Last week, around the world, candidates for certification sat for the Lamaze Certified Childbirth Educator exam. That test represented the culmination of weeks, months and often years of planning, preparation, studying and hard work. While the results are still some weeks out, I thought it would be interesting to learn about the science behind the Lamaze exam and what makes it the gold standard of childbirth educator certifications from Judith Lothian, PhD, RN, LCCE, FACCE, the chairperson of the Lamaze Certification Council Governing Body. Today's families deserve the best, so they can push for their baby, with all the evidence and research that stands behind the LCCE credentials of their childbirth educator. Learn more about attending a Lamaze workshop and explore becoming an LCCE yourself so you can offer families in your community the gold standard of childbirth education. - Sharon Muza, Science & Sensibility Community Manager.

Lamaze International is extremely proud of the fact that the Lamaze certification examination is the only examination for childbirth educators that is accredited by the National Commission for Certifying Agencies (NCCA). Achieving and maintaining this accreditation is a rigorous and ongoing process.

Accreditation by NCCA assures you that the exam you take will accurately measure the competencies of a childbirth educator. The seven competencies of a Lamaze Childbirth Educator are supported by job analysis research that is done every 5-7 years. The last job analysis was conducted in 2012. The results of that analysis were published in the latest issue of the Journal of Perinatal Education. Lamaze members may access the full journal online after logging in to the Lamaze website. Basing the exam on the results of a job analysis is an important way to ensure that the exam accurately evaluates the competencies of a childbirth educator. Fairness is a very important issue and to that end NCCA has evaluated our policies, our procedures and the actual exam, including the construction of items and the exam itself as well as the evaluation of its performance. The NCCA stamp of approval is a vote of confidence that experts in the certification field believe that the Lamaze certification policies are fair and that the certificate examination accurately evaluates the competencies of a Lamaze Certified childbirth educator.

Lamaze is the only childbirth educator certification program that has received NCCA accreditation. Professional standards set by the Institute for Credentialing Excellence describe the difference between professional certification and assessment based certificate programs. "Professional or personnel certification is a voluntary process by which individuals' pre-acquired knowledge, skills, or competencies are evaluated against predetermined standards. The focus is on an assessment that is independent of a specific class, course, or other education/training program. Participants who demonstrate that they meet the standards by successfully completing the assessment process are granted the certification." The American College of Nurse Midwives and the International Board of Certified Lactation Consultants are examples, like Lamaze, of professional certification.

In contrast, an assessment-based certificate program is a non-degree granting educational program that provides instruction and training to help participants gain specific knowledge and skills and then evaluates achievement of expected learning outcomes and awards a certificate to those who successfully pass the assessment. Childbirth educator certifications, other than Lamaze, are assessment-based certificate programs. Because of this, many educators who have childbirth educator credentials from other organizations choose to sit for the Lamaze exam.

Why is this important? It assures you that the certification examination has met the rigorous standards of professional certification, that the exam is fair and actually measures what it is should to insure that you indeed have achieved the competencies to practice as a Lamaze childbirth educator.

The certification exam consists of 150 multiple choice questions and the questions reflect the essential information a childbirth educator should know (the competencies of a Lamaze Certified Childbirth Educator). An inside look at the process of item writing and exam construction and evaluation will give you a taste for how rigorous, and interesting, the process actually is.

The exams are put together by a test development committee that meets twice a year for 4-5 days. The committee includes expert childbirth educators, a public member who is not a childbirth educator, and, often a novice childbirth educator (a high scorer on a recent exam). Using the test blueprint (based on the latest job analysis) the committee writes questions and then a smaller group "constructs" individual exams from the item bank of questions.

Draft items are written in small groups, usually 2 or 3 educators. It is actually very, very difficult to develop a fair question that measures knowledge and skills that are important for the childbirth educator to know. It is tedious work and challenges all of us without exception! Once a small group has developed an item they think has potential it is, often with great trepidation, presented to the entire committee for discussion. Leon Gross, PhD, the psychometrician (a testing specialist) is at the meetings and at this stage he will often point out potential psychometric issues related to the items, including things like "it's too long", "there is extraneous information," "could there be 2 answers?" In developing and evaluating each item we ask ourselves: Is it clear? Is there only one right answer? Do we know the right answer (if we don't then we most definitely do not use it)? Is there any overlap in the answers? We edit each draft item for content and language, keeping in mind, that the distracters (the wrong answers) should be "plausable". It is an extremely honest and often raucous process! We all have to be prepared to have our questions torn apart! It helps to have a sense of humor and remind ourselves of the importance of the process. Then the committee decides to either put the questions in the permanent item bank or not. The entire process is done with expert psychometric support.

