Frequently Asked Questions

US MERA — which stands for US Midwifery Education, Regulation, and Association — is a coalition of seven US midwifery-related organizations inspired and informed by the global midwifery standards and competencies of the International Confederation of Midwives (ICM). US MERA is working to advance the vision of expanding access to high-quality midwifery care and physiologic birth for all women in all birth settings in the United States.

US MERA is comprised of representatives of the eight national midwifery organizations: Accreditation Commission for Midwifery Education (ACME), American College of Nurse-Midwives (ACNM), American Midwifery Certification Board (AMCB),
International Center for Traditional Childbearing (ICTC), Midwifery Education Accreditation Council (MEAC), Midwives Alliance of North America (MANA), National Association of Certified Professional Midwives (NACPM), and North American Registry of Midwives (NARM). The vision of US MERA is to improve maternity care in the US — and by extension, the health of US families — by aligning with international standards for midwifery education leading to entry-level certification for all midwives and supporting legislation leading to regulation that incorporates these standards.

Our shared mission is to elevate and grow the profession of midwifery in all 50 states, and all territories and commonwealths by applying the ICM standards to the education and practice of midwifery through collaboration and support of professional associations concerned with these issues in the United States.

We are focused on three primary purposes at this time:

  1. Create a shared vision for US midwifery within a global context by aligning with the three pillars of the ICM global standards;
  2. Generate an action plan for collaboration to strengthen and promote the profession of midwifery in the US; and
  3. Make a positive impact on US maternity care that will improve the health of all families and promote normal physiologic birth.

The seven organizations began meeting after the 2011 ICM Triennial Meeting at which ICM member organizations approved new global standards for midwifery education and regulation, core competencies, and definition of a midwife. Since that time, a steering committee has been formed representing all seven organizations which meets monthly via conference call with a professional facilitator. US MERA also holds in-person meetings at least once annually.

ICM is a non-governmental organization representing midwives and midwifery worldwide to achieve common goals in the care of mothers and newborns. ICM supports, represents and works to strengthen professional associations of midwives worldwide. ICM currently has 116 midwives associations, representing more than 300,000 midwives from 101 countries across every continent. ACNM, MANA, and NACPM are all member associations of ICM representing midwives from the United States. Click here for more information about ICM and its work to advance midwifery around the world.

Over the decades, our organizations have differed in our philosophies and strategies for how best to advance midwifery in the US. While we certainly have made strides despite these differences, sometimes our disagreements have prevented us from recognizing our shared vision and from working together effectively. The ICM global standards have provided us an opportunity to engage in dialogue, strengthen our relationships and unite to achieve our shared vision.

It is significant that the national midwifery membership associations, educational accreditors, and certifiers have, for the first time, agreed to work together to advance midwifery. It will take time for us to develop shared approaches on all issues, but we have made an important start and have agreed to continue working together. We believe that this work will help ensure that all women, in all birth settings, will one day have access to high-quality midwifery care. The opportunity to transcend our differences and work together is energizing, and we are all learning from each other.

We believe that the work of US MERA will increase access to midwifery care by achieving a much larger and diverse workforce of nationally certified midwives who are trained in the essential competencies for basic midwifery practice. To get there, we need to advance our profession in the eyes of policymakers, payers and the public. We need regulatory mechanisms that protect women and families by ensuring that all practicing midwives are safe and competent and work autonomously to provide high standards of care in all settings, within their scope of practice. We believe that moving toward accredited educational programs and aligning with global midwifery standards will enhance the recognition of our profession and our ability to create an integrated system of care that works for women and families. We also believe that this move will increase access to midwifery education, by paving the way toward increased education funding. Midwives should be able practice freely to the extent of their education and training, participate in any insurance company’s provider network, openly advertise their availability, and present themselves to the public and to other health care stakeholders in a manner that fosters collaboration, mutual respect, and seamless care transitions when needed.

US MERA organizations support the inclusion of the following language in state legislation for licensure of CPMs.

