So Long, "Nurse" Midwives? Hilary Schlinger CNM, CPM puts ACNM’s proposed name change in 20 years of context

hilaryThe American College of Nurse-Midwives (ACNM)  has a motion on the table to change its name to the American College of Midwives (ACM).  While there has been talk about this change for years, there may finally be enough support to approve the motion at the upcoming annual meeting in San Antonio.  Much internal discussion of the politics surrounding the name change and how it may affect direct-entry midwifery has been occurring privately — I would like to move the discussion into a more public midwifery arena.

I interviewed homebirth midwife Hilary Schlinger CNM, CPM about the proposed name change and her vision for the future of midwifery in the US.  Hilary has a long history in midwifery politics as both a CPM and CNM. She has served on the Midwives Alliance of North America board of directors and is the author of Circle of Midwives, a book about the history of the Midwives Alliance of North America and the resurgence of midwifery as a profession in the United States.

Sit tight, this is a long one but there is lots to chew on here.   For help with the acronyms, see the MANA glossary of terms here.


Erin:   Hilary, you have spoken out publicly against the proposed name change of the ACNM, yet you have also been vocal about your vision for unification of the profession among CPMs and CNMs.  Why do you oppose dropping the “nurse?” 

Hilary:  I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US.  Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized.  If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery?  As a corollary, is it going to change the title of all its members to CM – Certified Midwife?

Here’s another way of looking at it:  Let’s say that the pride of the membership of the ACNM was their position as APNs (Advance Practice Nurses), rather than their attachment to the title of midwife.  And let’s say that a motion was put forward to change the name to “American College of Advanced Practice Nurses.”  Members would still have to go to an ACME-accredited program and pass the AMCB exam – the educational path and certification exams of other types of Advanced Practice Nurses (FNPs, CNPs, and Nurse-Anesthetists) wouldn’t qualify.  Would you expect the excluded nurse-practitioners to think the name change was a positive move? That it wouldn’t confuse the public, or legislators?  That it wouldn’t have the potential to undermine the work by other nurse-practitioner groups on political and/or legislative levels?


Erin
:  One argument in favor of the change is that ACNM needs to be more inclusive of its Certified Midwife (CM) members.  Tell us about your understanding of the politics surrounding the creation of the “CM” credential?

Hilary:  For those who joined the ranks of midwifery after the early 1990’s:  The history of the CM credential is NOT one that the ACNM can be proud of.  To understand why this is so, one must understand the context of the times.

In 1989, the first Carnegie Foundation Seminar on Midwifery Education was held, with joint representation from ACNM and MANA board members to discuss the expansion of direct entry midwifery education.  One year later, Carnegie offered funds to establish an inter-organizational task force so discussions between MANA and ACNM could continue.  A result of these meetings was the creation of the (original) “Midwifery Certification in the United States” document, jointly endorsed by the boards of both organizations in 1993.  The document affirmed ACNM as the appropriate organization to oversee education, certification and advocacy for nurse-midwives, and of MANA to respectively do so for direct-entry midwives.

ACNM acted in direct violation of the agreement when, less than a year later, the idea of the CM credential was “sold” to the membership.  Leading the charge for creation of the CM at the ACNM convention was the NY ACNM chapter.  In essence, New York was being used as the “testing ground” for an ACNM brand of direct-entry.  While other states were concentrating on defining nurse-midwives as advanced practice nurses, the legislative push in NY was to separate midwifery out from nursing.  When I say ‘midwifery’ here, I mean ‘nurse-midwifery,’ as their intention was never to include the voice of the existing (but unlicensed) DEMs.  The New York CNMs saw themselves being held back by nursing issues, and felt that the creation of a Board of Midwifery was their best route to controlling the parameters of their own practice.  Add to this the desire of some influential CNMs to design a European-style direct entry for the US –  and NY became the perfect place to test this concept.

So, when the New York midwifery law passed, the CNMs from that state needed the ACNM to move quickly in acknowledging its own route to midwifery separate from nursing.  Again, they saw this new law as a triumph, as the opportunity to design midwifery according to their own visions, and this included the opportunity to create direct-entry education.  And the last thing they wanted was to muddy their dreams with concerns of those outside their ranks.  They didn’t want to talk about place of birth, or about CPM-style education – they wanted to create a brand of direct entry that they perceived would be acceptable to the American public – Master’s Degree educated, prepared for hospital practice, just not entwined with nursing.

In “selling” the idea of the CM, the membership was told that creating the CM was “good for” the existing DEMs because it would create a legitimate route for their practice.  This couldn’t have been further from the truth;  there was no intention of creating a mechanism for us to achieve certification – it was, and has continued to be, a route in direct competition for legitimization with the CPM.

Although the move to create the CM was a politically motivated effort, with the subtext of undermining MANA, NARM and MEAC by creating a direct-entry pathway that could be touted as more legitimate, it is not one that has been successful.  We need only look at how the CM has floundered while the credibility and acceptance of the CPM has grown to observe that this effort has failed.  However, if the name change goes through, I am anticipating a re-doubling of ACNM’s legislative efforts to promote the CM as a more legitimate direct entry midwife, and to block inclusion of the CPM.

It is naïve to think of this current proposal as altruistic, or to think that actions of the ACNM won’t affect all midwives.  It is always telling to know your own history.


Erin:  Voices within ACNM are promoting the name change as a step toward unity within the larger profession.  What do you think?

Hilary:  The ACNM is an organization whose charge is to represent its membership, but when that organization has been built on excluding those whose voices don’t fit with its philosophy, how can I trust that the future will be different – that the “new and improved” American College of Midwives is interested in building bridges?  With the creation of the CM, they were so willing to burn the bridge they had built with MANA the previous year, because of self-interest.  Now, I would like to hope that times have radically changed, that any political currency the organization has gained over the years will be spent on the promotion of midwifery as a whole…but I would not go to the bank with this hope.


Erin:  Many would argue that a similar oppressive and hierarchical dynamic is occurring between NARM/CPMs and DEMs who choose to remain uncertified and/or unlicensed.

Hilary:  This is not a new dynamic.  There has long been a rift between those midwives who perceive certification as limiting to midwifery practice and those who seek out certification, who want to find a way to be included as legitimate providers in the healthcare system.

NARM was born out of a desire for midwives to create their own standards regarding the parameters of midwifery scope of practice and education, rather than waiting for these to be imposed on midwives by the individual states.  I happen to believe that staying out of “the system” keeps midwifery care limited to those elite (usually middle class white women) who can afford to pay out-of-pocket for care, as well as making individual midwives vulnerable to charges, whether real or spurious, from any of those in power who feel threatened.

In order for midwifery care to be readily available and for home birth to move beyond the one percent, I believe we need to find a mechanism that allows for our inclusion in the greater health care system.  And of course the goal is for this to occur without destroying those qualities which make midwifery unique. I think the NARM/CPM approach holds more potential for achieving both these goals simultaneously than the ACNM one, which I perceive as being willing to dilute midwifery to a greater and greater degree as long as nurse-midwives gain a foothold in “the system.”  Theirs is not the model I want to emulate.  However, if we step carefully with certification and licensure, being very cognizant not to compromise away our principles in the process, then I think many of those midwives who currently choose to remain uncertified or unlicensed may look differently at the process.


Erin:  You started out as a DEM, became a CPM, and then later became a CNM — despite your criticisms of ACNM’s political tactics and being exiled from New York state midwifery.  Why did you pursue nurse-midwifery at that point?

Hilary:  I have alluded to my personal involvement in the events that occurred in New York.

When the law changed in 1993, I and twelve other DEMs applied for midwifery licensure.  During the prior legislative fight to establish midwifery as an independent profession in the state, we had been assured by the CNMs that we would have at least one seat on the New York board, which was never their intent, and did not happen.  Furthermore, we had been led to believe that our educations would be individually considered under a provision in the New York law which allowed licensure for those who could prove educational “equivalency” to CNMs.  Instead, the information we provided in our applications was forwarded to the punitive arm of the department, and eight of us received cease-and-desist orders, with felony charges if we failed to comply.

I chose two things:  to relocate to a state where I could legally practice, and to continue pressing the New York Department of Education to declare my education as “equivalent.”  This fight took over seven years, but finally, after enormous effort, in 2001 my education was deemed “comparative.”  I was given clearance to take the ACNM boards, which I did in November of that year, and thus became a CNM without ever attending a CNM program.  By doing so I opened a door to licensure that approximately 15 other DEMs have since stepped through.  It was a point of pride for me that I not attend an ACNM-created CM program, but instead have the state declare my existing education as equivalent.

Eight years later I chose to attend the only ACNM-accredited school where I could obtain a Masters of Midwifery rather than a Masters in Nursing, not because I needed this degree to practice, but to expand my ability to be involved in the future of midwifery education.


Erin:  Do you think the primary reason the ACNM fails to support NARM and the CPM credential is a perceived lack of adequate midwifery education in the CPM credential?

Hilary:  I’d like to tie that question to our history.  During our discussion, I have been taken back, again and again, to the original convictions that kept me from becoming a CNM during the 1980’s and 90’s.  During the time that I was working illegally in NY, I had more education than many of the CNM’s in my community (a bachelor’s from an Ivy League college plus midwifery training at The Maternity Center in El Paso plus licensure as a midwife in New Mexico, at a time when most CNMs were ADN’s who had gone to Newark for 9 months to obtain their midwifery certification), as did the women I worked with (3 of whom were British-trained direct entry midwives).  I also had more birth experience than many of the CNM’s around me, and I certainly didn’t see the need to repeat my midwifery education.  Yet my education wasn’t acknowledged as such by the CNMs in the state.  Was this because the education was inferior, or because it incorporated a philosophy at odds with the CNM educational model?