Our philosophy, in the writing of the items, in the evaluation of the items, and then ultimately choosing the items that will be on each exam, is that we only test what is really important to know. There are no intentional "trick" questions. It's important to know that if the committee struggles with identifying the correct answer it is automatically not used. And, the questions are written in order to evaluate the competencies of what we constantly refer to as the 'just good enough candidate.' So, this is most definitely not an exam where you have to be an "expert" to pass. In order to pass this exam you need to be "just good enough". This exam is intended to measure competencies of a beginning childbirth educator.

When the committee decides to put a question in the item bank we then establish the level of difficulty for the question. We look at each correct answer and then we look at distractors, the wrong answers. We discuss the distracters related to how plausible this distracter would be to a candidate who is just able to pass the exam. This is an example of the process:

What is the capital of Maryland?
1. Baltimore
2. Chevy Chase
3. Annapolis
4. Fredricksburg

There is one correct answer and three distracters. If you know the capital of Maryland, this is a very easy question. It's straight recall. If you, however, don't know what the capital of Maryland is, then you will be tempted to go for a plausible but wrong answer. The correct answer is Annapolis, but Baltimore is a plausible answer because it's the largest city in Maryland and, of these four choices, it is the most well-known city. For someone who does not know for sure that Annapolis is the capital of Maryland they would be tempted to think it was Baltimore. Therefore, we would label Annapolis the correct answer and Baltimore a "sophisticated distracter". We aim to have at least 50% of the exam questions with "sophisticated distracters". The more questions with sophisticated distracters the higher the level of difficulty of the exam. It's important to know this to understand how the passing score is determined for each test administration.

This exam is criterion referenced which means that the passing score is determined before the test is given based on the level of difficulty of the questions on the exam. Candidates who sit for the exam are never compared to each other and the passing scored is determined by how difficult the questions are, not a predetermined passing score. Candidates are evaluated against a standard not against the scores of the other candidates sitting for the exam. The more items on the exam that have sophisticated distracters, the higher the level of difficulty, the lower the score you need to pass. The fewer items with sophisticated distracters, the higher the score is that you need to pass the exam. The pass score, the cut score, for passing the Lamaze certification exam has over the last years ranged 70 to about 75.

After the exam is given, the exam is scored and reviewed by the psychometrician. A detailed statistical analysis is done. There is an analysis of each item on the exam. How many testing participants got the answer right? What distracters did those who got it wrong go for? The item analysis also identifies what percentage of the high scorers got the question correct and what percentage of the low scores got the question correct. A "good" question statistically is one that discriminates between the high scorers and low scorers. This means that you would expect a high percentage of the people that did well overall on the exam to get a question correct and those that did not perform as well on the overall exam to get the question wrong. If we find that there is an item that most of the low scores got correct and only a few of the high scorers got that question correct, we would wonder why.

After the psychometrician reviews the overall exam and each item, he will flag the questions that may look like they may not be "performing" well. The small group that constructed the exam meets by conference call to discuss both the flagged items and the comments the candidates have made related to the exam. Every comment is reviewed. Whether or not we keep an item, or don't keep the item, is the decision of the committee. We also look at the performance of the exams that are translated into other languages and look at how individual questions performed for instance in Spanish compared to in English. We try to determine if there are cultural differences or whether there are translation problems. At times a question may be deleted from scoring in a language other than English and not in the English exam. Once we determine if there are items we will drop then the psychometrician will re-score the exam and determine, based now on the questions that remain on the exam (and their level of difficulty), a final cut score. It takes about 6 weeks to get exam results. During that time the certification team is working hard to make sure your exam is fairly evaluated.

The rigor of developing the exam, including the job analysis, and then the scoring of the exam are only one part of the requirements for NCCA accreditation. In addition, our policies and procedures related to everything from exam eligibility and grievance procedures, as well as confidentiality issues and the qualifications of both the staff and volunteers involved in the certification process, are rigorously evaluated. The end result, we hope, is a valid, reliable, fair certification exam that protects the value of the LCCE credential, and, most importantly, assures women and their families that the Lamaze Certified Childbirth Educator is competent. NCCA accreditation is a vote of confidence that we are indeed doing what we intend.

Are you an LCCE? Can you share why you chose Lamaze International and your journey? Are you considering becoming a childbirth educator? Have you explored Lamaze as an option? I invite you to consider certifying with Lamaze International and achieving the gold standard for childbirth educators. - SM

About Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

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