  1. For CPMs Certified BEFORE January 1, 2020: completing non-accredited education pathways: The US MERA Professional Regulation Committee proposes that NARM offer a Midwifery Bridge Certificate for CPMs. CPMs who were certified prior to January 1, 2020 through a non-accredited educational pathway will be required to obtain this certificate in order to be licensed in new licensure states. This certificate will be based on the completion of 50 hours of accredited continuing education, specific to content in emergency skills for pregnancy and birth, and newborn care, along with other midwifery topics addressing ICM core competencies.
  2. For CPM licensure after 2020 in NEW Licensure States: Beginning January 1, 2020, all applicants for CPM licensure in states with NEW legislation are required to complete an educational program or pathway, accredited by an organization recognized by the United States Department of Education AND pass the NARM examination or another national midwifery certification examination offered as part of an NCCA accredited credentialing program.
  3. For Licensure of CPMs moving from states with existing licensure to NEW licensure states: CPMs who have completed the Portfolio Evaluation Process (PEP) or a non-accredited educational pathway to sit for the certification exam in an existing licensure state must obtain the Midwifery Bridge Certificate as a requirement for licensure in the NEW licensure state.

At this time, this proposal does not apply to states where there is existing legislation for CPM licensure. However, as states revisit or review their licensure requirements, additional language may be added.

Consumers and midwives benefit when midwifery organizations work to pursue common goals. These agreements solidify the support of all US MERA organizations for legal recognition of CPMs, CNMs, and CMs in all states to the full extent of their education and training.

ACNM, ACME, and AMCB conducted a detailed gap analysis that compared the basic competencies and standards for the education of CNMs and CMs to ICM standards. It was found that the competencies and standards for CNMs and CMs meet or exceed ICM competencies and standards. A gap analysis was also conducted looking at the regulations related to CNMs and CMs, and it is clear that there is much work to be done to meet the ICM regulatory standards, especially in the area of achieving autonomy and full scope practice for CNMs and CMs in all states and territories.

ICM’s regulatory standards are based on the premise that health professionals are regulated at the national level—which is true in most countries. In the United States, however, health professionals are regulated at the state level. Bringing consistency to all state regulatory processes will be a long and arduous battle.

Here are some of the activities underway in the CNM/CM community to advance ICM standards:

Promotion of interprofessional education and practice. We believe that women and families are best served when health professionals can freely collaborate, consult and refer with and to each other with mutual respect to best meet the needs of their clients.

If you live in a state that already recognizes PEP training as a qualification for licensure, this recognition will not change as long as the current laws and regulations are on the books. However, as states revisit or review their licensure requirements, additional language may be added.

If you live in a state where CPMs are still working to gain legal recognition, the new US MERA agreements mean that when deciding whether to support CPM licensure legislation, all midwifery organizations have agreed to support legislative language that states that, by 2020, new applicants for midwifery licensure must have successfully completed an education program accredited by MEAC, and that CPMs already certified through a non-accredited program may obtain the Midwifery Bridge Certificate in order to be licensed. Because licensure in the US is a state-by-state process, there may be many variations in the licensure language. Midwives will need to meet all requirements for licensure determined by their state laws and regulations.

We encourage midwifery advocates who are working on licensure bills to reach out to other stakeholders to pursue a collaborative process, and by contacting US MERA early in the process at or visiting our website, If you are currently working to complete your PEP training to become a CPM, and you seek to practice in a state in which CPMs are not currently licensed to practice, you will want to monitor licensure efforts carefully that affect your ability to practice. US MERA organizations have agreed to work together to support state licensing that requires completion of an accredited education by 2020. Therefore, we do expect that licensure in those states for CPMs certified after 2020 will include a requirement for an accredited education.

US MERA is aware of the high cost of midwifery education and we are committed to addressing this issue as we also work together to support legal recognition, which offers consumer protections as well as benefits to CPMs. In addition to the range of affordable MEAC-accredited programs that are already available in the United States, US MERA is pursuing the development of new accredited direct-assessment, competency-based midwifery training programs. These programs will build on the innovations and affordability of the Portfolio Evaluation Process (i.e. PEP) pathway while leading to an accredited midwifery education that will facilitate gaining legal recognition, expanding professional opportunities for CPMs. Our hope is that by adding additional educational pathways, the midwifery workforce will be able to scale up to adequately meet the needs of women in the US, and align with global standards for midwifery education as well as the standards of the US Department of Education. By meeting these standards, we are better able to work to increase the funding for midwifery education, which will be critical to maintaining affordability.