When the New York legislative push came to the forefront, I spoke publicly about how the New York DEMs needed to be included in the process.  And those of us involved weren’t just any DEMs – of the three primary DEMs involved in the legislative effort, two were founding members of NARM, and I was then the North Atlantic representative to the MANA board.  In our naïvety, we believed that if we participated in the legislative effort, if we demonstrated the validity of our education and practice, then we would find a place at the table.  But this didn’t happen – instead, our voices were forced out, and all three of us ultimately ended up leaving the state.  In essence, it became clear that our having more experience with direct-entry (and, for some of us, higher educational degrees) than the CNMs in the state didn’t matter; the point was that our goals didn’t line up with theirs.

So now, when the ACNM has twice raised the educational bar, and can thus wave the flag of “education” as the primary difference between CPMs and CNMs I have to sit back and ponder, “Is this really the issue underlying it all?”  And my answer is a resounding NO.  If the ‘sticking point’ back then had been education, surely those of us with national experience in direct-entry education would have been welcomed at the table during the planning of CM programs, not barred from participation.

What it boils down to for me is that the roots (and subsequent actions) of the ACNM are in the gaining of power and legitimacy by being presentable to the powers-that-be.  Even though the ACNM was born from out-of-hospital midwifery (be it in Santa Fe, Hyden or NYC), the emphasis from the start has been on incorporating midwifery into the existing medical and educational systems.  And if this meant that those midwives had to wear a nurse’s cap, so be it.  And if it later meant that they had to obtain a higher degree (regardless of their own research showing that ADN/certificate midwives had superior performance on the job), then so be it.  And if it meant that they had to present a more medicalized version of midwifery in order to gain entrance to hospitals, then so be it.

Thus the question isn’t about “educated” versus not, but about the acceptance of midwifery knowledge that is both applicable to and acquired outside of, versus inside of, institutions.

This comes back to your question of how CPMs are viewed by the CNM community.  One of the largest misperceptions about CPMs is that they have no didactic education, because for many it has occurred outside of the walls of standardized institutions.  CPMs are all educated; however, a substantial percentage have not opted for “traditional” institutionalized education, often for the same philosophical/political reasons that lead them to avoid birthwork in medical institutions.

For those who don’t know, the NARM credential was created in conjunction with the National Assessment Institute to be in line with accepted psychometric standards.  To quote Ida Darragh of NARM, “NARM does have a required curriculum – over 800 topics – which must be mastered both in theory and in practice.  There is no requirement that it happen in a classroom, but it must happen and must be verified by a qualified preceptor through over 50 pages of documentation.   All candidates then must pass the exam. It is NARM’s job to evaluate the educational pathway.  There IS education, and it IS evaluated.”

We are seeing a veritable revolution in “non-traditional” education within many fields.  Programs such as Empire College within the State University of NY system grants credit for demonstrated life experience, and Harvard admits homeschoolers.  Both ACNM and NARM recognize didactic education online (ACME via Philadelphia University, Frontier, and SUNY Downstate; MEAC via National College of Midwifery, Midwives College of Utah, to name a few).  So if both CNMs and CPMs now mutually acknowledge that nursing is not a prerequisite to midwifery, and as a society we are increasingly acknowledging multiple routes of education, then why are CNMs reluctant to acknowledge NARM certification as valid?Is the issue really about education, or is it about the underlying philosophy?

To turn the scrutiny the other way, we need to look at CNM education, as well.  Most CNM education is lacking in continuity of care, in large-volume birth experience, in non-technological birth, in hands-on labor care, in newborn care, and the majority of ACME-accredited programs are educating CNMs only for employment in hospital settings, not for out-of-hospital (or even for true full-scope midwifery) practice.  As a dually-educated midwife, I see the practice and the educational scope of each branch as overlapping circles – neither has it all, but merged together they would encompass the full scope of midwifery.


Erin:  You have mentioned merging nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve women?  Wouldn’t it mean less choice for them?

Hilary:  It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

I believe that there is great potential for merging the two branches of midwifery via education, specifically via educational opportunities that have evolved due to the internet, as well as by weaving innovative midwifery programs into state colleges. Imagine a system where each midwife is educated (and permitted) to practice in all settings, incorporating the best of both NARM and ACME educational elements. Imagine a system where women who want to be midwives do not, on the one hand, have to spend years studying nursing when their true goal is midwifery; or, on the other, spend years studying midwifery, yet have no college credits to show for it. Imagine that midwifery education is available in every state college system, thus increasing the diversity of the midwifery population while decreasing the educational costs. There are waiting lists for state nursing programs; but I would bet that a fair number of those standing in line would jump at the chance to become midwives instead (and I’d bet that, for some, this was already in their plans). Imagine that we build birth centers in rural communities which serve the dual purpose of providing needed care while providing training sites for midwifery students.

And, if you can, imagine that we channel all the energy we have been wasting on fighting each other, and instead make a concerted effort to grow the profession. Imagine that the word “midwife” is known to every pregnant woman, and we read “more women demand midwives” in our local papers. We could stop celebrating when the number of midwifery-attended births in a particular state have reached the double digits, and instead look forward to them becoming the majority.

I am privileged to work in the state with the highest percentage of midwife-attended births in the US. Not surprisingly, we also have the lowest percentage of cesareans in the nation. I have full prescriptive privileges, the ability to provide primary care, am an independent provider, can write my own practice guidelines, and am reimbursed by all health insurance plans, including Medicare, Medicaid and private insurance. I am not saying that everything is ideal here; for example, hospitals are not required to grant admitting privileges to midwives, there is still a rift between the majority of CNMs and CPMs, and I only know of one midwife in the state who attends both home and hospital births. Still, I have gotten a glimpse of the vast potential for midwifery by working in New Mexico over the past 15 years. I believe that expanding the scope of practice for CPMs to include more well-woman and primary care, while simultaneously expanding the education and practice of CNMs to include more of the “midwifery model” qualities that CPMs hold dear, would serve to broaden choices for all women. It is only our misperceptions and petty squabbles that keep us from achieving unity. We will never know what opportunities for midwifery expansion are available as long as we continue our in-fighting. The current system limits choices; joined together we would have a much stronger voice, and the potential to reach all American women.


hilaryHilary Schlinger, CNM, CPM, MS, RN, is a Certified Nurse-Midwife (ACNM), a Registered Nurse and a Certified Professional Midwife (NARM). She holds midwifery and nursing licenses in both New York and New Mexico. She first became a Licensed Midwife in NM in 1982. Hilary has attended approximately 1000 births, with a focus on home birth practice, and has provided well woman care for hundreds of women. Hilary holds a Bachelor of Science degree from Cornell University, an Associate of Science in Nursing from Regents College, an Associate in Midwifery from the National College of Midwifery, and a Masters in Midwifery from Philadelphia University. She held a seat on the Board of Directors of the Midwives Alliance of North America for four years. Hilary is the author of the book Circle of Midwives, editor of four midwifery texts, and has been a guest lecturer and workshop presenter in settings from medical schools to midwifery conferences. She has served as preceptor for numerous midwifery students, and is currently a faculty preceptor for the National College of Midwifery as well as adjunct professor for the Department of Continuing and Professional Education at Philadelphia University, where she teaches the on-line course “Homebirth Practice Essentials.” She lives and works in Albuquerque.

 

42 comments

  1. Janet says:

    Wonderful post, Erin. So much good stuff being said. I remember some of the doings in NY. My sister was pregnant with her first and it was up in the air whether her midwife could attend because of felony charges. And I remember how happy I was for women in VT as the LMs became a reality. I wish this in-house bickering would stop so all midwives could work towards the benefit of the women they serve. And as I stand poised to start my own path towards nursing and an advanced nursing degree, I know that I will struggle with this hierarchy in a different way. It makes me sad that ego and dollar signs are motivations in a healing practice.

  2. Mary Lou Singleton says:

    “Those who do not learn from history are doomed to repeat it.”
    –George Santayana

    I wish all midwives would learn their history. Having just completed the first half of UNM’s nurse-midwifery program because it is also the first half of the FNP program, I believe there is a concentrated effort to avoid teaching comprehensive midwifery history to CNM students. In my policy class, our textbook actually referred to the ICM, the global midwifery organization, as the International Confederation of Nurse-Midwives. When I mentioned that this was incorrect and the the M in ICM stands for midwife, not nurse midwife, my teacher just ignored the comments and none of the students in the class seemed interested. This is especially egregious given US nurse-midwifery history and the huge effort on the part of the ACNM to keep MANA out of the ICM.

    Most Americans are woefully ignorant of history, and what we see among midwives in our country is just a microcosm of this reality. Personally, I don’t think CNMs really want to know the history of their organization as it relates to the oppression of other midwives. The first nurse midwives actively denigrated and pushed for the elimination of highly-trained immigrant midwives. They moved on to do the same to African American community midwives in the south. And what about our own Native American midwives and Spanish parteras here in New Mexico? These women are never mentioned in the official story of the development of nurse midwifery in the state.

