How do I become a homebirth midwife in Colorado?
The practice of midwifery was legalized in Colorado in 1993 and is now regulated by the Department of Regulatory Agencies (DORA) Midwives Registration Program. Direct-Entry Midwives in Colorado are called Registered Midwives and this is, for all intents and purposes, considered the same thing as a Licensed Midwife.
This document describes the pathways to Homebirth (or Direct-Entry) Midwifery practice in Colorado for the entry-level midwife.
First, a brief description of the entities and organizations that are involved in midwifery membership, training and certification in the United States and North America:
MANA stands for the Midwives Alliance of North America and is a professional organization for all midwives in North America. In 1994, MANA developed a comprehensive list of Core Competencies for Basic Midwifery Practice, and this list forms the basis for national certification as a Certified Professional Midwife (CPM).
MEAC stands for Midwifery Education Accreditation Council. MEAC sets the standards for midwifery education programs and accredits programs and institutions in the United States based on these standards.
NARM stands for the North American Registry of Midwives. This organization is responsible for establishing and administering certification for the Certified Professional Midwife (CPM).
Requirements for Registration
To become a Registered Midwife in Colorado, you must graduate from a MEAC-accredited midwifery program or obtain substantially equivalent education. This substantially equivalent education is achieved by completing the NARM Portfolio Evaluation Process (PEP) or undergoing a credentials review performed by the International Credentialing Associates or the International Consultants of Delaware. The credentials review is appropriate for midwives trained in other countries.
Applicants who are already credentialed as a Certified Professional Midwife are automatically deemed eligible for Colorado Midwifery Registration.
(Prior to 2003, midwives were required to prove they had achieved appropriate didactic and clinical experience through an apprenticeship with a qualified preceptor. In 2003, the Colorado requirements for midwifery registration were changed to include graduating from a MEAC program or obtaining equivalent education.)
Those who apply for Midwifery Registration after graduating from a MEAC-approved program or after attaining educational equivalence must pass a written examination administered by DORA which measures competency in the practice of Direct-Entry Midwifery. Currently, this examination is the same one that is administered by NARM to those applying for the CPM credential.
MEAC-Approved Midwifery Training Programs
The MANA Core Competencies for Basic Midwifery Practice form the basis for the CPM certification program. MEAC-approved schools create their curricula based on the requirements in the Core Competencies and graduation from a MEAC-approved school indicates the candidate is qualified to practice midwifery. The student may submit her diploma to the Colorado Department of Regulatory Agencies for permission to sit for the written exam.
There are currently no midwifery schools in Colorado, but many have formed in different states across the country. Some of these programs require physical attendance at the school and some offer distance-learning programs. Distance-learning programs require the student to work with a local preceptor in order to learn clinical skills; the didactic portion of the training is accomplished either online or through self-study following a curriculum provided by the school. Some schools offer a hybrid program, requiring physical attendance for perhaps one weekend a month or a few weeks per year; the rest of the training is accomplished in the student’s home town under the supervision of a qualified preceptor.
A more traditional approach to Homebirth Midwifery is through apprenticeship: the student apprentices with an experienced midwife, learning everything there is to know about midwifery from her. There are no formal rules about how apprenticeships work; it is up to the preceptor and apprentice to work out the expectations and requirements for their particular partnership.
It’s important the apprenticeship include both didactic and hands-on skills training sufficient to fulfill the requirements of the NARM PEP process, which is the process NARM uses to determine educational equivalence to a MEAC-approved program. In general, the apprentice begins by attending prenatal and postpartum appointments with the midwife while studying, reading books, and researching issues relevant to midwifery care. When the preceptor determines she has attained sufficient knowledge, the apprentice begins attending births with the midwife, learning hands-on skills for managing birth. Eventually, the preceptor will hopefully determine the apprentice is ready for independent midwifery practice.
NARM Documentation for the Apprentice Process
Apprentices must document their education and experience wherever and however they get it. NARM provides a complete set of forms that must be completed in this process. This documentation is called the Portfolio, and NARM uses it to thoroughly evaluate each student’s education to ensure it is equivalent to what could be obtained through a MEAC-approved program.
