Future-Thinking Midwifery Education: Birthing the Midwives We Need

Midwifery Today, Issue 139, Autumn 2021.
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The most exciting thing to me about the future of midwifery is the non-traditional nature of midwifery education in America and the potential it has to become a model for the world. Student midwives can train by apprenticeship at the same time they also earn college degrees in midwifery, without ever leaving their home community. This is a game-changer.

Non-Traditional Education

From my vantage point of having lived and learned for six decades, I feel fortunate to have benefited from non-traditional education for most of my life. The majority of my own 20 years of formal education was non-traditional in nature, starting with grade school in a one-room log cabin schoolhouse on a remote ranch in the American West, and culminating in two advanced degrees—a masters of midwifery and a masters of intercultural studies—both earned at a distance while I was practicing midwifery and running an international nonprofit. In a circular return to my rural roots at the start of my school years, my last degree from a seminary in the Philippines was earned while I was living on a remote island, traveling by boat to pick up books and turn in assignments (and I was attending approximately 20 births per month during those years as I trained a birth center staff on that island). Non-traditional higher education has allowed me great flexibility in my education as an on-call midwife, which I have so appreciated.

Non-traditional higher education is defined as education that is offered in ways other than common daytime college classrooms. Typically, students who start college at age 25 or older are also labeled non-traditional. Due to my own unique educational experience, and the benefit I have seen in the lives of others, I am a proponent of non-traditional education that is able to be accomplished in the midst of life, at any age, and in any location.

Mercy In Action’s History

In the 1990s, I worked with my friend and mentor Elizabeth Gilmore on the foundations of what became the National College of Midwifery, her vision of a “college without walls” for midwives everywhere. Mercy In Action’s midwifery school was a college within those “walls” for almost 20 years. Following Elizabeth’s death, we applied for and received our own accreditation from the Midwifery Education Accreditation Council (MEAC).

Providing quality distance and community-based education to our students is at the heart of what we do at Mercy In Action College of Midwifery. Our students have between three-and-a-half to seven years to complete a bachelor of science degree in midwifery, without ever sitting in a classroom. Their academics are completed in both synchronous and non-synchronous classes they attend online, within a cohort model and with peer learning groups for support. Our school attracts a diverse student body from all walks of life and ages, which makes these cohort groups even more beneficial. Clinical apprenticeship takes place at the student’s own pace, with the ongoing support of their clinical director and their peers. The real strength, though, is in the reality that students learn in a clinical placement they choose, in a community birth setting that they choose. This freedom of choice in a midwifery clinical placement site is rare anywhere else in the world and represents non-traditional midwifery education at its best.

Global Midwifery Education

Globally, countries around the world require their midwives to attend an accredited program of instruction, based on the International Confederation of Midwives core curriculum. Some countries require their midwives to become nurses first; others are direct entry. In most cases, both the academic and clinical portions of midwifery education occur within an institution.

In the Philippines, where I have lived on and off for the past 30 years, the standard for the education of midwives changed recently from a two-year associate degree requirement to a four-year bachelor’s degree requirement. As midwifery colleges made this shift nationwide, practicing Registered Midwives were encouraged by the government to go back to school to earn a bachelor’s degree in order to not be phased out. Mercy In Action provided scholarships for several of our staff midwives for the bachelor of science in midwifery (BSM) program, many of them after decades of practice. These BSM programs were “traditional” in nature, requiring set times in the classroom and set times in local hospitals for the clinical rotations that were required. From my point of view as a midwife educator and clinical leader, this system was not very conducive to adult learners or practicing midwives who needed to be on call for their own clients. There was not much flexibility in the model, though the long-term benefit was understood.

The Need for More Midwives

Many health experts are proposing that we need more midwives in the US, to meet the growing demand of birthing mothers and to reduce the high rate of unnecessary intervention around childbirth, intervention that is not improving outcomes and may be making them worse. I have attended endless webinars and read reams of research on the subject of reducing maternal and neonatal death rates in America, and the subject of needing to scale up the availability of midwives usually comes up. In fact, currently legislation to fund midwifery education (for both Certified Nurse Midwives [CNM] and Certified Professional Midwives [CPM]) is being proposed toward this end.

And it is not just happening in the US. Around the globe, researchers, policymakers, scholars, and visionaries are saying the same thing—that the world needs more midwives everywhere and they need to be trained to the highest caliber in order to save lives. North America or Asia, Africa or Latin America, developed countries or developing countries; the message is clear—the world needs more good midwives.