    I remember very clearly that during the early 1990s under Joyce Roberts, the ACNM was pushing that any birth provider who did not complete an ACNM-approved route of education should not be allowed to call herself a midwife, but should be labeled a “traditional birth attendant.” This is not ancient history.

  3. Lori Pearson Kramer says:

    Hi Erin,

    I could not agree with you more. Thank you so much for putting this in a historical context, and imagining a better way. I had to take the long and drawn out way to midwifery, first a bachelors, then an RN degree, and now a masters-and honestly wish I would have paved my path differently. I wanted to be a CNM specifically so my only clients wouldn’t be wealthy white women, and sadly I admit, to be ‘legitimate’. My clinical education thus far has been far from what I had envisioned midwifery education to be. I’d rather be labor sitting, and honing my motivational interviewing skills than seeing how many patients I can get through in a day without forgetting anything major. It’s heartbreaking really.

    In striving for legitimacy, and for the right of hospital privileges, we are letting the medical model dictate how we practice, and a CNM’s life is fraught with constant compromise and fighting to keep our practice resembling something like midwifery. ACNM needs to realize that there should be a marrying of philosophies for us to provide a full spectrum of midwifery care instead of just OB-light. If they can’t or won’t do it I think they should consider changing their name to something else that doesn’t have ‘midwife’ in it. I realize now that I would have probably been better served (personally) with a DEM education, but it’s sad to me that in order to get the perks of a CNM (prescription privileges for example) that a want-to-be-midwife has to choose between philosophies of education, and by virtue of their degree has to take sides in the CM, CPM, DEM, CNM debate.

    Lori
    SNM
    UNM

    • erinmidwife says:

      Lori, thank you so much for sharing your experience in your CNM program. It is particularly relevant to this discussion because the nurse-midwives at UNMH have a reputation for being decidedly “midwifey” in the CNM spectrum of practice, so I suspect women in other CNM programs might face even greater pressures on their midwifery ‘values’ in their clinical and academic education.

      Like you, many would-be DEMs choose to go the CNM route because they desire to serve a broader spectrum of women than the average DEM is capable of within the legal and financial confines of our health care system, and they’re going to be paid more to do it. Of course, ALL women have a right to midwifery care with legal CPMs. In the absence of nation-wide legal recognition of DEMs and medicaid reimbursement for their services, very few DEMs can make a living practicing midwifery. Even in states where there is medicaid reimbursement, CPMs struggle to make a decent living because the reimbursement levels are so low.

  4. With regard to education, I actually think both groups have it wrong (opinionated midwife that I am). To wit: if ACNM raises the educational bar any higher, who will want to jump up there? If I were 20 again, would I choose to spend 6 or 7 years getting a Master’s in Nursing, perhaps soon to be another year or two beyond that for a DNP? Why, so I could work long hours, still have to compromise my philosophy, and make less than an L&D nurse? I’d probably opt go to medical school, thank you. Or, to flip the coin to NARM, would I be able to find some odd job where I could leave at any hour (oh, right, and get someone to watch the kids when I leave at 3 am), plus have the discipline for self-study, or the financial resources to pay for some non-accredited program for which I get no transferable degree or credits, so I can get a certification that may not mean a thing in my state, so I can practice illegally – or, if I’m lucky, practice legally, but only serve the shrinking numbers of those who can pay out-of-pocket? Which of these options would YOU pick? So when I say “education,” I don’t mean either of these. IMHO: Where do most of those without money or privilege go to access education past high school? To community college or to a state college. Why do you think that after all these years of debate, nursing still has to “tolerate” those ADNs (“my god, they don’t have advanced degrees…what do you mean they’re really good on the job?!?”)? Because that’s where they get their numbers, it’s how they ‘bring the masses’ into their profession. And it doesn’t take forever, and the tuition’s really cheap, and Pell grants and FAFSA are available, and you can even fit the classes in around your job, and there’s a campus in every community, and just look around, the diversity of the student body pretty much matches the diversity of the community….so that’s where I think entry-level midwifery education belongs.

    • erinmidwife says:

      Hilary, you raise an excellent point about the drawbacks of DEM education residing outside the ‘system.’ It is true that by and large only a small subset of women can afford direct-entry midwifery schools. They are the ones who can either pay the steep tuition or, if they attend a federally recognized program, know they will have assistance in repaying their loans. I am one of those privileged few who had help repaying my student loans for a “certificate” program. It would have been impossible for me to repay my loans after graduation on income earned solely from practicing midwifery. This issue, in my experience, is not something the DEM community likes to talk about. We don’t like to talk about how OOH birth in this country consists primarily of privileged women who can afford to pay out-of-pocket fees hiring DEMs/CPMs who could afford to apprentice for years on end without income and/or went to expensive schools, and/or are not dependent on their midwifery income to support their families. The exceptions of course would be in the states where a significant portion of OOH births are with medicaid families, or in cases where midwives and clients are using alternative payment models like bartering, sliding scale fees and so on.

  5. Katie R says:

    This is my dream: a bachelor’s of midwifery(one program in every state) , where at the end you can either be a hospital based midwife (a CM if you will) or sit for the NARM exam. I am on the path to being a midwife and highly discouraged.

    PS- my midwife for my second child was thoroughly amused when she found out I was reading Circle of Midwives :).

  6. Barbara A. Hotellling says:

    The NC Friends of Midwives have been working hard for licensure for CPMs here in NC. We are hopeful. My thoughts are that we have NPs, PAs, CNMs, and CPMs. As the Sesame Street song goes: “One of these things is not like the others, one of the these things just isn’t the same.” NPs and PAs are trained by nursing and non-nursing routes yet they are both licensed. So why can’t CPMs? You spoke to that brilliantly. Many thanks.

  7. dbsm says:

    Every time I read something written by Hillary, I gasp in awe of her no-nonsenseness. Where I might disagree, is with providing midwifery education housed in colleges and universities. One only has to look at what happened with the midwifery program at Miami Dade College (which was formerly a community college) in 2008 in Miami, Florida http://mdcmidwives.blogspot.com . This was the only direct-entry midwifery program (NARM, not AMCB) housed in an institute of “higher ed” at that time. Coincidentally, while that program was abruptly ending, Seattle Midwifery was going to Bastyr.

    Nurse-midwifery options in Florida were decreasing as well due to low enrollment (or at least that was the official answer). U South Florida and U Miami ceased their programs (though I heard through the grapevine that UMiami will accept students that show interest). U Florida is the only remaining nurse-midwifery option–and it is pretty well known how medically oriented that program is. In fact, they switched to the DNP so fast it left heads spinning. Like Hillary said, who wants to go to school for 7+ years for midwifery? Who can afford it?

    Thankfully, other routes exist like the Florida School of Traditional Midwifery and the new school, Commonsense Childbirth School of Midwifery. However, pursuing this route is often complicated by the inability to receive federal funding–no pell grants, loans, etc. Students must pay out of pocket or get personal/private loans from their banks (FSTM finally became eligible though!).

    Being housed in colleges/universities does increase the pool of people who are able to attend, however it then appears that, the guidelines/rules of that institution restrict midwifery education and practice ie liability insurance issues. Furthermore, the midwifery programs are located in schools of medicine and/or schools of nursing, which is antagonistic, even if we try to look at it in a hopeful manner. I consider this the “guarding” of midwifery.

    I do not have high hopes about the ACNM because as Hillary said, they are a membership organization. I went to an annual meeting. As a minority member (in color and in prospective licensure), I felt like I was in that short story where the townspeople pick numbers and then stone people for no “valid” reason….is it called The Lottery? Young and old, there seemed to be opposition to anything non ACNM/AMCB, unless you attended the Bridge Club (members bridge understanding, etc between ACNM and MANA, in short). They are nurse-midwives, without a doubt. It is my observation that nurse-midwives put their education on a pedestal similar to the way in which the house negro upheld his status in relation to the field negro, even though they all were slaves–because it gains them favor with the massa/medical establishment. Remember that the elimination of the midwife in this country was not based on evidence–just as the denigration of the CPM by the CNM is not based on evidence (despite all the evidenced-basedness that CNMs hoot on about). CNMs get to guard midwifery.

    For example, in North Carolina, where they are trying to legalize CPMs, the CPMs are forced to (my words) pacify the CNMs in order to gain their support, by adding language that limits the educational pathways one may take in order to become a CPM. CNMs don’t like PEP (the portfolio based method). They don’t see it as valuable. They really don’t like “the apprenticeship model” either. However, if there is no compromise, it makes the political battle even harder for CPMs.

    What has historically been one of the biggest opposing forces to the legalization of direct entry midwifery at the State levels? Nursing.

    Hillary, please correct me where I am wrong. I’ve only had a few years in this :)

    I have to tell you I do not value my education right now. I’m near resentment. A CPM program would have better served me, my philosophies, my learning needs, but I chose this route because of finances and needing to raise children out of poverty. It shouldn’t have been this way.

    • erinmidwife says:

      “I chose this route because of finances and needing to raise children out of poverty. It shouldn’t have been this way.”

      Exactly. Women cannot reliably support families on a DEM income and schedule without exceptional assistance from their communities and extended families and even then it is almost impossible. And a single mother, forget it. We talk about “a midwife for every mother,” and many of us are working towards that end, but the educational component of the equation has been lost in the shuffle, and this is where Hilary’s voice is so vital. We *might* be able to, say, double the number of existing CPMs if more schools open up but they are not going to come from the communities that need their care the most.

