The International Path to Midwifery Education
By Vicki Penwell, CPM, MS, MA
Founder and Director of Mercy In Action School of Midwifery, a non-profit NGO dedicated to safe motherhood and newborn survival in developing countries
There are many paths to gaining a midwifery education. Some may even take you down tracks far from home, where local customs are foreign, the landscape is exotic, and the language is as yet incomprehensible to you. While an "out-of-country" (a term coined by NARM) midwifery internship may not be for everyone, for a well-rounded world-view of midwifery, nothing can beat some time spent learning birth customs in a foreign country. An "out-of-country" internship allows you to serve among birthing women different from you, with different needs and different stressors, different family structures, and certainly, a different set of possibilities for complications and emergencies surrounding birth. And yet when all is said and done, a cross-cultural experience will help you realize that all women are more the same than different when it comes to giving birth on planet earth.
Same-Same but different
This concept is best expressed by a common saying used in the open markets in Thailand to describe an item that is similar to another. The vendor will see you looking at a particular scarf, for example, and then hold up another in a different color or style and exclaim "same-same but different!" I have often thought this expression perfectly fits the different sites of midwifery education; in all sites, babies come out of mothers, and the physiological process of birth is the same. But the customs, beliefs, complications, nutritional status, and outcomes can be vastly different. The location for birth, the rituals, and the actions and attitudes of the birth attendants can be vastly different, too, depending on the country or region.
In this article, we are going to limit our discussion only to "out-of-country" sites that provide a standard Midwifery Model of Care, as approved by the North American Registry of Midwives (NARM), and would qualify as an educational site that contributes to the student earning the Certified Professional Midwife (CPM) designation. The Midwifery Model of Care can be translated into any setting, in any country, with dramatic results. For example, Mercy In Action builds all of our educational programs upon the Midwives Model of Care, ensuring that the longitude and latitude where the birth takes place is not as defining as is the underlying philosophy of care. By doing this, we have been able to achieve outcomes that are similar to USA perinatal statistics, as opposed to the 4 times higher rates of perinatal mortality of the country we are working in.
Rich cultural experience or post-traumatic stress?
Whether or not a midwife or student midwife should seek a placement in a high-volume birth practice in an under-developed country depends on her personality and ability to process cross-cultural experiences in a positive way. Most midwives will feel enriched by the experience; others may come home with symptoms of post-traumatic stress. To help a potential student decide, I have listed some pros and cons below:
*Rewarding to feel like you really make a difference
*Get high volume birth experience
*Exposure to a variety of complications
*Exposure to variations on normal vaginal births, (breech, twins)
*Confidence building that comes with more and varied experience
*Learn a little bit of a foreign culture and language
*Make international friends
*Come away with a world-view of midwifery
*The rewards that come with travel and seeing the world.
*May see death as well as birth
*May feel overwhelmed by poverty and suffering
*May feel frightened of the variety and frequency of complications
*May fear for personal safety, or fear getting robbed
*May feel unprepared for cultural differences, or fear the feeling of being out of control in a culture in which you do not understand the basic rules of that society.
*Expensive to travel to a foreign country to learn
It is important for a student midwife who is considering a foreign placement, whether 2 weeks or 2 years, to be self-aware and honest in assessing her own ability to function in that setting. It may help to ask trusted friends and family members who know you well to help you make that assessment. It is no shame if it is not a fit for you. But if you think it may be, read on...
NARM “out-of-country” clinical sites
At the time of this publication, the North American Registry of Midwives (NARM) has approved eight programs as “out-of-country” sites for training midwives. These eight sites are in diverse locations; Asia, Africa, Latin America, and Europe. With the exception of the site in Holland, all are in under-developed countries where the felt-need for midwives is acute. Three of the eight sites are directed by midwives who were trained in part by this author in the Mercy In Action School of Midwifery program, a fact that makes me proud to know that our culture of sharing knowledge is being passed on around the world.
The following excerpt was taken from the NARM website (www.narm.org):
Midwifery students seeking certification from the North American Registry of Midwives may seek training in clinical sites outside of the US and Canada (OOC sites). Students must be supervised by a qualified preceptor who is physically present in the room with the student when clinical skills are performed. Births attended by the student may count toward NARM certification requirements as Active Participant births if the student is able to perform various midwifery skills under the supervision of the preceptor, and if the preceptor is able to give instruction and feedback to the student before, during, and after the clinical experience. Births may count as primary births only if specific conditions have been met and if the clinical site has received approval from NARM. Approval by NARM as an out-of-country clinical site does not constitute an endorsement of a particular site based on setting or conditions such as accommodations, sanitation or cultural customs, but rather as verification that the clinical training students receive is in accordance with the NARM guidelines for primary under supervision and the Midwives Model of Care.