Additionally, it is important to note that currently, most health insurers, including most Medicaid programs, do not currently cover the services of CPMs. As more CPMs move toward accredited education as the path toward licensure, it is likely that additional public and private health insurers will agree to provide coverage for CPM services, expanding access to midwifery care to additional women and families and increasing CPM earning potential, which may help to offset the increased costs of going through an accredited educational program.

We acknowledge the importance of community-based education and the need for more educators, preceptors, and clinical sites to ensure the success of the work of US MERA. US MERA is committed to working from the top down (policy work) and from a grassroots level upwards (community based training).

Innovations in higher education, as well as new guidelines from the US Department of Education, are creating new avenues for educating midwives and other health professionals in accessible, accredited programs in a manner that retains the strengths and innovation of the PEP process. These innovations hold promise for actually increasing access and affordability of midwifery training that will meet the needs of students who are seeking a flexible and accessible pathway for becoming a midwife and will support achieving full legal recognition in all states.

Instead of awarding credits based on the completion of courses and how much time students spend learning, the direct assessment model awards credits based on whether students can prove they have mastered competencies — the knowledge, skills and abilities required in an area of study. In competency-based education, it’s not about the amount of time the program lasts, but rather, what you know and are able to do. Direct assessment is now recognized by the US Department of Education as an alternative pathway for establishing competency in accredited programs. Direct assessment program students are eligible for financial aid – opening up all kinds of exciting possibilities for increasing access to midwifery education. Those who value and/or have trained through the PEP pathway will find this model entirely recognizable.

There aren’t yet any accredited direct assessment programs for midwifery, but in the schools that have launched direct assessment for other occupations, tuition is fixed at a much lower level than regular programs that rely on course instruction. Competency-based education is a growing model that directly takes aim at affordable access to education. In higher education in the U.S., there is a rising tide of college education access and affordability enabled by competency-based education. Accredited programs can offer access to federal funding that can significantly offset the cost of education.

NARM will continue to administer the CPM certification process for PEP trained midwives because it is a legal avenue to licensure in many states. CPMs who trained in non-accredited programs would have to obtain the Midwifery Bridge Certificate to apply for licensure in a state that utilizes the new US MERA language in their licensure law.

Yes. We have agreed to use a Delphi process for this important but challenging work. A Delphi process is a method for structuring a group communication process that is effective in allowing a group of individuals, as a whole, to achieve consensus with a complex problem. It involves a series of rounds of collecting information about a topic from participants, which is analyzed and fed back to participants for further rounds of information collection and analysis. It provides an opportunity for individuals to revise their judgments based on this feedback and anonymity for individual participants. The Delphi report is expected to be available in late summer, 2015, and will be a companion document to the US MERA proposal on licensure. All US MERA documents will be available on the website.

We encourage organizations that wish to improve access to high-quality maternity care to support US MERA agreements as the means of achieving our goal of expanding access to high-quality midwifery care to all women in the US in all birth settings. We believe that to do so, we must also be committed to strengthening our official US midwifery organizations and their ability to work together toward a common purpose, aligning our work with the global standards of the International Confederation of Midwives. We believe that activities that conflict with the work of US MERA will undermine our ability to meet our goal of a strong and unified midwifery profession that can meet the needs of more consumers over the long term.

US MERA has developed a formal memorandum of understanding between our organizations that includes a process and criteria for additional organizations to apply for membership with our collaboration. Organizations that are current members of US MERA have met the ICM standards for professional associations, or are agencies that accredit midwifery schools (recognized by the US Department of Education) or certify midwives through an NCCA-accredited process in the US. Organizations interested in membership should email or contact us through the website’s contact page.

For more information, send questions to or contact us through the website’s contact page. All questions will be shared with the full Communications Committee for consideration and we will respond as soon as possible. Please understand, however, that US MERA is still working on several key policy issues and we may be unable to provide further clarification on these issues until additional decisions are made.


Learn more about competency-based and direct assessment educational models:
Learn more about the Delphi process:
  • Business Dictionary: Delphi technique
  • British Council: The Delphi technique

  • updated August 20, 2015