  8. Yes, the Miami-Dade program closed; the only community college currently housing a midwifery program is Southwest Tech in Wisconsin. However, I don’t think that we should consider that pathway as a “failed experiment” based on an example of one. What we CAN do is look at which factors led to both its successes while running and to its demise, and take these into consideration when planning for the future.

    I am NOT saying that NARM or apprenticeship should be abandoned; what I AM advocating for is the creation of new pathways for women such as you – women who need the availability of funding like Pell grants, FAFSA, and loans, women who can afford state college tuition but not the astronomical costs of private college (especially when this includes graduate-level educational costs – which then encourages employment in institutions on graduation because of the burden of these student loan payments).

    Yes, malpractice played a part in the struggle of Miami-Dade to stay afloat. Midwives have been working on innovative solutions on this front – for example, Ann Geisler has just created “The Midwife Plan,” which arose out of meetings where midwives and insurance reps brainstormed on ideas, then contributed to studies needed to approach insurance carriers regarding the true statistics regarding the liability of out-of-hospital practitioners. http://deaninsurance.cc/malpractice.html

    Yes, I believe midwifery programs need to be housed in “allied health” departments separate from both nursing and medicine. I have written a grant proposal for initiating such a program in my state (NM), pairing education with birth center development, so the birth centers can both provide needed care and act as clinical sites for midwifery students. The largest resistance I have met has, by far, come from nursing department chairs. However, I am not planning on letting this stop me from pursuing this route.

    I also think that current CPM midwifery schools need to look for routes of accreditation so students CAN be eligible for federal aid, perhaps by creating alliances with existing university systems. In the same way, moving birth centers out of private ownership and creating alliances with Federally Qualified Health Centers (which are exempt from paying malpractice under the Federal Tort Claims Act), and by supporting the pending federal bill which would create a category of Federally Qualified Birth Centers with the same exemption, would increase the viability of birth centers as training sites for CPMs.

    I do not believe that the paths I propose are the only ones, or even the ones that will come to fruition – they are just those I envision from where I sit right now. We have so many innovative women within the midwifery community; if we could only stop draining our energy and resources by fighting each other and by struggling to protect our own hard-earned little plots of soil, we could direct our energy towards creating innovative models for both education and practice. It doesn’t have to be ONE path; as far as options go, the more the better.

    Lastly, to address the current issue re the ACNM: they are caught in the dilemma of having a ‘split personality.’ On the one hand they have advocated for nurse-midwives as advanced practice nurses – and this is how CNMs are licensed and/or certified in all but five states. This alliance with nursing has meant both accepting the requirement for more graduate-level education and the dilution of the midwifery model vis-à-vis education and practice, with the perceived gain of entrance to the hospital, prescriptive privileges, independence from supervision in practice, and expanded scope into primary care. In real terms, it has made CNMs more similar to OB/GYN advanced practice nurses than midwives.

    On the other hand, they present themselves on both the international and national health fronts as representative of midwifery in the United States; in this, they cling to their identity as midwives, to the exclusion of all others. In my mind, their foray into the CM shows their true colors: since its creation, only 122 CMs have been certified, the credential is only accepted in 3 states, until this year only one ACME program offered a CM route, & CMs have been left out of most ACNM advocacy efforts in national health reform. In essence, the ACNM can trot out the CMs to ‘prove’ they are midwives rather than advanced practice nurses, but in reality the CM was an ill-thought-out move that served one state (NY) at a particular juncture in time, not a referendum on the future direction of the organization. Are there CNMs within the ACNM who identify as midwives? Definitely. And are there CNMs who are practicing in what we would identify as the midwifery model of care? Again, most definitely. However, is this the ACNM truly representative of these women, or of midwifery as I (and you) would define it? And, more to the point, is there consensus within the organization that, with a name change, their new mandate would be advocacy to move from alliance with nursing to advocacy for midwifery as separate from nursing? I believe not. Unless they are ALL willing to be CMs, unless they are working state by state to have midwifery legislated as separate from nursing, unless they are working to be hired in institutions as midwives rather than advanced practice nurses, unless they are looking to reinforce educational routes that are not dependent on an initial nursing education, unless they are willing to devote their energies to incorporating the entirety of midwifery in the US, then they are not the American College of Midwives.

    • erinmidwife says:

      “…Is there consensus within the organization that, with a name change, their new mandate would be advocacy to move from alliance with nursing to advocacy for midwifery as separate from nursing?”

      I hope this question is put forth at the ACNM meeting this week and that someone shares the response here.

  9. dbsm says:

    *breathless from Hillary’s response* I knew you’d fill in the gaps, Hillary.

    How quickly I forgot about the midwifery program in Wisconsin.

    I didn’t necessarily think of Miami Dade as a failed experiment…we’ll just have to wait and see about the successes in Washington & Wisconsin. What I did see was that low enrollment/lack of interest was not an issue. Need was not an issue. The community in South Florida rallied in support of the program. The [black] infant mortality in that area (hell in several areas) is abysmal. The c/s rate is 75% at one hospital (and over 40% in others). Legislators, organizations & media were contacted. There was even a summit on maternal health in Florida prior to this event. Donations were given. End the end, the College said it was the economy, meanwhile FIU (don’t quote me) was starting a med school. The Board wouldn’t budge one bit.

    That program was completely affordable (as is the one at Southwest Tech). With the ability to receive pell grants and loans, programs like these are nearly accessible to everyone. My graduate education plus my undergrad debt would buy me a 2K sq ft home on a couple acres of land in Georgia. I pray that I’ll be able to get an HRSA job for reimbursement, owing them service like I’m in the military or something. This is while I sweat it out for a handful of years as a hospital based midwife.

    “The largest resistance I have met has, by far, come from nursing department chairs.”

    And there it is. And here we have nurse-midwifery programs talking about we need to recruit more nurses into the field. This is what I believe creates the conflict of interest and undermines midwifery. We need nurses as allies, but until there is some paradigm shift, I don’t believe they need to be targeted for midwifery recruitment. This is the dilemma of the “split personality” of which you speak in the ACNM.

    “moving birth centers out of private ownership and creating alliances with Federally Qualified Health Centers (which are exempt from paying malpractice under the Federal Tort Claims Act), and by supporting the pending federal bill which would create a category of Federally Qualified Birth Centers with the same exemption”

    Wow. I had no idea!

    “And, more to the point, is there consensus within the organization that, with a name change, their new mandate would be advocacy to move from alliance with nursing to advocacy for midwifery as separate from nursing?”

    Hell no. I keep being told that they/we “need” nursing. Nursing is a large force. But isn’t nursing what’s holding midwifery back?

    And your last few sentences pretty much sums it up. Regarding expanding the CM, the response continues to the be the same: Its up to the efforts of individual states. Regarding expanding non-nursing routes: the response was about resources.

    I stand by my house negro argument and sadly, if that’s the best that ACNM has, then there won’t be a united midwifery any time soon. I never realized how superficial a name change could be. Can’t we all just get along?

  10. dbsm says:

    Also, the motion’s intention was to look at the implications of a name change, wasn’t it? We don’t even know the results of that research yet.

  11. How we define the words we use plays a critical role in how we shape our opinions of the world. What do we mean when we say “midwifery?”

    In Missouri, there are only a handful of CNMs practicing independently. In the St. Louis area, the hospital based practice CNMs are not even allowed to attend births. They provide prenatal care under physicians. As many of us know, the ultimate responsibility for care is assigned to the “highest” credentialing on a chart. It is a short leap of logic to realize that a CNM, practicing under an OB/GYNs supervision, is going to be pushed to provide care that will not get the OB in trouble if something goes wrong. The OB will be judged according to medical standards, and this means the CNM will be expected to provide care that fits this standard and model.

    After looking over the laws, the regulations, and the normative practice of CNMs here, I am slowly coming to the conclusion that (at least in our state), less than a quarter of CNMs practice midwifery. What CNMs generally practice is limited scope, low-risk Obsetetrics and Gynecology. In Missouri, it would probably be more accurate to describe CNMs as Advanced Registered Nurse OB/GYNs.

    I have heard all sorts of rationale as to why this is. Money. Power. Misogyny. I think there may be a simpler explanation that is relevant to our discussion: academic education.

    Philip Zimbardo has been doing some work the last decade or so on something he calls “Time Perspective.” For a longer explanation, you could read his book “The Time Paradox,” (http://www.amazon.com/Time-Paradox-Psychology-That-Change/dp/1416541985) or for a shorter, more entertaining explanation, you could watch http://www.youtube.com/watch?v=A3oIiH7BLmg. Key to his finding is the idea that more education leads to a bias towards a “Future Time Perspective.” Key characteristics of people with a future time bias include lower empathy for others, focus on a plan with a predictable path and end, and a preference for cause-effect thinking. This is the philosophical root of the medical model of care, which is not surprising, given the Northern European roots of modern Western medicine and it’s extreme emphasis on long, demanding, academic education.

    I would like to suggest that the first difference between midwifery and obstetrics is a cultural and philosophical bias towards what Zimbardo calls a present orientation. Empathy for the mother, attention to the current situation instead of making decisions based on adherence to a idealized schedule, and holistic thinking are among the most distinctive hallmarks of midwifery. A bias towards a present orientation does not imply an inability to use the future time perspective, planning ahead, or making objective decisions. It is to say that when a mother stalls in labor, the present oriented midwife looks to the mother to find a possibly multi-variate challenge to labor instead of presuming that the most commonly successful and predictable medical intervention is the most appropriate solution. Present orientation demands a development of practitioner skill in addition to knowledge.

