system, and the established midwifery system. It investigated how respondents viewed their preparation for midwifery and how they felt about the relationship of nursing to midwifery; and, it addressed how these midwives related to, were influenced by, and influenced the two major professional midwifery associations in the United States, the Midwives Alliance of North America and the American College of Nurse-Midwives. The results showed that, overall, the respondents valued their lay midwifery background, felt positive about their CNM educational programs, and showed a preference for direct entry and apprenticeship programs in which the RN is not a prerequisite (Ventre et al 1995) A paper by Myers-Ciecko (1999) describes the re-emergence of ‘direct-entry’ midwifery in the United States, and focuses specifically on the over 1,000 midwives nationwide who are licensed in the 16 states where direct-entry midwifery is legal and regulated, and/or certified by the North American Registry of Midwives; it does not focus on direct-entry midwives or nurse-midwives who are certified by the American College of Nurse-Midwives Certification Council, Inc. The professional development of direct-entry midwives is highlighted, including the establishment of core competencies and articulation of values, the creation of a certification process, and development of education program accreditation. The current status of licensed midwives in Washington State, where state policies have supported the development of direct-entry midwifery and the integration of direct-entry midwives into managed care systems, is presented as one example of the evolution of professional direct-entry midwifery in the USA. Additionally, recommendations from the UCSF Centre for the Health Professions Taskforce on Midwifery, which address particular areas of concern for direct-entry midwives, are discussed. Government support for midwifery As the U.S. health care system struggles to respond to demands for accessible, quality, sensitive, and cost-effective care, the contribution of nurse-midwives is receiving renewed attention (Williams 1994). In 1995, the American Public Health Association issued a policy statement calling for increased and improved educational and professional support for midwives in the USA (American Public Health Association 1995). As in other western countries, public health authorities are being encouraged to promote the expansion of midwifery within a collaborative framework as a key strategy to improve access to care for childbearing families, leading to a subsequent improvement in birth outcomes (Gabay & Wolfe 1995; Smith 2000; Gaskin 1996; Lawrence 1997; Baldwin 1999). There is a paucity of literature specifically addressing the efficacy of collaborative practices composed of midwives and physicians. However, Miller and King (1998) have presented a compelling argument for midwife-physician collaborative practice by presenting the literature documenting the effectiveness of interdisciplinary teams of various health care providers combined with the literature on the effectiveness of midwifery practice. Gabay and Wolfe (1997) suggest that CNM care appears particularly well suited to help improve the health status of newborns and to address the excessive use of medical interventions during childbirth. Despite the fact that CNM care has been found to be safe and cost-effective, only a small fraction of those pregnant women who could benefit from CNM care use midwifery services. Lack of consumer awareness is part of the problem, but barriers also exist to accessing CNM services. Sixty-four percent of CNM practices responding to a survey reported practice restrictions, most commonly due to state laws, hospital policies, and inappropriately restrictive physician back up. One state, Florida, is aggressively promoting the use of CNM care as the standard of practice for healthy pregnant women (Gabay & Wolfe 1997). Rookes and Ernst (1999) examine and discuss the future role of midwifery in the USA in the light of the continuing conflict between midwifery models of care and the growing emphasis on medical technology in childbirth. The advantages of the midwifery model of care are reviewed and challenges for the future of midwifery are examined. In similar vein, Bradley and Bray (1996) compare infant mortality in the USA which ranks 22nd in the world with the Netherlands which ranks 5th. They suggest that several components of the Dutch health care system could be adapted in the United States to lower the infant mortality rate in particular government funding of midwifery care. A Taskforce on Midwifery was set up in 1998 to explore the effects changes caused by market-driven reforms in health care delivery and financing in the United States have had on midwives, and how managed care may effect the midwifery profession in the future. The Taskforce concluded that 'the midwifery model of care is an essential element of comprehensive health care for women and their families that should be embraced by, and incorporated into, the health care system and made available to all women’ (Centre for the Health Professions/ Pew Health Professions Commission 1999). A study comparing ambulatory visits and practices of CNMs compared to those of obstetrician/gynaecologists suggested that, ‘with more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States’ (Paine et al 2000). When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to obstetrician/gynaecologists in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. Face-to-face visit time was longer for CNMs, and involved more client education or counselling. This population-based comparison suggests that CNMs and obstetrician/gynaecologists provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. The authors suggest that enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable (Paine et al 2000). Two studies on the determinants of midwife-assisted birth