September 10, 2019


Line Dempsey: Welcome to another edition of our podcast, Regulation Matters: a CLEAR conversation. I'm your host, Line Dempsey. For those who don't know me, I was a senior investigator with the North Carolina Dental Board for 16 years. I recently stepped down from that position and am now the chief compliance officer for Dr. Riccobene and Associates here in North Carolina. I'm also on the CLEAR board of directors, as well as the current chair of the National Certified Investigator Training committee and the vice chair of the annual conference program committee with CLEAR.

As you may be aware, the Council on Licensure, Enforcement and Regulation, or CLEAR, is an association of individuals, agencies, and organizations that comprise the international community of professional and occupational regulation. This is our podcast, and it's an opportunity for you to hear about the latest and greatest in your community. Today I'm joined by Ida Darragh, the executive director of the North American Registry of Midwives. I've known Ida for a long time. Actually I serve with her on the CLEAR board, and so I'm really excited to speak with you today. So thanks for joining us today.

Ida Darragh: I'm happy to be here, Line.

Line: Excellent. And the North American Registry of Midwives, as I understand it, issues a certification for midwives who are specifically trained to attend birth outside of the hospital. For you, I know your work focuses on test development, maintaining accreditation for the credential, and working with states that are creating licensure programs for certified professional midwives. I guess the topic I'd like to talk about today with you is certification and licensure (that's what we do at CLEAR) and the benefits of using a national certification as an eligibility to hold a license. So let me start with asking, I guess, what are some of the benefits to a state in using a national credential as an avenue to licensing for a profession in that state?

Ida: Well, Line, the primary benefit is for standardization and quality assurance. If the credential is accredited then it has met stringent standards for the creation of a credential, including standards for governance, test development and administration, and recertification. This means the state does not have to create and maintain those standards but can be assured through certification that their licensees had met rigorous criteria for their demonstration of knowledge, skills, and abilities.

Line: Gotcha. Well, what are the benefits to a licensee when a state uses a national credential as an avenue to licensure for the profession? I know this is something that I've looked into. I've been taking an EMT course for fun, and that's certainly something that we've looked at. But how does that benefit a licensee?

Ida: Well, the primary benefit is portability. If multiple states recognize the national credential for entry to practice licensure programs, then those professionals can move from state to state and more easily qualify for licensure. During their licensure period, they can be working toward meeting the license renewal criteria. Regardless of moving from one state to another where they live, they're working on the same standards for re-accreditation.

Line: So is there a need to be concerned about that?

Ida: Well, state rights has always been an important part of our national history, and licensure is a state-by-state issue in many professions. So one state might require a certain type of education and/or supervised experience, while another might require a test that's crafted by the state professional association but might not meet any standardized criteria for both validity and reliability.

If a state uses a test for entry to practice licensure and that test does not meet nationally accepted standards, then it can be challenged as not being legally defensible and establishing a right to practice. Of course, any test can be challenged, but if it has been nationally accredited, then it's more likely to hold up under those challenges. Also licensure requirements that are not consistent state-to-state can be challenged by an applicant who has been licensed and worked in a previous state but doesn't meet the different criteria that are set in another state.

Line: That makes sense. Well, looking I guess more specifically towards your work, how does the North American Registry of Midwives work with states that license certified professional midwives?

Ida: Well, Line, when the CPM credential was created in 1994, there were only 12 states that licensed midwives, who were called direct entry midwives, or midwives who were not educated in the nursing profession initially but who attended births in out-of-hospital settings such as homes and birth centers. The educational and clinical requirements for licensure in those states varied widely, and each state had written its own test for applicants to pass in order to get licensed to practice. Almost immediately after the NARM exam was created and nationally standardized, those states discarded their exams and adopted the NARM exam as a licensure exam. And the credential itself, which set standards for education and supervised clinical experience prior to taking the standardized exam, the credential became the standard as more states adopted licensure for midwives and the midwives who were attending births in homes and birth centers instead of hospitals.

As of today, there are 35 states that license these midwives, and all require either the NARM exam or the full CPM credential. There are still some states that have different additional requirements--for example, another exam on state law or state regs--but most are consistent with the guidelines for the CPM certification.

Line: So like in a situation like that, they may have their own particular jurisprudence test that you would need to take in addition. We're recognizing you because you've taken the NARM exam, but you also still have to take this state-specific test - is that right?

Ida: That's right. Most states have that. Not all states do, but it's a way to be assured that you understand their regulations and have agreed to practice by them.

Line: And that's certainly how, obviously, having worked for the Dental Board for 16 years, that is something we do with our credentialed professionals that are coming in, whether that be a hygienist or dentist. They still have a couple of things that they have to do specific to our state. Well, let me ask this, what about the states that do not have a license process for certified professional midwives?