    ACNM has significantly increased the threshold of academic education necessary for midwives. The theory is that this increases their knowledge. I believe that midwives with more extensive knowledge and training is a good thing. I just think that HOW we teach practitioners is as important as WHAT we teach them. Putting academic work ahead of practical skill will lead to Obstetrics. Putting practical skill ahead of knowledge is, I believe, definitional of midwifery.

    I believe that ACNM has pursued more and more academic education in order to gain acceptance by the medical community. This has increased the influence and bias towards a future time orientation. This has the benefit of resonating better with the physicians, but it also undermines the philosophical basis of midwifery. If what CNMs, CMs, CPMs, or DEMs practice is no different from OB care, are they really midwives?

  12. I agree with much of what you say, just wanted to add a little regarding education. I feel the telling phrase you used is “academic education.” The emphasis that the ACNM and its educational accrediting arm, ACME, has chosen to promote in the educational arena has been on academics (the reading of studies, performing research, understanding statistics, health policy, etc) rather than on clinical education. And just because someone is an academic who can churn out studies worthy of journal publication doesn’t mean they excel in their clinical skills and assessment. I have been having an on-going conversation with a British-trained direct-entry midwife. She has often related to me how her original training began with observing large numbers of normal births (~75) interwoven with didactic education re normal birth, & only after being steeped in this orientation was the “abnormal” (read need for medical intervention) introduced. Together we have lamented the abandoning of “lost” midwifery skills (be it version, breech or twin delivery) in favor of perceived gain of status within the prevailing educational and medical systems. So we now have ‘midwives’ who know more about inserting internal monitor leads than about the course of uninterferred-with labor; who can “manage” an epidural, but have not a clue how to auscultate a fetal heartbeat without a Doppler; who are skilled with the ultrasound machine, but can’t palpate fetal position.

    I believe that a “present orientation” is born out of experience – for midwives, of seeing tens of (perhaps hundreds) of labors take their natural course, complete with plateaus and non-linear progress; with being able to adapt to the situation as it evolves, rather than needing to control the process. As long as CNM education emphasizes graduate-level book learning rather than clinical experience (and I know those 25 required births often include last-minute walk-in-the-room-and-put-your-hands-out-to-catch-the-baby numbers rather than labor sitting & continuity of care), we will have CNMs who apply the future-time bias. And as long as the push of the ACNM is on incorporating ‘their’ midwives into the existing medical model, there is little hope for changing the predominant obstetric paradigm.

  13. deena chamlee CNM/NP MS says:

    Hilary,

    here you are outside the boundaries of the ACNM blog. You have made me think but after more pondering and reading I remain throughly confused as prior. In Oregon CPMs LMs are fighting to legislate the following:

    Absolute Risks – Certain conditions that warrant the midwife and client to plan for an in-hospital birth.If an absolute risk comes up in the prenatal period, a hospital birth should be planned. If an absolute
    risk comes up during labor, the midwife must arrange for transfer of the mother to the hospital unless the birth is imminent. If an absolute risk comes up after the birth, the midwife must arrange for transfer
    of the mother and/or baby to the hospital. Refer to OAR 332-025-0021 for a complete list. Examples of absolute risks include: active cancer, cardiac disease, chronic hypertension over 140/90, preeclampsia/
    eclampsia, placental abruption or previa, HIV positive status with AIDS, triplets or more, pregnancy lasting longer than 43 weeks gestation, suspected uterine rupture, prolapsed cord, labor or
    PROM less than 35 weeks gestation, uncontrolled postpartum bleeding, Apgar less than 7 at 10 minutes of age, and central cyanosis in the infant.

    Non-absolute Risks – Certain conditions that warrant the midwife to EITHER transfer care to a hospital facility/provider OR consult with one Oregon licensed health care provider as defined in OAR who has
    experience handling risks as the one presented, determine whether out-of-hospital birth is safe, advise the client regarding the risks and possible adverse outcomes as well as recommendations from the
    consulting provider, and document advice and consent from the client for continuing with a planned out-of-hospital birth. Examples of non-absolute risks include: significant glucose intolerance,
    inappropriate fetal size for gestation, anemia at term, seizure disorder requiring prescriptive medication, previous uterine incision other than low transverse cesarean, twins, malpresentation at term (breech,
    transverse), persistent unexplained fever in labor over 101, labor or PROM 35-36 weeks gestation, retained placenta greater than 3 hours, and infant weight less than 5 lbs.

    Please enlighten me how this can be a positive for all those practicing midwifery. And as far as a 32% rate my colleagues are no where near that rate. We are more at 8-10%. If we are going to bridge the gap there will have to be compromise! Compromise and what shall I say evidence based humility!

  14. Deena, I’m not clear on your question regarding the OR midwives’ proposed guidelines. The regulation of midwifery varies by state. In some states midwives practice under individual practice guidelines, while in others the state provides a general framework which defines the scope of practice. Overall however, I do have some thoughts about how the (often pathologized) medical-model view of birth gets imposed on those practicing at home (I am going to assume your need for clarification is in the arena of breech/twins/VBAC, or other situations that are considered ‘high risk’):

    1) In the main, the ACNM has been willing to accept a medical-model view of “normal” in order to better fit into ‘the system.’ In my mind, this has led to a current generation of both OBs and CNMs who have lost many skills – whether safe breech delivery, external cephalic version, safe twin delivery, or simply the ability to know how to help a stalled labor without resorting to cesarean, or how to palpate and auscultate without technology. There is a subset of homebirth midwives who are keeping these “lost arts” alive – and who know that, although there is increased risk regardless of place of birth with breech & twins & VBAC, being at home with a provider who is skilled in these arenas often carries LESS risk than being in a hospital with providers who panic at the thought of anything other than a vertex singleton, and can only resort to surgery.[…of course I can go on endlessly on how the ACNM has traded normal birth for first assist, breech birth for colposcopy, labor support for primary care….which then brings me back to the core definition of midwifery, which I don’t see the ACNM keeping alive….]

    2) In one of my postings on the ACNM Motion blog, I wrote “We cannot simultaneously keep CPMs out of “the system,” and then chastise them for not appropriately partaking of “the system.”” I believe we need to create a system where the individual midwife has the ability to remain a woman’s caregiver regardless of setting, where ‘appropriate site selection’ for the individual women is the norm, rather than having a different care provider in each setting. Imagine that the CPMs (and homebirth CNMs) had hospital privileges. Imagine that transfer was simply a “change in venue” for the mother – the midwife she had worked with the entire pregnancy remained her care provider regardless of change in situation, whether during pregnancy or labor. When such a system is in place, mothers AND midwives reap the benefits.

  15. I have two thoughts about the system and credentialing, one shorter and the other a bit longer and more questioning.

    1) Did you know that CPR certifications have now eliminated the paper exam? Apparently, the American Heart Association studied competency differences between individuals required to take “academic” tests in addition to skills testing and found no improvement over individuals only tested on skills. This is hardly the only instance where we have discovered that a college education is not really a good predictor or practitioner skill or ability.

    2) What are the costs and benefits of “the system?”

    It is hypocritical, short-sighted, and silly to refuse to license someone and then prosecute or persecute them for not being licensed. Referring back to point one, it is inescapable that the “danger” of skills certification is that it is seemingly arbitrary. The instructor or examiner states whether you have the skills or not. It is easy to imagine biased tests and results. Paper and pencil tests feel much less arbitrary. There was a right answer and a wrong answer. You either provided the right answer or you did not. You are truly certified by “the system” not an individual. We can look back to check whether you provided the right answer or not. However, the problem we face is that the “non-arbitrary” academic testing does not actually test practitioner skill, ability, or real-time access to their knowledge. In this way, I wonder if the academic programs are testing “Medical IQ?” IQ tests are notorious for only really testing how well people take IQ tests. Have we really examined whether or not all that academic education improves the quality of our providers?

    I suppose the question really is what are we trying to accomplish through licensing and registration? What are we really trying to accomplish by requiring more academic education? Is there any evidence that supports that the methods we are suggesting will achieve the ends we seek? I truly, deeply worry that there isn’t.

    What I think we have done is to defeat the basic ability of clients to make informed choices. Free markets only work when the clients and customers have access to accurate and unbiased information. Economic theorists all the way back to Adam Smith have warned us that professional licenses primarily serve to limit the number or professionals, which raises the licensees salaries, which gives them a powerful incentive to keep the supply of providers low. As it stands now, there is not a lot of transparency in health care. Locally, there is a (non-OB/GYN) provider who has 4 times been caught in an inappropriate relationship with a client. This physician’s name is not publicly available, and he is still practicing.

    I do not see this as a problem that is somehow unique to physicians or any other profession. There is an extreme shortage in his specialty, and publicly defrocking him would damage the reputation of all the local physicians. It is the cost of choosing to credential yourself by your title, certification, or license. Suddenly, people do not see you as a person. They see the “uniform” of your license. Any damage to an individual wearing that “uniform” effects everyone wearing the “uniform.” This will be true for physicians, nurses, midwives, social workers, used car dealers, and pretty much anyone else.

