In 1983, the Midwives Alliance of North America (MANA) created a Credentialing Committee to gather information about the credentialing of midwives. By 1985, the Credentialing Committee was working in conjunction with the Standards and Practice Committee and the Education Committee to develop proposals for a voluntary Registry for direct-entry midwives. In 1986, MANA established the Interim Registry Board (IRB) to develop a test that would measure midwifery knowledge based on the MANA Core Competencies. In 1991, the first test was administered to groups of midwives across the United States. This “trial” exam was revised under the guidance of a testing consultant, and by November of 1991, it was officially administered as the IRB Registry Examination. With yearly revisions, the Registry Examination continued to be administered and those who passed were listed on the “Registry.” Another important step in 1991 was the formation of the Interorganizational Workgroup on Midwifery Education (IWG), which was made up of an equal number of certified nurse midwives and direct entry midwives as Subject Matter Experts (SMEs) who represented the educational viewpoints of the American College of Nurse Midwives and the Midwives Alliance of North American, and public members. A series of IWG meetings was funded by the Carnegie Institute. The purpose of this group was to establish guidelines for midwifery education. The outcome of these meetings was the realization that direct-entry midwives needed to develop their own credentialing and accrediting mechanisms. The IWG members began the task of assimilating direct-entry skills lists from the existing educational institutions and other resources. The final meeting of the IWG contributed to the development of a skill/task checklist to identify skills necessary for competent entry-level practice of midwives who practice in predominately out-of-hospital settings. The skills identified by the IWG and the idea of developing a certification process were presented to the MANA Board.
As a result of the IWG meetings, NARM adopted the certification process and the IWG approved the Skills List. With the aid and support of the Florida Psychometric Department, this list was compiled into a survey and sent to a large group of midwives identified all across the country. The results have been used as the blueprint for ongoing test development.
In 1992, The Interim Registry Board incorporated as a non-profit corporation named the North American Registry of Midwives, more commonly referred to as NARM. From 1993-1995, five Certification Task Force (CTF) meetings were held around the country, and were attended by over 150 nurse-midwives and direct-entry midwives. These meetings were sponsored by MANA, NARM, and the MANA Education Coalition that would become the Midwifery Education Accreditation Council (MEAC). The purpose of these meetings was to gather input from midwifery educators and practitioners from diverse backgrounds, geographic areas and cultures to guide the development of the certification process. As a result of the CTF meetings, the certification process would require two components: education and certification. The educational portion consisted of a specified clinical component as part of the educational evaluation, documentation of clinical skills with preceptor verification of proficiency, and a hands-on practical Skills Assessment administered by a trained Qualified Evaluator. The certification verification was comprised of an extensive Written Examination that would be based on a Job Analysis survey that would determine the essential body of knowledge and skills necessary for safe and competent entry-level, out of hospital midwifery practice.
The 1995 NARM Job Analysis was undertaken by NARM in conjunction with the National Assessment Institute. The survey instrument was developed by the participants of the Certification Task Force meetings, and included every possible midwifery skill and knowledge aspect for out-of-hospital practice. The survey was mailed to 3000 midwives practicing in predominately out-of-hospital settings who were identified by state midwifery organizations, midwifery magazine mailing lists, and the Midwives Alliance of North America membership list. This extensive survey, which took an average of 12 hours to complete, was returned by 850 midwives. One-third of the respondents were Certified Nurse-Midwives and two-thirds were direct-entry midwives. The results of this survey formed the basis for the next version of the NARM Written Examination and the development of the NARM Skills Assessment.
In 1996, NARM contracted with Schroeder Measurement Technologies (SMT) to oversee test development for the written and the skills examinations, test administration, and the processing of the portfolio application program. The earlier versions of the exam (Forms A-C) had evolved from a combination of multiple choice and essay, to a total multiple choice format of 350 questions. Each subsequent version of the written exam has been 350 multiple-choice questions. The first administration of Form D of the Written Examination, developed by SMT, was in August of 1996. The exam has been updated every two years, per NCCA Standards, following the test blueprint identified by the Job Analysis.
NARM’s goal was to establish an entry-level certification that would define the minimum levels of training under supervision that would adequately prepare a midwife for safe, independent practice in predominately out-of-hospital settings, and to define the knowledge and skills that must be demonstrated for the entry-level practitioner. The Certification Task Force participants, through a consensus process, determined the amount of clinical experience necessary for competent entry level practice:
• 20 births as an assistant (active participant)
• 20 births as a primary midwife (assuming full care, but under supervision)
• 75 prenatal examinations, including 20 initial exams
• 20 newborn exams
• 40 postpartum exams
• 3 births with continuity of care (defined as 4 prenatal exams, birth, newborn
exam, and postpartum exam)
• 10 births in out-of-hospital settings
The certification process requires that these minimum clinical experiences be performed under the supervision of a preceptor who verifies that the student can perform the skills, and exhibits the knowledge necessary for the safe, independent practice of midwifery.
