CPM Eligibility Review: Focus Group, Survey, and Outcomes

Rationale for Eligibility Review

The primary mission of the North American Registry of Midwives is to develop, administer and evaluate a certification process through a standardized system for those engaged in midwifery practice. This process results in the credential, Certified Professional Midwife (CPM), which is accredited by the National Commission on Certifying Agencies (NCCA). NCCA sets standards for the evaluation of criteria for certification that NARM follows in the development and ongoing administration and evaluation of educational content utilized in the validation of skills and knowledge required for certification.

Certified Professional Midwives have the potential to play a critical role in the development of systems of maternity care that incorporate the principals of the Midwives Model of Care. The CPM is a rapidly growing profession, with 150 new CPMs certified in 2009 and a steady increase in new applicants every year. There are currently 26 states that utilize the CPM or components of the CPM certification process for licensure and there are at least 10 states with legislative efforts underway to achieve recognition of the CPM. In 2009, an unprecedented campaign was undertaken to achieve the goal of federal recognition of the CPM credential through inclusion in the Health Care Reform legislation. The MAMA Campaign was incredibly successful in drawing together advocates and organizations dedicated to integrating the CPM into the maternal child health care system.

This heightened attention on the CPM credential has led to increased scrutiny of all components and standards for certification. Advocates for CPMs have had to face public denigration of the quality of education and training required for certification. Despite the fact that there is significant evidence to show that CPMs are adequately trained to provide safe and effective maternity care, NARM is being asked again and again to raise standards in order to answer concerns among the greater maternity care community about the quality of care that CPMs provide.

The developers of the CPM credential originally determined general education requirements outside of specific skills and knowledge content areas defined in the job analysis. These include experience requirements (such a minimum number of births attended prior to submission of application for testing), prerequisite education documentation (such as CPR, high school education), and requirements for documents related to professionalism (such as practice guidelines and informed consent documents). For a more detailed history on the creation of the CPM credential and NARM standards for evaluation, please see History of the development of the CPM.

The NARM Board determined that ongoing evaluation of general education requirements for all applicants should be conducted in a format that is in keeping with NCCA standards. The board developed a process that includes all of the steps involved in setting criteria for skills and knowledge.

NARM recognizes that any changes to requirements will have an impact on the number and quality of applicants for certification. The goal is to minimize as many unforeseen consequences of any changes as possible and to ensure that all changes are made with the intention of maintaining the high level of competency that the credential ensures to the public and to our profession.

Four Phases of Review

  • Phase 1: The first step in the process is an initial focus group of stakeholders to provide a platform for review and discussion of proposals developed by the NARM Board for possible changes to current General Education requirements.
  • Phase 2: The second step in the process involves a survey developed by the NARM Board that carries forward the response to the proposals from the Focus Group. This survey will include revisions to the proposals based on the report from the Focus Group and will be designed to seek further input from CPMs on the potential impact on any proposed changes.
  • Phase 3: The third step in the process involves evaluation of all feedback and final determination by the NARM Board of changes to requirements.
  • Phase 4: The fourth and final step in the process involves determination of implementation steps for any changes. The Board recognizes that some changes will require careful implementation as we consider applicants who are midway through their education process and the impact on schools and programs that will need time to integrate any new requirements into their curriculums.

Phase 1: Focus Group Report

On Wednesday, October 13th 2010, NARM held a Focus Group as Phase One of a four step process to review General Education Eligibility Requirements for certification as a CPM.  The following is a summary report of the findings of the Focus Group. The report includes a rationale for the review process, an overview of the 4 steps in the process, and summaries of feedback on proposals presented by the NARM Board.

The purpose of the Focus Group was to bring subject matter experts together in one room to review proposals from the NARM Board and bring forward critical input relating to the criteria for competency in the practice of midwifery by CPMs and the impact on stakeholders of any proposed changes.

Review Criteria:

Group participants were asked to print out and review proposals prior to the meeting. Multiple opportunities were given during the meeting to provide feedback to the Board and to the other members of the Focus Group.

For each proposal, members were asked to provide answers to two questions.

Question 1: What would be the impact, positive or negative, of the proposed change?

Question 2: What would you suggest to improve this proposal?

Proposal #1

Current requirements:

There is no category for “Observed Births” in NARM’s current requirements.  Births as an Active Participant (Form 111) are births where the apprentice is being taught to perform the skills of a midwife. Just observing a birth is not considered being an Active Participant. See Preceptor Policies for more information.