    So what are the costs and benefits of “the System?” The benefits might be easier, as they include ability to get paid, avoid persecution, and being able to see the profession grow and develop. The costs, it seems, are the price of freedom: “Eternal Vigilance.” In this case, vigilance against the corruption we see in “the System,” both real and imagined.

  16. In recent events, a midwife in Virginia was charged with manslaughter after the death of a breech baby born at home; she subsequently pled to the lesser charge of practicing without a license. The national ACNM was asked by the Washington Post to submit an Op Ed piece “weighing in” on this issue. This is what the ACNM had to say:

    “News of the unnecessary death of an infant during a home birth in Virginia last year and the guilty plea last week of the unlicensed midwife who attended the birth was both heart-wrenching and horrifying…First, we state unequivocally that this incident is not representative of the birth care practices of certified and licensed midwives who expertly attend nearly 320,000 births annually in the United States. This calamity resulted from practices falling far below the rigorous standards required by the American College of Nurse-Midwives and respected by certified nurse-midwives (CNMs) and certified midwives (CMs). This case involved a baby in a breech position in a first-time pregnancy—a situation in which the risk of complication is high. In fact, a local CNM practice reportedly decided they could not attend this birth at home and advised the family that a hospital delivery would be required. The basic criteria for a safe, planned home birth were not present in this case.

    The word “midwife” may still conjure up old-fashioned images, but today’s reality is far different. CNMs and CMs (who attend of 94% of midwife-attended births) are licensed professionals with graduate degrees from accredited higher education institutions and are required to stay current on the latest research. While 96% of births attended by CNMs and CMs are in hospitals, others take place in fully-equipped birth centers and—with appropriate screening and access to hospital transfer if necessary—in homes. Certified professional midwives like the practitioner in this case may acquire their skills through alternative pathways which do not require a minimal educational degree and usually practice in out-of hospital settings. The standards for CNM, CM, and CPMs require that they practice collegially and collaboratively with physicians.”

    I asked Brynne Potter, a CPM in Virginia, to clarify VA’s regulation of CPMs (which the ACNM did not address). She had this to say:

    “VA’s licensing law was passed on a primary message of patient autonomy. It was, from the beginning, a consumer driven process to license CPMs. Our law stipulates that the regulations cannot require a woman to be seen or assessed by a physician or other health provider. This is not because CPMs don’t want to collaborate with physicians, but because at the time we were working on our bill, VA CNMs could not freely or easily practice out of hospital because of some of the most restrictive collaborative practice language in the country. There was no point in passing a bill that would require an agreement with physicians that CNMs were unable to get in almost every community in VA.

    In 2009, our law was amended by a constituent bill (not us or the docs) to require that “evidence based informed consent” be provided to women seeking high risk births at home. To our knowledge, this is the only law in the country that requires a provider to provide informed consent that is evidence based.

    Bottom line: VA law upholds patient autonomy as a priority risk assessment criteria. According to National Center for Health Statistics, in 2006, VA and MD had the highest rise in home births in the country. Combine that with the fact that at the same time VA had the highest decline in CNM practice in the country and you can see what pressures the CPMs are under. More and more women are running away from hospitals that ban VBAC, and require c-section for twins and breech. CPMs in these communities feel enormous pressure to care for these women and have sought additional training and experience to safely consider these cases at home. A significant number of breeches and twins were born with the support of licensed (and one well known unlicensed) CPM in the Northern Virginia area in the last 5 years. The community standard is that area is that it is reasonable (among midwives) to consider home birth for these situations.

    It is never easy to be an outlier from the routine and the expected. But there is something going on in VA that warrants everyone’s careful attention. We are holding a line for patient autonomy that impacts all women birthing out of hospital in the state. There is enormous pressure to restrict our scope of practice and limit access to home birth for some women.

    The conversations about balancing patient and profession are never more relevant than in this state where we are specifically granted the authority in statute to attend ANY woman at home and at the same time are restricted from carrying or administering any controlled substances in the course of our care. It’s ironic to live in a state with a long history of being a battleground for opposing forces. And while it’s true that we are witnessing a rising tide of confusion and frustration, we also have some of the best community bridges between CNMs and CPMs of any state in the country. CNMs have historically stood beside their CPM sisters and continue to work toward a unified front that requires communication and respect.”

    Ida Daraugh, president of NARM, added more perspective”

    “Does the ACNM believe that the “rigorous standards” have prevented all deaths in the care of CNMs and physicians? Do they have any evidence that a lack of “university” education led to this death? Do they understand that all birth carries some risk and that parents have the right to an informed consent as to WHICH risks they will take? The risks of mandatory cesarean vs the risks of breech birth? Do they really believe that risk is determined by the credentials of the care provider?

    How quickly the ACNM decided to judge this midwife, and to do so for political gain. They did not advocate for licensure (and regulation) of CPMs. They did not acknowledge that the legal system actually worked as intended by convicting the midwife of practicing without a license (a verifiable truth) rather than manslaughter (which was the initial charge). They actually admit that CNMs and CMs rarely provide home birth services, and yet they do not support CPMs to provide those services that CNMs are unwilling to provide.”

    And my reaction? Midwifery historian that I am, after working through my initial disbelief, I went digging through my shed for my copies of the MANA News from the late 80’s and early 90’s. And in the July 1991 issue, there I found it – MANA’s then-president Diane Barnes quoting ACNM’s then-president (and authoress of the current name-change motion) Joyce Thompson in her 1991 address to the ACNM membership:

    “Just maybe it’s time to exchange our myths for facts, our fears for hugs, and our dreams for a vision… A vision in which professionals give up their turf wars in order to reach out to each other and say, “We will no longer settle for being alone.”

    Now, to the best of my understanding, Joyce was referring to the nurse-midwives of the ACNM and the midwives MANA reaching out to each other. Remember, at that time definite steps (albeit wary ones) were being taken to achieve understanding between the two groups. And today, ACNM proclaims it is taking similar steps. However, when I juxtapose such proclamations with the membership response to Joyce’s name-change proposal of today (where a hefty percentage is still using the appellation “lay” midwife), with the discovery that the history I both lived through and documented is being rewritten, and with the Washington Post op ed piece signed by the current president of the ACNM (using language promoting ACNM’s midwives by bringing back the “dirty, illiterate midwife myth”), I must again come full circle to our initial question: Is the ACNM is ready to become the American College of Midwives? Is this the organization that is representative of midwifery in the US? And again I say a resounding NO.

    • dbsm says:

      I am so DISGUSTED.

      Look at the ACNM’s use of emotive words: “was both heart-wrenching and horrifying…”. The only people who can make this claim is those who were directly affected by it, namely, the birthing mother. But this goes back to something that most medical people and power hungry people don’t understand and what the person from VA that you spoke to emphasized: people, that includes birthing women, have a right to choose their risks.

      But then again, this goes along with reproductive rights and overall choice–which we are still fighting for in 2011.

      And then there’s this: “CNMs and CMs …are licensed professionals with graduate degrees from accredited higher education institutions and are required to stay current on the latest research.”

      Latest research performed by whom? ACOG is the answer 85% of the time…research that practicing OBGYNS don’t even follow. Research that we don’t even have time to investigate ourselves with our big graduate-level midwifery research skills because we are too busy learning about primary care, epidural drugs, drugs, and more drugs.

      And of course this: “While 96% of births attended by CNMs and CMs are in hospitals, others take place in fully-equipped birth centers and—with appropriate screening and access to hospital transfer if necessary”

      More is better. At least that’s what the ACNM is selling to the public. Because if you’re not “fully-equipped,” then you’re missing something.

      I could go through the entire piece but I’ve won’t as you’ve already said what was necessary. What kinda crap is this, really?

  17. For those of you reading this blog who don’t have access to the internal ACNM discussion of the motion, I wanted to bring you up to date. The ACNM hired the services of a marketing firm to explore the financial impact of the proposed name change. The firm came back with a report highlighting how the ACNM could “rebrand” the word ‘midwife’ in order to best market it. My reply:

    Isn’t that what this IS about – ownership (and marketing) of the word MIDWIFE?

    Up until the ’90’s, the membership clung to the identity of “nurse-midwife,” using the ‘nurse’ part to distinguish itself from “the good-hearted, loving but untrained midwife either of past history or in rural areas of the South today, or functioning as birth attendants for those disenchanted with the present health care system.” (Varney, 1980, p. 21). And this is not just “old history,” as evidenced by this week’s submission to the Washington Post; to quote Holly, where she brought back this old ghost by saying, “The word “midwife” may still conjure up old-fashioned images.”

    But now, as the membership realizes nursing really doesn’t carry the status or respect it seeks (oh, but maybe “advanced practice nurse” does?!?), the organization wants to jettison the nurse part, claim the word MIDWIFE for itself, polish it off and present the new-and-improved MIDWIFE to the US public (…but don’t pay attention to those CPMs behind the curtain). Good grief.

