How Does Continuing Education Influence Maternal and Infant Mortality and Morbidity?
Disparities in maternal mortality and morbidity between Black, Indigenous and People of Color (BIPOC) and their white counterparts are well documented and indisputable. It is also well known that the primary reason for these disparities is racism and the impacts of systemic, institutional, and interpersonal oppression, prejudice, and harm.
Racism and oppression are baked into the public health systems, education systems, provider training institutions, professionalization processes, and laws that regulate healthcare and the paths to becoming a provider (among many other spaces), which were largely developed by and for white people, and which continue to uphold structures of white supremacy, whether intentionally or not.
There are numerous ways to disrupt and dismantle these oppressive systems, some of which include using the institutions and structures that currently exist to push change.
When we’re talking specifically about direct entry midwifery and out of hospital birth, what structures exist that can be used to push change?
The Institutions and Structures That Impact Midwifery
State Laws and Regulations
The ability of direct entry midwives to practice legally is state specific, as is their scope of practice, both of which vary greatly across the US. According to The Big Push for Midwives, only 37 states currently offer licensure for professional midwives. Of these 37 states, most require a midwife to obtain the CPM credential and/or graduate from a Midwifery Education Accreditation Council (MEAC)-accredited midwifery program.
Accreditation and Professionalization
MEAC is a US Department of Education (USDE) recognized accreditation agency, and graduation from a MEAC-accredited midwifery program is one of five pathways to the Certified Professional Midwife (CPM) credential granted by the North American Registry of Midwives (NARM).
Accreditation is a tool of accountability that sets standards for education and prioritizes the protection of students in terms of their financial investment in their education, the quality and relevance of the education they receive, and the experience they have during their education.
Academic and Clinical Training
All MEAC-accredited institutions and programs include two components: academic instruction and clinical apprenticeship. The contents of these components are outlined in MEAC’s Curriculum Checklist of Essential Competencies. The policies and procedures of the program or institution, which include the training requirements, review processes, and accountability structures for faculty (folks who provide academic instruction) and preceptors (experienced, legally-recognized midwives with whom students complete their clinical training or “apprenticeship”), are outlined in the Standards for Accreditation.
Continuing Education
In order to maintain the CPM credential (and to maintain licensure in many states), active midwives must earn a specified number of Continuing Education Units (CEUs) each licensing/certifying cycle. Midwives can accomplish this by attending conferences, workshops, and seminars on various topics related to their work.
How do these institutions and structures directly influence maternal and infant mortality and morbidity?
Healthcare outcomes are directly related to the health care that folks have access to, which is dependent on the providers available to them and the education the provider has received and continues to receive.
The availability, quality, and safety of providers is dependent on the aspiring provider’s ability to navigate the educational system, as well as the content and quality of their educational institution or program, which can be influenced by accreditation requirements and oversight.
The Role of Accreditation in Reducing Disparities
As mentioned above, accreditation is a tool of accountability that can deeply influence education. It can either be a way to minimize harm and maximize innovation and inclusion within education, or a tool to codify and reinforce white supremacy and systems of oppression.
MEAC recognizes that education and healthcare systems and structures disproportionately harm Black people, Indigenous people, people of color, LGBTQAI+ people, immigrants, Disabled folks, and other populations and individuals who experience harm as a result of supremacy culture. MEAC believes that it has not only the ability, but also the responsibility, to influence midwifery education, and thereby midwifery practice, in the adoption of principles and practices of justice, equity, diversity, and inclusivity.
MEAC sets standards that help schools and programs embrace and support their students, recognizing and celebrating their intersecting identities, as well as how those identities influence a student’s path to midwifery, their motivations and barriers to becoming a midwife, and ultimately the communities they serve and their way of serving them.
The Role of Continuing Education in Reducing Disparities
Nearly half of a student’s midwifery training takes place in their clinical apprenticeship during which they are trained and supervised by a currently licensed or otherwise legally authorized midwife. During this time, the student midwife works in the precepting midwife’s practice, and cares for the precepting midwife’s clients.
Most often, the student is not compensated for the work they provide to their preceptor, and is also unable to work an outside job due to the on-call nature of birth work. Most preceptors recognize that the labor they receive from the student is fair compensation for the energy and experience required to teach the student midwife. Some schools choose to pay preceptors as a sign of respect and to motivate preceptors to engage, while other schools choose not to pay preceptors, as the payment would come directly from the student’s tuition (meaning a student pays twice for the opportunity to learn, once in tuition and again with uncompensated labor).
The relationship between preceptor and student midwife has a deep impact on the student’s ability to succeed and learn, and apprenticeship has been cited as one of the biggest challenges midwifery students face, especially for BIPOC and LGBTQAI+ students. Many students have cited unreasonable expectations, verbal and emotional abuse, overt racism, microaggressions, homophobia, transphobia, and invalidation of gender identity or expression as reasons for needing to leave an apprenticeship. When this happens, it comes at a great financial and personal cost to the student and can derail their path to midwifery.
One way to address harmful preceptorships as a barrier for BIPOC and LGBTQAI+ student midwives (which makes becoming a midwife more accessible, and thereby supports the health outcomes of the student midwife’s community) is to develop a diverse, culturally responsive, and actively anti-racist and anti-oppressive pool of preceptor midwives.
MEAC is authorized to approve CEUs for active midwives, and recently completed a full reexamination of its CEU application through an anti-oppressive lens to ensure that the courses we approve appropriately address maternal health disparities, racism, homophobia, transphobia, and other sources of harm faced by pregnant people and their families, as well as midwifery students.
Organizations like BADT, founded on principles of justice, and focused on culturally appropriate, diverse, and action-oriented courses, are vital to our shared vision of a more equitable world. MEAC staff and board members strongly encourage BIPOC and Queer owned and operated educational organizations that address the intersections of identity and birth work to apply for CEUs for their courses. All courses are evaluated by our CEU coordinator and volunteer reviewers. The application can be found here, and the list of approved courses can be found here.
We hope that when midwives take BADT courses for CEUs, they become safer and more compassionate providers and preceptors, who can thereby ensure that all people have access to the Midwives Model of Care.
Katie Krebs (she/her) is President of the MEAC Board of Directors and Executive Director of National Midwifery Institute, a MEAC-accredited, direct entry midwifery school.
Katie holds a BA in Molecular, Cellular, and Developmental Biology from the University of Colorado, studied Public Health and Comparative Health Systems in Bremen, Germany, and received an MPH from Boston University. During her graduate studies, Katie focused on Perinatal Epidemiology, and specifically, access to options in childbirth and reproductive health care.
Katie has spent the majority of her career supporting and managing clinical research programs, while teaching childbirth education, developing birth and health related curriculum, and providing labor support on the side. Throughout all this work, Katie’s primary focus is on bodily autonomy, client/patient agency, and respect and dignity for all people.
While not a midwife herself, Katie firmly believes the world needs more midwives and specifically, more midwives to serve every body. Katie is dedicated to working in the systems that train midwives to ensure the structural barriers that lead to homogeneity in midwifery can be removed and a more just, accessible, and vibrant educational and training system can take root and thrive.
Katie lives in Maine with her partner, two kiddos and Freckles the dog. When she’s not working, you can find her knitting, hiking, cooking, or collecting sea glass on the beach.