presented interesting data to inform policy decision-making regarding the potential acceptability of midwifery care in American society (Paine et al 1999; Stewart 1998). Paine et al (1999) studied prospective data on 16729 visits collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. The researchers estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. The conclusion of this study was that CNMs substantially contribute to the health care of women nationwide, especially for vulnerable populations. Stewart (1998) employed logistic regression analyses using birth-certificate data on 149,437 Michigan births in 1990 to examine the characteristics associated with midwife-attended births. Women who paid for childbirth with Medicaid were 3.5 times more likely than those paying with private insurance to use a certified nurse-midwife. This effect varied significantly by race, with Medicaid payment increasing the odds of midwife use threefold among whites and nearly fivefold among non-whites. The effect of education on midwife use also varied by race: A college education significantly increased the likelihood of midwife use among white women (odds ratio of 2.1), but higher education decreased that probability among non-white women (odds ratio of 0.74). Father's education and age, were also significantly associated with the likelihood of a midwife-attended birth; the babies of college-educated fathers had higher odds of being delivered by a nurse-midwife, as did the babies of men in their 30s. The author concluded that the relationship between socio-economic status and the use of midwives might not be as straightforward as previously thought. The patients of nurse-midwives are a diverse group whose socio-economic characteristics and probable reasons for choosing a midwife over a physician vary widely. Standards for midwifery education and practice As in Australia, there has been strong support from midwifery organisations for national standards for midwifery education and practice. This is evidenced in the position statement issued by the American College of Nurse-Midwives (ACNM) in 1996, regarding their support for a national mechanism for accrediting midwifery education programs and in documentation produced by the Midwives Alliance of North America (Rooks and Carr 1995). Brucker and Reedy (2000) comment on the ‘dramatic changes’ in nurse-midwifery over the last 25 years and describe how multiple models of midwifery education leading to certification exist, all within a competency-based framework. They suggest that the processes associated with the accreditation of education programs and the certification within nurse-midwifery remain examples to others. According to Williams (1999), since 1925 when nurse-midwifery emerged as a new health profession in the United States, and over the past 30 years under the auspices of the American College of Nurse-Midwives (ACNM), national standards for education, certification, and practice have enabled nurse-midwives to provide the quality of care that is highly valued by policy-makers and consumers. Williams (1999) describes the education and practice of over 7,000 midwives who have received national certification through mechanisms developed by the ACNM, describes the strengths of the profession, and reviews the impact of managed care on the practice of midwifery. Also highlighted is the ACNM's development of a partnership with the Maternal and Child Health Bureau, to study the impact of changes in the health care environment on pregnant women and ACNM certified midwives. This partnership is presented as an example of how the ACNM has evolved into an organisation that is well positioned to preserve midwifery in a managed care environment. An appendix lists colleges in the United States that offer ACNM accredited/pre-accredited nurse-midwifery and midwifery education programs (Williams 1999). The Core Competencies for Basic Midwifery Practice, as promulgated by the American College of Nurse-Midwives (ACNM), was first published in 1978 to provide a standard approach to nurse-midwifery education. Since then, this document has been revised three times, most recently in 1997, and it now serves as the curricular template for ACNM-accredited education programs. Avery (2000) has discussed the historic evolution of the core competencies and the document's use in midwifery education and practice. The North American Registry of Midwives (NARM) was set up by the Midwives’ Alliance of North America in 1987 to establish and administer certification for the credentialling of a "Certified Professional Midwife" (CPM). The aim was to develop an international certification process that would encompasses multiple educational routes of entry to midwifery including apprenticeship, self-study, private midwifery schools, college-and university-based midwifery programs, and nurse-midwifery (NARM 1998). A series of events that took place in 1994/1995 could be seen as a
milestone in terms of setting standards for midwifery in the USA (Burst
1995). The North American Registry of Midwives became the first
organisation in the United States to offer national certification via
examination and a process that validates the skills, knowledge and
experience of midwives who are already practising (Cairns 1995). At the