  18. Ida Darragh says:

    So interesting that the ACNM now wants to distance its identity from being a nurse-midwife to being just a midwife. Sounds like an inclusive move until you notice that the change is all about rebranding and marketing. The fact is that most CNMs/CMs are practicing in hospitals. A few are in birth centers, and a very few attend births at home. The birthing public is wise to this, and is seeking CPM services in greater numbers because of the perception that CNMs are continuing to provide the medical model of care. Families who want the Midwifery Model of Care are choosing CPMs. The ACNM is seeing its market sliding over to those who are allowed to practice the midwifery model. So, now they are reversing their long-term strategy of claiming that their medical/nursing knowledge makes them superior. They will maintain that mantra with AGOC or legislators or when opposing CPMs, but they want to market to the consumer as “regular” midwives in order to avoid the perception of being too medical. They want it both ways. Remember when they were so worried that CPMs were “confusing the public” and the public wouldnt understand that “those” midwives werent nurse-midwives? Now, they want to reverse and re-brand themselves as midwives so the public wont notice they are nurses? It’s about marketing. They want to speak out of both sides of their mouth, and promote the nurse/advanced degree message to the political lobby and the warm/fuzzy midwife message to the consumers. What, do they think we are all wearing blinders?

  19. mnm says:

    I found this post very interesting and informative. I am a CNM student and I think that it is important to keep ACNM as it is. Namely, because it does distinguish the separate educational pathway between a Nurse-Midwife and a CPM/DEM/LM. It helps consumers understand what services they are choosing and I am also not sure that the ACNM is going to be inclusive of “all” types of midwives if the name change occurs.

    I do have an issue with people who have never attended a Masters-level nursing program talking about how it’s lacking “this and that” and then making the comparison of CNM education to the PEP entry into practice model. They aren’t the same. Similiarly, CNMs have a four year bachelor’s of science degree in Nursing, which their MSN program is built upon. While I respect an alternative entry into practice for other midwives, I wish those who have not attended a BSN or MSN course would spend less time putting down what’s learned in these courses (which they likely know little about) and instead focus on why YOUR pathway to midwifery was suffice for providing you with the skills needed to become a good midwife. As we ALL know, there are midwives everywhere (CNMs, CPMs, LMs, DEMs) who practice negligently…and a particular licensure or education is not indicative of clinical competence.

    Clearly, Ms. Schlinger has decades of experience and varied clinical and educational experiences to fall back on in her clinical practice. Still, we have plenty of DEMs and LMs who unlike Ms. Schlinger, do not hold a bachelor’s degree from an ivy league institution and have not been privvy to preceptorships at some of the finer midwifery institutions our nation has to offer. These folks have not necessarily completed a MEAC or other (i.e. AAMI) course and some may not hold more than a high school education. There is a vast difference between this midwife’s experience and that of Ms. Schlinger.

    • erinmidwife says:

      I thought the people here questioning the model of care being taught in CNM programs were currently in (or had completed) MSN programs? Personally, I am in favor of greater experience requirements and educational standards for the CPM credential, and by that I do not mean more degrees. I mean more hands-on experience with normal pregnancy and birth, more hours and numbers, more opportunities to demonstrate clinical excellence and critical thinking ability. I am unsure of the hours/numbers requirements for CNMs so I cannot comment there.

  20. dbsm says:

    1. As it stands, the ACNM’s name doesn’t even reflect its OWN pathways to midwifery, because it leaves out the CM. So either, they should dump the CM, which would be really f*ed up at this point, or do something about the name to reflect the baby that they created over a decade ago.

    2. The ACNM’s name standing as is doesn’t help the consumer one bit, because consumers are aware of individual midwives, not their organization…just like average consumer doesn’t go around talking about ACOG.

    3. People needn’t have attended a master’s level nursing program in order to critique it. Besides, CNMs continue to critique non AMCB routes without providing a shrill of evidence of the difference in outcomes in practice.

    4. Not all CNMs have a 4 year bachelor of science degree in nursing. You might want to research that. There have been changes over the recent years, but even so, I do not think that was ever the case.

  21. mnm,

    Thank you for your reply. I think that it highlights the difficulties facing midwifery very well.

    I will relate a story to explain my opinion. In Missouri, a Family Practice/OB/GYN physician was asked to back up her local birth center and she agreed. When she started, she thought she knew more than the midwives based on her academic education and hospital experience. Then she experienced midwifery. She will tell anyone who asks that she knew nothing about normal birth or how to manage labor without medical and technological intervention. She learned the art of midwifery from the “lay midwife” she was “supervising.” Medical Degree and License notwithstanding, she learned midwifery through the apprenticeship model. What we practice and how is not simply a statement of what we consider our scope of practice or how much knowledge we bring to bear on our clients. Midwifery has a unique philosophy, history, and mentality.

    You state very clearly that you see your MSN being based on your BSN. I think that most of the people who have posted here agree with you on that. The question at hand is not “Does an MSN make a practitioner dangerous?” The question is whether you are going through an academic program to be an Advanced Registered Nurse Practitioner or a Midwife. Given only what you have written here, it seems that you are on track to be a very well-trained and competent advanced practice nurse with a fine and useful academic education. I can say that I have yet to find a midwife who learned her midwifery from a book. You may have a different opinion, and you have a right to have a different opinion.

    I can also comment on how your response sounds to those who believe that midwifery is passed on through apprenticeship or preceptor/mentoring instead of academic study. You write very clearly, “some may not hold more than a high school education.” This entirely dismisses these women’s learning and is very insulting to the entire profession. It also very clearly insinuates that these women are lacking something. In truth, I know quite a few very bright midwives who choose not to go to college. They realized that they were smart enough, self-motivated enough, and had the opportunity to learn from a qualified preceptor. They chose to get 6 years of experience and education instead of 6 years of education. For my baby, I’d rather have the midwife I know has good skills rather than the one that I know has good knowledge. (For the record, my second was born with the care of one of my wife’s former students, so I really REALLY mean this!)

    You write “I respect an alternative entry into practice for other midwives,” but it does not come across that way. Calling the international, traditional, and otherwise “normal” route to midwifery the “alternative” route reinforces this perception. The nursing route is the “alternative route” from the point of view of many midwives. It was an experiment to see if midwives could get acceptance and support by trying to “play along.” In Missouri, midwives get a small degree of acceptance from “the system” as long as they are making money for the system and practicing according to hospital policy and the OB/GYN protocols.

    I suppose my question is just, “Does it matter that they let you call yourself a midwife if they won’t let you BE one?”

  22. dbsm says:

    “I suppose my question is just, “Does it matter that they let you call yourself a midwife if they won’t let you BE one?””

    WOW!

    Another question I have is, how many CNMs have seen a “natural birth?” Had I not briefly apprenticed in a birth center concurrently in my first semester in school, my graduate education wouldn’t have afforded me to be a witness to such a thing. However, the CNMs in that birth center did do directed pushing as the norm, and were very uptight about maintaining their ability to practice in the current climate. What I am seeing throughout my 2 years of midwifery ed, are some very angry, confused, disappointed CNMs attempting to practice in a way that causes them great grief. This creates an abusive climate…in school and in the hospital.

  23. Sharon says:

    Rebranding in the face of the grassroots movement to legalize direct entry midwifery in every state is some sort of attempt to steal thunder or capitalize on dilligence and hard work already done and re-direct it at the least .
    I really dont see how we are ever going to come to a meeting of the minds, with the push towards CNM’s holding doctorates, it seems very far from the community college approach . Something that nurse midwives should consider is re-naming another direction. Physician Assistants have considerable less schooling, than many APNs with often similar scope of practice and they get paid the same or more… That word physician holds alot of credibility , so how about advanced practice physician assistant , or advanced practice obstetric assistant…

  24. dbsm says:

    I don’t think it’s an attempt to “steal thunder.” Similar motions have been made for the past several…years…decades? Furthermore, this particular motion was merely to look at the implications of a name change. This was a softer, more innocent way to introduce the members to a name change–which they have opposed, obviously since forever.

    Nurse midwives are not going to name themselves anything with the word physician in it. That doesn’t make sense, even if what they practice seems akin to being an OB assistant. They are nurses. If you’ve ever been to nursing school you know that becoming a nurse is a big deal. A big portion of the education is about how nursing is different from medicine/being a doctor (even if some people become nurses because of not feeling like going to medical school). It is a pep rally of some sorts. Knowing this also explains why the the majority of ACNM members, feel the way that they do. It is about NURSE-midwifery.

  25. mnm says:

    I in no way intended my comments to mean that my educational pathway is in some way superior to others. By stating that I am seeking the CNM route is a way to qualify my decided entry into practice.

    Again, here we have non-CNMs saying that there is no apprenticeship that goes on during a CNM program. All midwifery students, irrespective of practice setting, practice an apprenticeship model. We are all required to to shadow another, experienced midwife for hundreds of hours and practice under her license. Don’t presume to have all of the answers or that your model provides a better gauge of “normal” birth. It is the consistent “us against them” attitude that continues to separate rather than unite midwives as a whole.

    For me, part of the reason why I am choosing the CNM model is not because I want to know only how to manage “normal” birth (which in my opinion should be extremely hands-off). Rather, it is important for me to learn how to manage complications, which will arise. I am not worried about the 99.5% of normal, uncomplicated births; instead, I am intent on being well-equipped to handle the major complications that are likely to arise 0.5% of the time. Even one dead mom or baby on my watch is too many. Working with high-risk , complicated birth has also allowed me to see the other side of the spectrum and will ultimately make me a midwife able to recognize and refer out dangerous complications long before emergency services are required.