The ongoing demand for midwives means those of us concerned with education should consider the future of midwifery and how we “birth” those future midwives. Models must be identified that are reproducible, scalable, and, most important, practical and effective at improving maternity care outcomes.

A Model Worth Sharing

As I have traveled the globe in my work over the past 30-odd years, I have observed an interesting phenomenon: the vast majority of midwives in developing countries are trained in hospitals in the big cities, even though many of them are expected to serve in out-of-hospital and often rural locations upon graduation. This has made me consider how CPM midwifery education is unique in that the hands-on clinical training occurs outside of a hospital, usually in the learner’s community. This could be an important model for other places in the world.

Even with the global requirement for midwifery programs to be accredited (which is pretty standard in most countries in the world at this time) and the shift to requiring a bachelor’s degree (which is rapidly becoming standard in many countries) it would be possible for the US model of midwifery education to show the rest of the world how midwives can be educated in their own communities, without a brick-and-mortar school and without an associated teaching hospital. We hold this knowledge of how this is possible in the United States—we have something important we could share.

There are currently many high-quality and distance programs to train midwives in America, both CNMs and CPMs. These programs are online for the majority, if not all, of the academic portion and allow clinical experience to be gained in the student’s community, for the most part. What if this model caught on around the world?

Countries that require nursing as a prerequisite to midwifery training could look to ACME accredited programs online, such as Frontier Nursing University, Thomas Jefferson University, and George Washington University, to name a few. Countries that train their midwives in a direct-entry model could look to the MEAC-accredited schools in the US that offer a bachelor-level degree and teach by distance education, including our Mercy In Action College of Midwifery, Midwives College of Utah, and National College of Midwifery. These programs could serve as models for the rest of the world, making midwifery education, and birth outcomes, better for it.

Mercy In Action is already modeling a different kind of clinical training on a small scale in the Philippines. One of our birth centers (noted as being one of the few midwife-led, ICI-approved* sites in the country) is now an official clinical training site for the regional midwifery college and we are currently consulting with another midwifery college on a different island. For decades, our Filipina midwives have encouraged both student and post-graduate midwives to shadow them to learn respectful family-centered maternity care on the job, and we will continue to offer these valuable (and non-traditional for the Philippines) mentoring internships.

Big Picture

As I have pondered the future of midwifery, I believe we need to think of the big picture. Midwifery is stronger when midwives have the option of staying in their home communities to train. Homebirth is stronger when the practitioners have been trained hands-on in that model during their own education. Birth is safer when women have more options, including birth in their own community and birth at home when it is a safe choice. Forward-thinking planners should take all this into consideration as new and better models are created for birthing the future midwives that the world so desperately needs. As goes the future of midwifery, so goes the future of birth, and the future of midwifery will benefit most from creative solutions in non-traditional education that meets global standards of excellence.

*The International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care. https://icichildbirth.org/initiative/

Vicki Penwell (62) has been a midwife since the age of 21 and a midwife educator for as long. She makes her home in the Philippines and the US when not traveling to speak around the world and divides her time between oversight of the Mercy In Action birth centers in the Philippines, the Mercy In Action College of Midwifery in the US, and the many global educational programs and trainings she helps create. Vicki has been married to her husband Scott for 42 years, and they have three sons, two daughters-in-law, and five grandkids, most of whom are involved in the midwifery or medical profession. She is addicted to lifelong learning!

About Author: Vicki Penwell

Vicki Penwell, LM, CPM, MSM, MA, has provided clinical maternity care for decades in low-resource, high-mortality countries and regularly teaches on midwifery best practice, dividing her time between living in the USA and the Philippines. She is the founder and Executive Director of Mercy In Action, a global NGO sponsoring birth centers in the Philippines, and Mercy In Action College of Midwifery, a MEAC-accredited school in the USA that promotes a global perspective on the provision of maternity care. Through the college, Mercy In Action offers many accredited CEU courses for practicing midwives, as well as offering a post-graduate diploma in midwifery & maternal/child health. Vicki has earned a master’s degree in midwifery and another master’s degree in intercultural studies. She is married to Scott, her husband of 42 years, and together they have raised three “Third Culture Kids” and now have two daughters-in-law and five second-generation TCK grandkids. Among their descendants are three CPMs, one MD, and one in medical school now; they all work for or volunteer with Mercy In Action in some capacity!

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