Proposed Change:

To add a category for Experience Requirements called “Observed Births” and to change the category name called “Active Participant” to “Active Assistant”. Observed Births would be categorized as births at which the participant has no clinical role other than labor support such as doula, friend, or family member. Minimum number of Observed Births would be 10. Observed Births may be signed off by any witness and occur in any setting. Active Assistant births, which must occur in a setting that supports the MMOC, would be required to be signed off by a qualified preceptor.

Focus Group Response Summary:

Adding Observe Births:

Response to this proposal was heavily weighted to the positive (4:1).

Positive comments included feedback that the proposal would: increase screening of potential midwives and help them to determine early in their training if they were cut out for midwifery, help them to learn by observing without the pressure to perform, increase experience in all settings if there was a requirement for hospital or out of hospital observes.

Negative comments included feedback that the proposal would: impact privacy for mothers in labor by having “extra people” at the birth, increased difficulty to find opportunities for observes especially in rural or underserved areas, concern about observes being in hospital and not with the MMOC.

General comments to improve the proposal included suggestions to: require that observed births be signed by a qualified preceptor, allow for observes to go back up to 10 years, and limiting the number to 5.

Active Participant/Active Assistant and Preceptor Signature Required:

Response to this proposal was heavily weighted in the positive (5:1).

Positive comments included feedback that this change would: increase commitment from aspiring midwives, improve clarification of the roles and responsibilities of the assistant (esp. if in combination with Proposal 1), help the student develop skills on a deeper level and increase an understanding of the process.
Negative comments included concerns that this would increase the time it would take to get through the process, increase costs, give the preceptor too much power over deciding whether a birth is an observe or an assist, and limit advance placement in schools.

General comments to improve the proposal included: addressing how transports would be handled, considering evidence to determine the right numbers needed,  better define the terms by clarifying which kinds of skills are learned as an Active Assistant.  There were also comments suggesting that reconsider the new term.  The terms “student”, “assistant”, “participant”, and “involvement” were all mentioned as meaning different things to different midwives.  NARM will need to carefully define our terms.

Proposal #2

Current requirements:

20 Primary Births Under Supervision

Proposed Change:

To increase the minimum number of births in the category of Primary Birth Under Supervision to 25.

Focus Group Response Summary:

Response to this proposal was heavily weighted in the positive (6:1).  16% of the positive respondents felt the number should be raised even higher (30-40).

Positive comments included feedback that this change would increase entry level experience and knowledge and would solidify the CPM as the “expert” in out of hospital birth.

Negative comments were mostly about the time it would take to get more clinicals, and the access to preceptors. Some were concerned that the cost of finding supervised clinicals would be increased. Two were concerned about the impact this would have on states that list their numbers in their law, and that a change might jeopardize the laws. One worried that the political message would be that are current training isn’t enough. Some were concerned about the impact this would have on schools. One felt that there should be no absolute number – that the readiness should be determined by the preceptor (note: the preceptor currently has the responsibility to determine which births “count” so that would not be a change). One suggested provisional certification with minimal numbers and full certification after more numbers (note:  Certification means “ready to practice” – and licensure based on certification depends on certification actually meaning “ready to practice” so a provisional certification could not be implemented.  If the student is not ready to practice, then the certification should not be issued.)

Proposal #3

Current requirements:

As most CPMs do not practice in hospital settings in the US, the CNM/CM route of entry is the primary route that allows hospital primary birth experience as part of certification requirements. NARM policy states that all clinical experience (not including Observe Births, as proposed) documented as part of training occur in a setting that supports the Midwives Model of Care. CNMs are required to document 10 out of hospital births as part of documentation for certification.

Proposed Change:

To require that all Primary Births Under Supervision be Out of Hospital Births.

Focus Group Response Summary:

Response to this question was hard to quantify based on confusion about the proposal itself. There was significant lack of clarity on how this proposal would be implemented. Some were concerned about not counting transports because transports are a valuable part of the training (note: the current requirement for OOH does allow for some (2) births to be transports; there is currently no proposal to change this number). Other concerns were for CNMs or foreign midwives who have a difficult time getting more OOH births. Several comments were concerned that this would restrict overseas clinical opportunities. Several thought we should encourage hospital birth in order to seek hospital privileges in the future. A majority of responses indicated the opinion that the CPM is an OOH credential and that most births should be in an OOH setting. This question will need to be clarified and rephrased in the survey to clarify the impact on transports, CNMs, foreign trained midwives, and out of country clinical sites.

