The Certified Professional Midwife credential, issued by NARM, is accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the Institute for Credentialing Excellence (ICE, formerly NOCA). The mission of ICE is to promote excellence in credentialing for practitioners in all occupations and professions. The NCCA accredits many healthcare credentials, including the Certified Nurse-Midwife. NCCA encourages their accredited certification programs to have an education evaluation process so candidates who have been educated outside of established pathways may have their qualifications evaluated for credentialing. The NARM Portfolio Evaluation Process (PEP) meets this recommendation. The CPM is the only NCCA-accredited midwifery credential that includes a requirement for out-of-hospital experience.
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 and documentation of clinical skills with preceptor verification of proficiency. The certification verification was comprised of an extensive 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 Examination.
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 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. While these numbers have increased as the certification process evolved, the original requirements were:
- 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 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 test specifications for the NARM Examination were based on the content ratings from the 1995 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 were:
- Midwifery Counseling, Education, and Communications: 5%
- General Healthcare Skills: 5%
- Maternal Health Assessment: 10%
- Prenatal Care: 25%
- Labor, Birth, and Immediate Postpartum: 35%
- Postpartum: 15%
- 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 NARM Examination. The testing company stores the databank for the test items, and prints, stores, ships, and scores the 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. All candidates must have their education validated by one of the above routes before proceeding to the Certification Examination (the NARM Examination).
In accordance with state of the art psychometric procedures, the Job Analysis was repeated in an updated form in 2001, 2009, and again in 2016. 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 Examination 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 repeaters may take a different form on retake.
In 2010, the NARM board embarked on a survey process to review and consider changes to the eligibility requirements for the CPM credential. The proposal involved four steps:
- 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.
- 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.
- The third step in the process involves evaluation of all feedback and final determination by the NARM Board of changes to requirements.
- 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.
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. Over 100 CPMs met with the NARM board and a professional facilitator to discuss the current eligibility requirements and some potential changes. The proposals concerted the number of births or clinicals required for certification and the criteria for preceptor status. There were also proposals to require births in specific settings, to increase the continuity-of-care requirements, and to modify the time frame of the clinicals. Discussion included several options for change in these areas and identification of the advantages and disadvantages of each proposed change. Following this meeting, NARM consolidated the proposals and created a survey that was sent to all CPMs. Following that survey, NARM identified the elements with the most support and made these changes to the program:
- The levels of documentation for the application were divided into four phases which could be submitted upon completion of each phase. A new initial phase for 10 Observed Births was added, Phase Two included the births and clinicals as an assistant, Phase Three included 20 births and clinicals as a primary under supervision (upon completion the candidates was eligible for testing) and phase four for 5 additional births as primary under supervision.
- For the births in specific settings, changes were made to include two (observed) births in a hospital setting, at least ten must be in homes or other out-of-hospital settings, ten must be within three years of submission of application, none may be older than ten years, five require full continuity-of-care (at least two prenatals in two trimesters, birth, newborn exam, and at least two postpartum exams), and at least ten of the non-COC births must have at least one prenatal by the student.
- A new Phase Four was added to include five additional births as primary under supervision. All documentation for Phases One through Three would be required before authorization to test, but Phase Four births could be done before or after testing. Full certification would not be issued until all four phases were complete and the test passed.
More information about the Eligibility Review Process can be found here.
2016 NARM Job Analysis
The NARM Job Analysis was performed again in 2016. This was the first Job Analysis Survey done electronically and the first to include some elements of the standards from the Internal Confederation of Midwives (specifically pertaining to care of low risk women in out-of-hospital settings). A Job Analysis committee met in person in March, 2010, composed of seven NARM board members and eight additional CPMs. Items from previous Job Analysis surveys were reviewed along with suggestions from current CPMs obtained via internet questionnaires and elements from the ICM standards. The committee reached a consensus of 733 items to be listed on the 2016 JA survey. The domains were renamed to:
- Professional Issues, Knowledge and Skills;
- General Healthcare Skills;
- Maternal Health Assessment;
- Prenatal Care;
- Labor, Birth and Immediate Postpartum;
- Postpartum; and
- Well-care Baby (up to six weeks).
Renaming the domains and adding additional skills to each list required new item classifications for every skill. The survey was pilot tested with 30 CPMs which resulted in some additional clarification. The survey was finalized in May, 2016.
2126 CPMs who had current certification in May, 2016 were sent links to the survey. Some emails bounced, but of 2108 sent, 1126 opened the survey, 950 began the survey, and 706 completed the survey. Full statistical results of this survey may be found here.
Based on the results of the 2016 Job Analysis, new Item Writing workshops were held to create new questions for the NARM Examination. All current questions in the item bank were relabeled to the current test blueprint based on the Job analysis, and new items were incorporated into the appropriate domains.
Computer Based Testing
Prior to 2014, the NARM Examination had been administered only on paper at college and university testing centers. Exams were administered only in February and August at regional sites and a third time at the site of the annual MANA conference. In 2014, NARM contracted with ProvExam to administer the exam electronically at computer testing sites contracted to ProvExam. These exams could be administered almost any day of any month, therefore increasing the convenience to all candidates.
In March of 2020, all physical sites closed due to the pandemic. By May, the NARM Examination was able to be administered via home computers with live proctoring via webcams. That option will continue as long as approved by the NCCA.
In 2021, NARM changed test providers to Professional Testing Corporation, which began administering the exam through Prometric testing sites in September of 2021.