At the outset of the certification program, it was recognized that many experienced midwives had been practicing for years and no longer worked under supervision. The “Experienced Midwife” category was created to allow an avenue for certification for those midwives who could document attendance at at least 75 births and 300 prenatal exams as primary midwife, but who no longer worked under the supervision of a preceptor. All midwives, regardless of eligibility through “Entry Level” or “Experienced Midwife” were required to pass the NARM Written exam. The first CPM credential was issued in November of 1994. This marked the end of the NARM Registry process (list of those who passed the exam) and the beginning of the NARM Certification Process (verification of education and experience, and passing the written examination). Midwives who had taken the earlier versions of the NARM Registry Exam and who wished to become CPMs had to furnish a portfolio application verifying education, training, and experience to meet the standards established by NARM. The initial certificants were midwives with extensive experience, most of whom had served as Subject Matter Experts for the development of the examinations and the certification process.
Another category of midwives who wished to become Certified Professional Midwives were already legally recognized by a state and had taken the state’s exam for licensure. NARM offered states and jurisdictions with legally recognized midwives, who met the NARM experience requirements, to have their qualifications analyzed to see if they consisted of the same components as designated by the 1995 Job Analysis. If the state licensure process was equivalent to the NARM entry level criteria and if the state licensure exam was evaluated as equivalent to the NARM exam by an outside test agency, the National Assessment Institute, these candidates had proven competency in a manner deemed equivalent by NARM. They were not “grandmothered” merely by having been in practice prior to the development of the credential; all had taken an equivalent written exam. Approximately 20 candidates were issued certification in 1995 based on
having taken an equivalent exam and meeting the CPM entry level requirements. After 1995, all candidates were required to take the NARM Written Exam regardless of their licensure status. By this point, all states with licensure had adopted the NARM Written Exam as their
state licensure exam.
The NARM Board and participants in the Certification Task Force identified which tasks, based on the 1995 Job analysis, would be tested through the hands-on Skills Assessment. The knowledge base for all tasks would be tested on the Written Exam. The book, “Practical Skills Guide for Midwives” (PSGM) was chosen as the reference text for the Skills Assessment. Selected skills from the PSGM were compiled into two versions of the Skills Assessment, and a cut score process determined the passing standard for both versions. A training program was developed in conjunction with advisors from Schroeder Measurement to train Qualified Evaluators to administer the Skills Assessment. The first QE training program was given in November, 1995, in Scottsdale, AZ. The Skills Assessment would be given to candidates who were admitted through entry-level eligibility.
The test specifications for the NARM Written Examination were based on the content ratings from the Job Analysis. Subject Matter Experts used the test specifications to create a blueprint for the test that delineates the specific number of test items assigned to each area or domain to be tested. The domains and percentage of questions on the exam are:
Midwifery Counseling, Education, and Communications: 5%
General Healthcare Skills: 5%
Maternal Health Assessment: 10%
Prenatal Care: 25%
Labor, Birth, and Immediate Postpartum: 35%
Well-Baby Care: 5%
In 1997, NARM contracted with National Measurement and Evaluation (NME). At this point, NARM established its own applications processing department. NARM resumed processing applications and registering candidates for the Written Examination and Skills Assessment. The testing company stores the databank for the test items, and prints, stores, ships, and scores the Written Examination. NARM handles all communications with the candidates and test sites. NME later changed its name to Personnel Research Center (PRC).
The Certification Task Force met for a final time at the MANA Conference in Traverse City, Michigan, in the fall of 1998. All midwives attending were invited to give direction and advice to the NARM Board on the certification program. Based on these recommendations, NARM reorganized the Certification Process into two distinct parts: Education and Certification. The educational portion could be completed in three ways: through graduation from a MEAC or AMCB (formerly the ACC) accredited program, through legal recognition from a state or province that has been evaluated for educational equivalency from NARM, or through the Portfolio Evaluation Process (PEP). The PEP application evaluates education through apprenticeship, special circumstances, or international programs, and includes verification of supervised experience and the hands-on Skills Assessment. All candidates must have their education validated by one of the above routes before proceeding to the Certification Examination (the NARM Written Examination).
In accordance with state of the art psychometric procedures, the Job Analysis was repeated in an updated form in 2001 and again in 2009. The Job Analysis resulted in minor changes in the test specifications. The lack of major changes was a significant sign that the job of the midwife is something that does not change rapidly. This evidence will allow more prolonged periods between Job Analyses. The NARM Written Exam is revised every two years and reflects the knowledge and skills identified on the most recent Job Analysis. At least two test forms are in use at any give time, so that repeaters may take a different form on retake.