Proposal #4

Current requirements:

There is no requirement to attend any of the total 20 primary births at home, but ten of the primary births must be in out-of-hospital settings, which may include birth centers or homes.

Proposed Change:

To require that a minimum of 5 Primary Under Supervision Births be Home Births.

Focus Group Response Summary:

Response to this proposal was heavily weighted to the positive (4:1).

Positive comments included feedback that this change would: insure quality midwives, validate CPMs are experts in homebirth, OOH birth, give experience in the setting most CPMs will be practicing in, improve safety for mothers, great proposal, very much needed, homebirth is heart of this credential.

Negative comments included concerns that this would increase the time it would take to get through the process, increase need for more preceptors, may be hard to find preceptors, decrease CNMs as preceptors (which would diminish collaboration between CPMs and CNMs), may have negative effect on schools and in illegal states, divisive.

Some suggested an increase of more than 5 homebirths.

Some suggested that there be a minimum requirement for birth center experience as well.

Proposal #5

Current requirements:

3 Continuity of Care primary births are required. Continuity of Care is defined as four prenatal visits, birth, one newborn examination, and one postpartum examination as primary or primary under supervision.

Proposed Change:

To require that the minimum number of Continuity of Care Births be raised to 10.


The required clinicals (prenatals, birth, newborn exam, and postpartum) for a Continuity of Care would be signed by the same preceptor.

Focus Group Response Summary:

Response to this proposal was overwhelmingly weighed to the positive (8:1).

Positive comments included feedback that this: is an essential component of MMOC, would increase consumer confidence and enhance public perception of the CPM credential, would better prepare students and commit them to a longer course of study, would give students a deeper understanding of the process.

Negative comments included concerns that this would increase the time it would take to get through the process, increase need for more preceptors, may be hard to find preceptors or clients willing to have student care, would be difficult to achieve in underserved areas, when clients are not compliant, acts as a barrier for students to attain their certification.

General comments: Many suggestions to increase COC to 5, 10,15 or half of Primary Under Supervision births, many suggestions to change definition of COC, ie increase number of prenatals, require first and second trimester visits, allow a percentage of transports.

Proposal #6

Current requirements:

10 of the primary births must occur within the last 3 years, there is no currency requirement for the remaining 10 primary births.

Proposed Change:

To require that all primary births should occur within 10 years of application. (The current requirement that 10 of the primary births must occur within the last 3 years will remain.)

Focus Group Response Summary:

Response to this proposal was heavily weighted in the positive (8 to 1).

Positive comments supported a more recent time frame for getting the clinicals. Most felt that ten years was too long for the whole body of clinicals. There were many suggestions to shorten the period when all clinicals must be obtained to 5-7 years, even if the number of clinicals increases.

Negative comments were not opposed to the proposal, but instead asked about exceptions for rural areas or special circumstances where access to experiences is harder to obtain.

Proposal #7

Current requirements:

There is a minimum requirement of 1 year from first to last primary clinical (prenatals, births, postpartum, or newborn exams). Documentation of Active Participant (Assistant, as proposed) is currently only for births, not prenatal, postpartum, or newborn exams.

Proposed Change:

To change the minimum requirement for duration of clinical training with the following options:

    1. Change definition of minimum to one year from first to last primary birth under supervision. OR
    2. Extend the minimum requirement for duration of total primary clinicals to at least 2 years, including prenatals, births, postpartum, or newborn exams. OR
    3. Add requirement for documentation of Active Assistant (training) in all clinicals (prenatals, births, postpartum, and newborn exams) and extend the minimum requirement for duration to total clinicals to at least 2 years.

Response to Option 1 (change to Primary Birth as criteria for one year minimum):

There was a lot of confusion around this question, most likely because many people were unfamiliar with NARM’s current definition of “birth” and “clinical”. 25% of the respondents did not understand the question or were asking for clarification rather than providing feedback.

The remaining responses were weighted in the positive (2 to 1).

Positive comments included feedback that this would strengthen the credential by increasing quality and duration of training.

Negative comments included feedback that more time would not make better midwives and concern that this would negatively impact schools.

One general comment was that we should define training based on clinical hours or numbers of clinical, and not by the total time frame.