Ida: Well, there are certified professional midwives working in every state, but not all states license or regulate the profession. In a state that does not license direct entry midwives, there may be midwives who hold the CPM credential and who practice according to national standards, but there may also be midwives who do not hold any credential or meet any criteria for education and training. So without licensure, the public has no way to determine which midwives are trained and which are not. Certification assures that, but not all of the public will know to check on certification criteria or to even ask of the midwife is certified. But when there's a licensure program, then the license must be displayed and the client can know that the midwife has not only met those standards but is accountable to that authority.

Line: Right. Well, how does the state agency obtain the authority to license midwives?

Ida: Well, licensure is authorized by the state legislature, so a law must be passed that defines who will be regulated, which authority will oversee the regulation, and usually some criteria for the licensure requirements and some scope of practice issues. Unfortunately, many state legislators know next to nothing about childbirth or the knowledge and skills that are needed for safe care. And that's why using a national credential that is recognized by many other states is a good standard for these states to use in crafting a licensing law.

Line: Yeah, I can attest to some of that, taking this EMT course lately. I'm now approved to help birth a baby.

Ida: [laughter] Yeah.

Line: I hope I don't ever have to [laughter], but I've been through the training now. So here's always the loaded question that I like to ask: Is licensure always the best way or best answer to protecting the public?

Ida: Well, not always. While some states have a detailed scope of practice issues embedded in their laws, others are choosing not to impose the expense of a bureaucracy into what many consider a private and personal choice of where and how they birth. So some states, like Missouri, have passed a law saying that those who hold this credential may practice legally without any state oversight or regulation. So they take the bureaucracy out of it. They don't have state oversight; they don't set rules; but they allow you to practice if you hold and maintain the national credential.

And one other thing - several states have a regulatory process that allows the use of specific meditations by licensed midwives, but they don't require licensure for those who do not carry or administer medication. So that's known as voluntary licensure. If you want this particular privilege, you must be licensed, but if you don't accept that privilege for your practice, then you can practice without a license. So that happens in some states as well.

Line: Okay, that's interesting. Well, what kind of state agency licenses midwives as you've described?

Ida: Well, this is one of the most interesting and varied aspects of midwifery regulation. While nurse midwives are almost always regulated under a board of nursing, the direct entry midwives are regulated under many different types of state agencies. The most common ones are departments of health, departments of professional regulation or licensure, and some under boards of medicine. But there are a couple of states that actually regulate midwives under boards of nursing and some under separate boards of midwifery or boards of alternative healthcare. And two are actually under the Department of Commerce. So the licensing agency is one of the most inconsistent elements of the regulation of midwifery.

Line: Interesting. Well, I guess as more of a kind of a final question: Obviously you've been doing this for a long time; what kind of trends do you see in the future for this link between maybe certification and licensure?

Ida: Line, I think we'll see this trend continue as a method of standardization and portability. Both are becoming bigger issues in state regulation. The ability to communicate ideas and issues almost instantaneously has led to more commonality as we look at what others are doing while we are finding our own way.

For example, the International Confederation of Midwives has developed standards for midwifery education, for regulation, and also for professional associations. And that's now been shared with all midwifery groups all over the world.

We in the United States have done a gap analysis of our standards in these areas as compared to international standards, and we're now using more uniform language in the way we identify and demonstrate knowledge, skills, and even professional issues. This has led to more acknowledgement of our own national standards and more acceptance of those standards by each state that seeks to license or regulate our profession. Individual states are no longer trying to recreate the wheel when it comes to midwifery education and regulation, and the work done in these areas by national and international groups is bringing out the best ideas for the future.

We see states that have old licensure programs they passed back in the 80s. Regardless of the agency that does the regulation, they're older programs. And some of those are changing to meet these national standards. But most important, states that are just beginning to consider regulation are looking at the national organizations and the certifying agencies to provide the best practices for them to model in their own licensure programs. And we think that's going to continue as each year more states adopt a licensure program and they base it on this national certification.

Line: Wow, that's great. Well, thank you so much, Ida, for your time today and also being part of our clear podcast and serving on our Board. We do appreciate that.

Ida: My pleasure.

Line: It's wonderful to chat with people like this, and so often we're dealing with board business that it's difficult to talk about what we do in our real lives, so I appreciate that. And I also wanna thank our listeners. We'll be back with another episode of Regulation Matters: a CLEAR conversation very soon. Please subscribe to our podcast. We have it available in a lot of different avenues; it's available on Podbean, iTunes, Apple Podcast, Google podcasts and Google Play, Stitcher, Spotify or TuneIn. If you have enjoyed this podcast episode, please leave a rating or comment in the app. Those reviews help us to improve our ranking and make it easier for new listeners to find it. Feel free also to visit our website at www.clearhq.org for additional resources and a calendar of upcoming training programs and events. Finally, I'd like to go ahead and thank Stephanie Thompson, CLEAR staff; she is our content coordinator and editor for our program. Once again, I'm Line Dempsey, and I hope to be speaking to you again very soon.



The audio version of this podcast episode is available at https://podcast.clearhq.org/e/using_national_certification/



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