same time, Many institutions are seeking assistance as they move to credential certified nurse-midwives for the first time or as they reassess their credentialling policies and procedures. An article by Williams (1994) provides an extensive review of multiple issues relating to credentialling nurse-midwives including nurse-midwifery education, licensure, scope of practice, professional liability, relationship with physicians, and delineation of privileges. The article also reviews the Medicare Hospital Conditions of Participation and the Joint Commission on Accreditation of Healthcare Organisations requirements as they relate to nurse-midwifery practice. Midwifery education in the USA Midwifery education in the USA varies from post-graduate education for nurses to a diverse range of systems referred to as ‘direct entry’. The latter now include apprenticeship, self-study, private midwifery schools, college and university-based midwifery programs. These ‘direct entry’ models are widely different across and within states and territories in terms of design, theory/practice components, duration and eligibility to practise on qualification. For over 20 years, there has been midwifery education for home birth midwives at ‘the Farm’ in Tennessee. This rigorous apprenticeship-style midwifery training system has inspired midwives and attracted international attention (Davis 2000) ever since it was rendered famous by Ina May Gaskin’s seminal text, Spiritual Midwifery (Gaskin 1978). The other famous site of midwifery education, also associated with promoting home birth, is the Seattle Midwifery School, a non-profit making collective set up in 1978, which has prepared over 150 midwives for practice. Midwives emerging from programs such as these receive a Certificate in Professional Midwifery and are eligible to practise in certain states. The North American Registry of Midwives provides a national examination and a validation process for professional direct-entry midwives. It offers a nationwide certification process that validates skills, knowledge and experience leading to the qualification of ‘Certified Professional Midwife’ (North American Registry of Midwives 1995). The American College of Nurse Midwives have also developed a process for accrediting midwifery education programs for non-nurses resulting in a ‘Certified Midwife’ credential. In 1996, the Division of Accreditation (DOA) of the American College of Nurse-Midwives (ACNM) accredited the first direct entry program of midwifery education for candidates who already possess undergraduate degrees in non-nursing disciplines. Inaugurated through the partnership of the State University of New York Health Science Centre at Brooklyn and the North Central Bronx Hospital, this 1-year, post baccalaureate, certificate program of studies graduated two integrated classes of 22 registered nurse (RN) and nine direct entry (DE) students between 1997 and 1998. A study by Fullerton et al (2000) presents the experience of the first 2 years of this innovative program, focusing on the profiles of the DE students, their achievements, and their experiences entering the work force. The authors conclude that all of the data comparing nurse and non-nurse student progress through the program of studies strongly support the conclusion that, within an ACNM DOA accredited midwifery education program, DE students can achieve standards of academic excellence and clinical competency that are at least equivalent to those demonstrated by their RN peers. The American College of Nurse-Midwives' Division of Accreditation criteria for accrediting direct-entry midwifery education call for programs to require baccalaureate degrees for entry or to award them at the conclusion of the program. They also require faculty to be midwives certified by the ACNM Certification Council. Neither criterion can be met by any existing direct-entry program. Rooks and Carr (1995) argue against these criteria, based in part on familiarity with the Seattle Midwifery School. Their paper describes the development of the Seattle Midwifery School, summarises reasons for and against requiring degrees for midwifery education, argues against excluding faculty of existing direct-entry schools who are not certified by the ACNM Certification Council, notes other efforts to develop credentials for direct-entry midwives, and concludes that professional direct-entry midwifery must be based on widely respected, rigorous national standards (Rooks and Carr 1995). Lichtman (1996) also raises concerns about the decision of the ACNM Board of Directors to consider requiring an entry-level degree for nurse-midwifery practice and suggests that clinical competence should be the overriding requirement for graduating midwives. The ACNM and MANA have thus developed very different education programs and different qualifications for midwives who have not previously trained as nurses. The two organisations are unable to agree on a standard for professional education and practice. The president of ACNM has explained how this situation arose and describes the effect it has on the regulation of midwifery practice in the 50 states and four territories where CNMs can practise (Roberts 1998). Foot Notes: 1.This overview of midwifery education in the UK has been written in consultation with Tina Heptinstall, Senior Lecturer, pre-registration Midwifery Program Leader at the University of Greenwich, UK. 2.Project 2000 is the British nursing education program. Initially it consisted of an 18-month core program followed by 18 months of specialisation in a branch of nursing. Government recommendations have resulted in this course changing to a one-year Common foundation program, followed by 2 years of specialisation in a branch of nursing. 3.This overview of midwifery education in New Zealand has been written in consultation with Sally Pairman. BA, RGON, RM, MA, Head of the School of Midwifery at Otago Polytechnic Dunedin, New Zealand. 4.This Midwifery Education in the Netherlands was completed with the assistance from Beatrijs Smulders, Director of the Birth Centre, Amsterdam, Netherlands. 5.This overview of midwifery education in Canada was written in consultation with Anne Nixon, former Faculty member of the Midwifery Education Program, Ontario, Canada. 6.This synthesis has been reviewed by Holly Powell Kennedy and requires further review by two additional experts, given the complexity and contentiousness of interpretation of these issues. This process is in train but not complete as at March 2002 |
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