Response to Option 2 (change in minimum duration requirement for Primary Clinicals):

Response to this question was heavily weighted in the positive (5:1)

Positive comments were focused on great idea, what took you so long, will legitimize the credential and make better more competent midwives. It would help eliminate the “fast track”. It would give students a deeper more complete learning experience with more opportunity for continuity of care. This should go along with the increase in the clinical requirements.

Negative comments were focused on questions like, should it be measured in clinical hours instead of years? An example would be we have said that 1350 hours made up at year. So could we say 2700 hours was a two year program? This would help the “programs”, such as MLL. Other negative comments focused on what makes us think we need more? Where is the evidence for the change?  Will the two years limit access to care?

General comments questions to improve the proposal included: Do we need more than two years? We need at least three or we need to add other education such as an AA,  Anatomy and Physiology and/or Pharmacology

Option 3- (no response because this is a new proposal from the NARM Board in response to comments from the Focus Group)

Proposal #8

Current requirements:

Documentation of non-midwifery education is not required.

Proposed Change:

To require that all CPM applicants have a high school diploma or equivalent.

Focus Group Response Summary:

Response was overwhelmingly positive for this change (5:1)

Positive comments included: this will add to the legitimacy of the credential and wanting to keep the “equivalent language” in place. This would allow for Amish midwives, out of country, home schooler’s etc.  Requiring a high school education would assure a minimum age requirement. The academic level of the CPM requires a certain competency of reading, writing, and deductive and thinking skills. A review of the self-reporting demographics of current CPMs indicates that all have a high school diploma or equivalent. This new requirement should not have a large impact on applicants, but may have a significant positive impact on the public image of the profession.

Negative comments included thoughts that this was an example of “over regulation”, some felt this was not enough education and that we need more than a high school diploma. Some thought this would limit students to getting more education if this is all that is required and also limit access to midwives. There was one general concern that making this a requirement would bring attention to the fact that some CPMs don’t have more education than this.

As long as NARM only requires documentation of midwifery education, advocates for CPMs are justified in using that response to criticism about not requiring even more non-midwifery education (baccalaureate, etc). Once NARM requires any non-midwifery education, we lose that rationale.

Proposals from the Focus Group Participants:

What else?

This was an opportunity for participants to make additional proposals to the NARM Board for any changes in categories that we had not already made in our proposals. Participants were asked to include any comments for their rationale for this suggestion, including any impact that they anticipate from this change.

Focus Group Response Summary:

  • There was a proposal to increase preceptor requirements to include specific requirements for additional education in order to be a preceptor.  Comments on this proposal were evenly mixed.
      • Positive responses included: increased preparedness and effectiveness of preceptors.
      • Negative responses included: decreased availability of preceptors.

The remaining proposals received no additional comments. Proposals included suggestions to:

  • Limit the number of preceptors for one applicant (reduce “preceptor shopping”).
  • Ensure that applicants have more than one preceptor.
  • Make the NARM exam more difficult
  • Make the NARM exam easier
  • Create a mentoring program for new CPMs
  • Require research competence.
  • Require MANA stats contribution.
  • Include 1st and 2nd trimester prenatals in Continuity of Care births.
  • Increase requirements for foreign trained midwives.
  • Add Anatomy and Physiology or equivalent to requirements for General Education prior to application

Parking Lot:

There were 50 comments posted on the Parking Lot, which was a place for comments not directly related to Eligibility Review.  Some of the comments (preceptor experience level, continuity of care) were actually already reflected in existing proposal responses or Proposal 11.  Many of the topics (well woman care, nutrition, water birth, data collection, epidemiology) were related to the job analysis and would need to be addresses through that process.  Some of the comments were clearly conversations that were happening in writing between participants.  This seemed like a useful tool during the Focus Group process, but poses challenges for follow through.  One idea would be to address some of the comments (building consulting relationships and understanding midwifery at the state and national level, revoked preceptors, etc) as Position Papers, Frequently Asked Questions on our Web site or in future newsletters.