NARM requires documentation of at least 20 births attended by the apprentice as an “observer” or “active participant”, which means the apprentice is learning to perform relevant midwifery skills at these births. Eventually, the preceptor determines the apprentice has attained enough knowledge and skills to perform all aspects of midwifery care herself, and the apprentice becomes a Primary Midwife Under Supervision. In Colorado, we also call midwives at this stage “Interns”, harkening back to the days when the CMA Midwifery Certification Program was in effect.
NARM requires performance by the Intern of 20 Initial Prenatal Exams, 55 Additional Prenatal Exams, 40 Postpartum Exams, 20 Newborn Exams and management of 20 Births. The preceptor must be present in the room while these skills are being performed. NARM also requires 45 pages of basic midwifery skills performed by the Intern to be verified by the preceptor. Everything must be notarized and charts and other documentation may be requested by NARM at any time.
Once all of these requirements have been met, the Primary Midwife Under Supervision may submit her Portfolio to NARM for evaluation. Once the evaluation is complete, the student may be approved to take the hands-on Skills Test administered by a Qualified Evaluator. Once the Skills Test is passed the student may be deemed by NARM to have achieved an education equivalent to that obtained through a MEAC-approved midwifery training program. Documentation of this educational equivalence is submitted to DORA, and DORA may then approve the student to sit for the written examination. Again, note that at this time, the Colorado exam and the NARM exam are the same.
(Note that NARM recently implemented an alternative to the Skills Assessment by a Qualified Evaluator: Applicants can have a second midwife (who has the CPM credential and meets certain requirements) verify an additional set of skills performed by the Intern on a 7-page verification document. This second verification super cedes the need for the applicant to take the hands-on skills test. This document must also be notarized.)
In Colorado, the Midwives Registration Exam is administered twice per year, in February and August, by the Department of Regulatory Agencies in Denver. At the current time, this exam is the same one administered by NARM for the CPM credential, so the student will essentially be achieving the CPM credential and the RM credential at the same time.
Within a reasonable amount of time (usually a few months at most) after passing the exam, or after submitting proof of already having the CPM credential, DORA issues the Midwifery Registration Number and the applicant is deemed licensed to practice midwifery in the State of Colorado.
Challenges to Becoming a Midwife in Colorado
The biggest challenge you will encounter is finding a preceptor. There are about 60 Registered Midwives practicing in Colorado; many of them do not feel they’ve yet had enough experience to train another midwife. Those who have had a lot of experience probably already have an apprentice or two. It is going to take you some time to find a situation that will work right for you.
Consider becoming a member of the Colorado Midwives Association; attend our conferences, come to our meetings, get to know our members and the midwives around your area. Networking and developing relationships in the community is vital to someone new starting out and looking for a way to become a midwife.
You can plan on this process taking several years—4 to 6 is the average. It will depend on which distance program you enroll in, how motivated you are to complete the program, and how busy your preceptor is. If your preceptor attends 3 to 5 births per month, you will finish sooner than someone whose preceptor only attends 1 birth every month or two. Ultimately, remember that it is up to the preceptor to decide when the apprentice is ready to advance in her training, be it from student to apprentice, or apprentice to intern, or from intern to taking the exam and becoming licensed.
Midwifery Practice in Colorado
Registered Midwives in Colorado practice as independent care providers, with no requirement for physician backup or oversight. The Department of Regulatory Agencies provides a complete set of rules regarding midwifery practice in Colorado and is responsible for receiving complaints and taking disciplinary action where appropriate.
Midwives must renew their registration every year in November and pay a fee for that renewal. They must also submit a set of statistics to DORA regarding the number of women they cared for that year, number of births attended, Apgar scores of the infants, etc.
Registered Midwives in Colorado are a small group of healthcare providers who serve a small and distinct population. Approximately one percent of all births in Colorado each year take place at home under the care of a midwife.