One model for “out-of-country” midwifery education
Mercy In Action School of Midwifery in the Philippines is one of the NARM approved “out-of-country” sites for midwifery training. We have been in the business of midwifery education for decades (since 1981) and have thus far trained hundreds of midwives who went on to become CPM's and eventually train others. Mercy In Action Inc. is a USA recognized 501(c)(3) non-profit organization that trains both USA based and foreign-based midwives, and trains both midwives and medics to serve in under-served parts of the world. We are a faith-based Christian organization; however, this does not limit who can participate in our clinical or academic programs-our educational programs are open to participants of all faith traditions. We only ask that our values in offering our midwifery services be respected, such as guarding the dignity of all human beings, respect for the sanctitiy of life, and compassion toward the suffering and poor.
Since Mercy in Action is a non-profit organization that focuses on the crisis in maternal and newborn health care, we establish and fund free birth centers for low-resource families in the Philippines. All student tuition fees go toward this purpose, and to date more than 12,000 babies have been delivered free of charge for the poorest of the poor in birth centers that Mercy In Action founded. Many former students are particularly proud of the fact that they learned midwifery skills and contributed to better health for under-served women at the same time. Overall, the results have been positive, as having student midwives means there is even more attention spent on each individual woman in labor. Women and their families have continually expressed appreciation and gratitude for receiving care in a training birth center where their needs were met in a kind and competent manner.
Mercy In Action School of Midwifery provides numerous and varied learning opportunities overseas for midwives and aspiring midwives. These include but are not limited to:
* Academic schools of Midwifery
* Clinical internships in Midwifery
* Midwifery Training Retreats focused on midwifery topics specific to developing countries and women in poverty. * NARM Study Retreats to prepare for the CPM board exams
* MEAC Accredited CEU's for Continuing Education in Midwifery
Mercy In Action has also worked closely with the National College of Midwifery (a degree-granting college without walls) since the National College of Midwifery's inception in 1985. The brilliance of the "college without walls" concept is that students can duel-enroll in the National College of Midwifery and earn a college degree in midwifery accredited by the Midwives Education Accreditation Council (MEAC), which is approved by the USA Department of Education, all the while doing their clinical requirements anywhere in the world that has a Midwifery Model of Care and trains with Licensed Midwives or CPMs.
Mercy In Action has Licensed Midwives and CPMs in our “out-of-country” site that are qualified preceptors for the National College of Midwifery and the NARM PEP process. This is an important factor in choosing an “out-of-country” clinical site, because you want your clinical experience to count toward your eventual CPM or degree program.
The Midwifery School, as well as our clinical internships, seminars and training retreats are all designed to prepare midwives to meet the global shortage of skilled birth attendants around the globe. Many of our graduates are working now as midwives in desperately needy countries in Africa, Asia, and Latin America, making a significant difference in maternal/child health.
Go as a well-informed and gracious guest
For details about the specific programs, requirements and expectations of Mercy In Action School of Midwifery, or any of the other “out-of-country” sites you may be considering, go to the appropriate website, call the director, or ask other midwives (who have been there) for a recommendation. After discussing the pros and cons, consider whether this method of midwifery training is right for you, either as a supplement to a North American apprenticeship or as a full educational program.
If you decide to train in a foreign country, be sure that you do research on the country, such as learning the customs of that country, visa requirements, the currency exchange rate, and required vaccines, if any. By being informed and knowing what to expect, you raise the odds of a positive experience; for yourself, for the health care professionals running the “out-of-country” site, and most important, for the women and families you will serve while visiting their country as a student midwife.
Above all, remember that an “out-of-country” midwifery training program positions you as a guest in someone else's country, and we should treat this as an honor and privilege, as well as a valued learning experience.
Vicki Penwell is a life-long cross-cultural learner. She has earned both a Bachelor's and a Master's of Science degree in Midwifery in the USA from the National College of Midwifery, and a Master's of Arts degree in Missions / Intercultural Studies in Asia from Alliance Graduate Seminary. She is currently enrolled in a PhD program in International Maternal-Child Health. Vicki has been a licensed midwife since 1983 and a CPM since 1992. She lives in Asia with her husband Scott of 31 years, and works beside her son and daughter-in-law (both CPMs) in providing maternity care and primary health care for poor families in the rural Philippine Islands. Vicki writes frequently for publication and travels to teach all over the world.