Other comments to consider:

  • retired midwife category
  • more preceptor guidelines (written agreement between student/preceptor, relationships)
  • eliminate notary requirement
  • reflect on ICM definition of midwife in our deliberations
  • “accredit” PEP
  • Quality Assurance for CPMs
  • two step certification (entry level and advanced)
  • address all changes with the question, “Will this preserve home/normal birth?”
  • evaluate the skills assessment process for PEP
  • peer review requirements during training

Phase 2: Eligibility Survey

Every CPM was sent information on completing the following survey:

CPM Survey Questions-blank

The responses were compiled and are listed in this report:

CPM Survey Proposal Responses

Phases 3 and 4: Evaluation and Outcomes

The NARM Board and consultants reviewed the eligibility review responses and approved the following outcomes.

New requirements for Entry Level applications effective September 1, 2012:

    • All applicants must complete a minimum of a high school education or equivalent.
    • All applicants must submit proof of completion of an approved module on cultural competency for health professionals.
    • The title “Active Participant” Births will be changed to “Assistant under Supervision” and must be supervised by a qualified preceptor.  Preceptors who verify Assistant under Supervision clinicals will need to meet the existing definition of a qualified preceptor. This requirement will be in effect for clinicals (births, prenatals, newborns, and postpartums) that occur after September 1, 2012.

NEW requirements for Entry Level applications effective January 1, 2013:

The clinical requirements will be documented in four phases.  Documentation may be submitted as each phase is completed, or may be submitted as one complete application at the end of Phase 3.  The advantage of submitting the application in phases is to establish verification, through documentation, of meeting the requirements of each phase.

Phase 1:  Births as an Observer

Document attendance at ten births in any setting, in any capacity (observer, doula, family member, friend, beginning student). These births may be verified by any witness who was present at the birth. This form may be submitted when complete or at any time prior to submission of Phase 3 forms.

Phase 2:  Clinicals as Assistant under Supervision

Document at least 20 births, 25 prenatals (including 3 initial prenatal exams), 20 newborn exams, 10 postpartum visits as an assistant under the supervision of a qualified preceptor.  Eighteen births in this category must be completed before beginning Primary under Supervision births.  Determination of readiness for serving as Primary under Supervision is at the discretion of the supervising preceptor, and may require more births as an assistant before moving to the next step.

Phase 3:  Clinicals as Primary under Supervision

Document 20 births, 75 prenatals (including 20 initial prenatal exams), 20 newborn exams, and 40 postpartum exams as a primary midwife under supervision.  Two intrapartum transports are allowed if labor began in an OOH setting. CPR and NRP are submitted with this phase. The verification of Knowledge and Skills (Form 201) will be submitted with this phase, and may have been signed during Phase 2 or 3. The Knowledge and Skills list will include verification of both the knowledge base and the performance of skills in a clinical setting. The student is eligible to register for the NARM Examination once the first three phases have been submitted and approved.

    • Continuity of Care:
      Of the 20 Primary births required under Supervision in Phase 3, five require full Continuity of Care and ten more require at least one prenatal under supervision.
    • Full Continuity for 5 Primary Births:
      Five Continuity of Care as a primary midwife under supervision will include 5 prenatals spanning two trimesters, the birth, newborn exam and two postpartum exams. Multiple preceptors can verify the continuity of care.   The newborn exam must be done within 12 hours of the birth; maternal postpartum exams must be done between 12 hours and 6 weeks following the birth.
    • Prenatals for 10 Additional Primary under Supervision births:
      Students must have attended at least one prenatal (in a primary or assisting role) with the mother prior to her labor and birth for 10 of the 20 primary births under supervision in Phase 3 (in addition to the 5 with full COC).

Phase 4:  Five Additional Births as Primary under Supervision:

Document five additional births as Primary under the supervision of a Qualified Preceptor. These may have occurred after the last birth on Phase 3 documentation, and may be submitted before or after the Written Exam.  Only one maternal transport may be included if the labor begins in the OOH setting. Submission of this form is expected within six months of passing the exam unless a request for an extension is made.

Additional Requirements (not related to Phases)

  • Experience in specific settings: A minimum of five home births must be attended in any role in any phase.  A minimum of two planned hospital births must be attended in any role in any phase.  These cannot be intrapartum transports but may be antepartum referrals. These births may be included in documentation of Phases 1, 2, and 3.
  • Time frames: Ten out-of-hospital primary births must occur within the last three years.  All clinicals documented on the NARM application must occur within ten years of application submission.
  • Minimal time frames for entire experience: Clinical training documented in Phases 1, 2, and 3 must span at least two years. [A review of NARM application data indicates that most training spans three to five years. Theoretical/didactic education is integrated within the clinical training period.]