  26. dbsm says:

    CNMs, in general, do not practice an apprenticeship model. Apprentices spend more time on “clinical” skills and less time on “theory.” Apprentices work with a midwife while gaining more experience until said apprentice could basically be incorporated into the practice. CNM education is more punctuated…separated. There is little-to-no continuity of care. That is why it is more like an internship, but not until you get to the finale: integration.
    This is what I have observed as a student in an AMCB program. I’m asking questions. Learning things. Sharing information. I’m not any more “us against them” than what I personally witness at the Annual Meeting in combination with what I am currently reading on the motion thread.

  27. erinmidwife says:

    Everyone, let’s not diminish this productive conversation with personal squabbles. We can make our points clearly without getting personal. (I will delete or edit or comments that take on a negative personal tone). I do think it is possible and reasonable to sensitively critique an academic program without being enrolled in it. We all bring our own experiences to this discussion and hearing the inside perspective on our educational paths in this way is enlightening!

  28. Sharon says:

    So someone will update us on this I hope.
    Holbrook,Az had community college classes for LMs. What is needed are busy enough clinical sites to help train direct entry midwives. I have a friend who immigrated to Canada and their direct entry programs are pretty good and they have a bridge program – which is what my friend did in order to be licensed in Ontario, the problem with the program is lack of clinical sites where midwives can get out of hospital experience.
    several retired midwives live here and we have approached and looked into the local community college , they are not convinced it is worth their while.

  29. And I want to be perfectly clear that my opinion is based largely on how the legal, regulatory, and political climate of Missouri affects all midwives. This is especially true of my more emotionally charged statements like asking what good it is to be able to have the name midwife if you end up practicing OB/GYN. We know of groups that even bill their CNMs care under ARNP, OB/GYN because they claim to get a higher reimbursement rate for it.

    I think that highlights a difficulty for the midwifery profession. ARNP, OB/GYNs are reimbursed at a higher rate, they will be able to initiate the Annual Wellness Exam under the PPACA section 4103 while CNMs cannot, and yet, inside the midwifery community there is division.

    It looks like the nurses are moving the nurse-practitioners to be doctoral programs instead of master’s. Will ACNM do the same? I think this may be the point where CNMs will have to decide if they are midwives or nurses. If they are nurses, they will have to follow the nurses and shift to the Nursing PhD program. If they are midwives, they will likely buck that trend. It is hard to guess the consequences of either choice.

    The history of ACNM tells us that getting more education has improved the pay rate and access to insurance reimbursement. More education has expanded the scope of practice for midwives. More education has made work in hospitals acceptable in some places. All of these things are good things. But let’s talk for a minute about what this academic education is and is not.

    There is no evidence available that requiring all midwives to get more education improves care for pregnant women and babies. There isn’t even any evidence that proves that primary care providers need the expensive and time consuming education that we require of physicians. Elliot Fisher of Dartmouth has even done a few studies that suggest that practitioners are guided more by the prevailing treatment protocols in their residency or the local trends than by their academic education. If we want to talk about “evidence-based care” then it is vitally important that we focus a bit less on the academic side of education and a bit more on the practical, clinical side. This is where the midwifery tradition has an advantage. Midwifery already does this.

    As I read through the Flexner report I get the feeling that the medical education process was designed to do two things. 1) Create a centralized, politicized control organization that would prevent “snake oil” salesmen from pretending to be physicians. 2) Raise the status of the profession through politics, economics, and social engineering. This is a slightly cynical take on his work, but I still think it is accurate. I agree that more training, knowledge, experience, and “education” is a good thing. Educational and professional programs that model themselves on the “Medical Model” putting academic education ahead of clinical concern me for ideological reasons.

    The reason physicians hold the prominence that they do is largely because after Flexner wrote his report, the AMA started lobbying states to grant them a monopoly on health care. To this day, physicians enjoy a special legal status. As nurses, social workers, and midwives begin to increase their academic requirements, I wonder if this is really about improving care or about getting to also enjoy the benefits of being “more equal” than other people?

    The solution provided to protect people from fraudulent care created a system in which many people had no access to any care. To solve this problem, we created a system where those with no means are provided assembly-line care from overworked providers. I believe that midwives can do more than provide “coverage for the gap between demand for women’s health care and OB/GYN supply.” I think that by looking at programs like Jennie Joseph’s in Florida, midwifery could show America that it is in teaching people to care for themselves that we can truly revolutionize health in America.

    To me, the problem currently facing American health care is a question of equality. I don’t think that by grasping at the special status of physicians we will accomplish this. Look at the osteopathic physicians. Locally, we have a few who really seem to follow the DO philosophy, but I know as many MDs that practice holistic medicine as DOs. By attaining status, they joined the club, but only sort of. The physician’s board is still dominated by MD’s by statute. The DOs are pressured into practicing according to MD philosophy and theory. I do not see that midwifery will be any different unless midwives choose to be different.

    Enter the eternal struggle between “selling out,” and “staying on the fringe.”

  30. erinmidwife says:

    Hilary (and anyone else) can you update us on the ACNM meeting events? We’ve heard the name change motion did not pass but I think everyone is eager for some details!

  31. The bare details – the motion needed 240 “aye” votes at the annual meeting (which would have constituted a majority of those present) in order to be passed on to the full membership. There were 208 in favor, so it did not pass.

    As mentioned above, the ACNM had hired the services of Maia Marketing Group (MMG) to evaluate the impact of a name change. Interestingly, I believe that MMG’s report (available via the link in Erin’s posting above) hits the nail on the head. According to MMG’s survey of a group believed to be representative of the ACNM membership, “the disparities in opinion revealed in the member poll suggest a crisis of identity within ACNM, a split between who ACNM has been and who it should become….Given the internal and external disparities that emerged from the environmental scan – between name and mission, in views of whom and what the organization represents, and in conveyance of the brand – ACNM should closely examine its identity before it considers changing its name. This means it should realign its vision, mission, brand, strategies, goals, activities, and name to reflect a singular purpose and direction— i.e., who it represents, to what purpose, and in what ways. Only by first undertaking this systematic process of realignment can ACNM determine whether a name change is appropriate. Changing the name before completing this process would be “putting the cart before the horse,” and would result in additional confusion and division within and outside the organization.”

    This really sums up what I saw at the convention – a split between those who identify as midwives, and those who identify as NURSE-midwives. Within the group of those who identify primarily as midwives, there was another split – those who felt that the name change would have been a positive step – in essence, it would have sent a strong signal to the ACNM leadership that the membership wanted the future to be court of the “midwife” identity – and those like myself, who felt that the “identity alignment” (and an action plan to take steps in that direction) comes first.

    I have been mulling over whether my reluctance to join those who see name change as a positive first step has been fear-based – and if so, if this fear is based on twenty-year-old events that were unique to that period of time, or is grounded in the reality of today. There are so many wonderful INDIVIDUALS whom I had the pleasure of meeting at the convention. There was also a large emphasis on normal birth, on discussing “patient autonomy”, on homebirth practice. There was an obvious attempt to build bridges – eg, Holly Kennedy came to the Bridge Club meeting and apologized for the document mentioned above (which did NOT get published by the Washington Post), both for its content and the process from which it arose. HOWEVER, I still believe that the faction that holds more political power, the faction which wants to work state-by-state for inclusion of the CM over the CPM, which sees the power of CNMs being in their alignment with nursing, which discounts the knowledge of CPMs, does not have inclusiveness in their sights.

    So, should the ACNM choose to take the advice of MMG and perform an “identity alignment,” and if such alignment resulted in the group identifying that its true goal was to promote MIDWIFERY, then what would be the next steps? What would a true American College of Midwives look like? And how would we get there? Would there be discussions between NARM and AMCB on creating a unified credential? Would The Big Push for Midwives meet with the Political Action Committee of ACNM to plan how to push for Boards of Midwifery inclusive of ALL midwives in every state? Would ACME and MEAC start talking about combined educational programs, where students get “the best of both worlds”? Would the preceptor data base currently being compiled by the ACNM education committee list CPM-run practices on its site? Would CNM-run practices open their doors to CPM students? Would we all just be midwives?

    I don’t profess to have all the answers; however, being at the conference did give me a modicum of hope. The numbers of CNM/CMs who identify solely as midwives is growing, and the emphasis on preserving normal birth is growing. The frustration with the current state of affairs is palpable. Perhaps we can look to creative voices within all of midwifery and find the path to unity. I only hope I’m still around when that day comes.

  32. Helen McAdory says:

    This is the best articulation I have ever come across that clearly outlines the differences between the CPM and CNM political, educational and social worlds.

    I wil be doing my best to cross post to forums and blogs wherever I can.

  33. KAMILAH says:

    I have recently moved to Arizona from England, where I worked in Maternity services. I have been deeply surprised by the divide between Nurse Midwives and Licensed Midwives here in the U.S, and so I was very interested to read the response on the unification of the 2 professions. In England, birth is considered a Midwifery led event, and it is a direct entry, degree only profession.

    Newly qualified Midwives have to rotate between the community team which deals with home births, the pre-natal ward, pregnancy clinic, post-natal ward, and delivery suite, where they deal with normal births as well as C-Sections. The whole point of this is to keep up each Midwife’s clinical skills in all areas as well as their understanding of the whole regional Midwifery service.

    Women at home as well as those in hospital will therefore receive the same holistic care and approach from their Midwives, and a ‘divide’ between home birth Midwives and hospital Midwives, simply does not exist.

    It is my intention to make my way into the Midwifery here in the U.S. and I hope passionately that the 2 sides of the profession will therefore be merged in the future, although it seems there is a long way to go to reach that point………..

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