The American College of Nurse-Midwives (ACNM) has a motion on the table to change its name to the American College of Midwives (ACM). There has been talk about this change happening for years, but there may finally be enough support to approve the motion at the upcoming annual meeting in San Antonio. There has been internal discussion in certain midwifery circles about the politics surrounding the name change and how it may affect direct-entry midwifery. I think it is time to move the discussion into a more public arena.
I interviewed homebirth midwife Hilary Schlinger about the proposed name change and her vision for the future of midwifery in the US. Hilary is both a Certified Nurse-Midwife and a Certified Professional Midwife and has a long history in midwifery politics. 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: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?
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: But some ACNM members are saying that they need to be more inclusive of their CM members. Why is it important to understand 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 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/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 turned CPM, but eventually became a CNM despite your criticisms of ACNMs political tactics and being exiled from New York. Why?
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: Is a perceived lack of education the primary reason ACNM fails to support NARM and 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’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing 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.
Hilary 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.