On the Horizon for Safer Midwifery for Michigan

While spring has firmly settled in, there is much up and coming for Safer Midwifery for Michigan.  We figured it's time for an update post for our readers.  Baby Snyder is anxiously anticipated to make her arrival next week!!  It's a bit surreal, and as long as everyone comes home alive, we'll be tremendously happy. 

We have many important projects in the works that will continue moving forward thanks to leadership within our advocacy group.  The blog will continue as well, but may slow just a bit while we adjust to a new little one in our family.  We have several guest posts in the works that will help along the way, and look forward to sharing thoughts on everything from VBACS to the CM Credential, and more.   Below you'll find a brief update for our biggest projects...

Website
Thanks to a great deal of generous support, our website initiative is well under way.  Our initial ideas are being fleshed out with a designer who has started a prototype.  After we have worked through the design process, the implementation will begin.  It's a long, thoughtful process to do this job well, and we're grateful for so many collaborators on this project.  We don't have a project completion date, but are happy to share we've officially started in the right direction.  We'll be working hard on researching, and drafting content this summer.  

Data Team
With the help of an amazing epidemiologist and the cooperation from the State of Michigan, we have assembled a data team who will be carefully analyzing data on perinatal outcomes, (both deaths and injuries) in the state of Michigan.  We'll be looking at out-of-hospital data for deaths and injuries as well as in-hospital data, and considering comparisons by care provider type.  At this project's completion, we hope to have a thorough report to share with the public so they can be better informed, and we hope this project will simultaneously inform any legislation regarding midwifery in the near future.  Transparency matters a great deal when it comes to safety, and Michigan families deserve to have data to support them in the decision making process.  Safer Midwifery for Michigan has assembled a team to look at the data the state has collected, and further analyze it in order to promote transparency. 

Collaborative Care Initiative
If you live in or around the Lansing, MI area, you are likely well aware of the lacking options when it comes to the type of care providers in the birth world.   We have one CNM who delivers part time at McClaren Hospital, and none at Sparrow.  We have worked hard to express to Sparrow Hospital the need  for a Collaborative Care Model that includes CNMs as a care provider option in the same facility that houses our area's only RNICU.  Sparrow has adopted the Baby Friendly initiative in recent years, is working hard on a more concrete plan for a Collaborative Care Model, and a further develop a plan for facilities that support a focus on natural childbirth.  We appreciate the progress this project has made, and look forward to hearing more soon about a potential timeline for how things will proceed.  

Legislation
We've also worked hard to revise SB 1208, and submit detailed suggestions for change.  The two biggest changes we hope to see include altering the language so that it would eliminate restrictions on CNMs practicing in MI, and changing the minimum standard for education to be in line with International Standards.  We're hoping for reintroduction in coming months on the legislative front that would offer higher standards for education, a defined scope of practice for midwives practicing OOH in MI, and measures of accountability.  We'll be sure to keep you up to date at this project develops, and share ways you can support the effort as they become available.  
  
Stay tuned for more in coming weeks, and as always, thank you for caring about the important issues we discuss here.  

American Midwife Certification Board (AMCB)

ACOG and the AAP recently issued statements regarding planned home birth recommendations.  Among them was the recommendation that midwives attending home births be AMCB certified.  We couldn't agree more and thought we'd share with you what exactly this means. 

What is the American Midwifery Certification Board (AMCB)?
 
"Our mission: To protect and serve the public by leading the certification standards in midwifery" ~ American Midwifery Certification Board

The AMCB provides certification opportunities for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs), the only two credentials for midwives in the US that require graduate school level education. 

  
"The American Midwifery Certification Board (AMCB) is the national certifying body for candidates in nurse-midwifery and midwifery who have received their graduate level education in programs accredited by the Accreditation Commission for Midwifery Education (ACME). Certification by the AMCB is considered the gold-standard in midwifery certification and is recognized in all 50 states." 

What midwives qualify to take AMCB's certification exam?
Midwives with a graduate level, university degree may take the AMCB certification exam.  This includes Certified Nurse Midwives (CNMs), and Certified Midwives (CMs).  Regardless of educational pathway, both CNMs and CMs take the exact same certification exam to become certified by AMCB, and must continue education according to standards set forth by AMCB to retain their certification status, every 5 years. 

What is the Scope of Practice for AMCB certified midwives?
 Scope of practice is somewhat determined by state laws that license AMCB certified midwives (CNMs and CMs).  It is important to note that CNMs and CMs have an identical scope of practice, both able to attend births in and out of hospitals according to state laws. 

Why does AMCB certification matter? 
"Certification protects the public by ensuring that certified individuals have met predetermined criteria for safety in practice.   While state licensure provides the legal basis for practice, most states require AMCB certification for licensure, and many institutions require AMCB certification to grant practice privileges."

Consistently reliable, high standards for education and practice protect the people.  Why would we accept anything less, whether in or out of the hospital?  Midwives practicing without AMCB certification have not met the educational or practice standards set forth by AMCB, nor do they come close.    

What makes AMCB certified midwives different than CPMs, DEMs, and other midwives & why does it matter?   

I must explicitly point out that a Certified Midwife is very different from a Certified Professional Midwife or CPM.  CPMs are not eligible for certification through AMCB.  Their educational and clinical requirements are vastly different.  

This link: "Why AMCB Certification?" offers a thorough comparison between different types of midwives, their education and certifying bodies.  

We have recently posted a series on the Education of Midwives around the world here on the Safer Midwifery for Michigan blog.  It's important to note that AMCB certified midwives are on par with highly educated midwives serving women around the world.  CPMs would not however, be qualified to practice in any other first world country by current educational and practice standards.  I would encourage any reader wondering about the differences in credentials to visit these posts to learn more. 

Education of Midwives Around the World: Part I
Education of Midwives Around the World: Part II
Education of Midwives Around the World: Part III

The educational background and training of midwives is directly related to outcomes and safety.  One of the most important factors in fostering positive out-of-hospital outcomes is the component of hiring a highly educated midwife. 

Which Michigan midwives are certified by AMCB? 
All CNMs, whether practicing in hospitals or outside hospitals are certified by AMCB, and licensed through the State of Michigan.  If we had CMs in our state, they too would be certified through AMCB, but we currently don't know of any practicing here.  This is likely because our state does not currently license CMs. 

All other out-of-hospital midwives, (CPMs, DEMs, and other midwives) are not certified through AMCB.  These are the majority of midwives serving MI families outside hospitals.  (Majority meaning all but two in the entire state.)  If you're considering out-0f-hospital or home birth in the state of MI, you deserve to know that your midwife is likely not AMCB certified, university educated, licensed, or functioning within the high standards for practice described for AMCB midwives.  

The implication?  Explicitly stated, MI OOH midwives are not in line with ACOG and AAP recommendations for safe home birth.  They are not highly educated as a collective group, nor do they meet this critical component that contributes to positive outcomes.  

The statements issued by ACOG, and AAP directly support the notion that home birth outcomes improve dramatically when attended by highly educated and trained midwives. This is just one important factor in providing for the best out-of-hospital care.  Please be sure to read about the other critical factors here if you are contemplating out-of-hospital birth or home birth. 

Recommendations & Guidelines

• American College of Obstetrics and Gynecology: Recommendations for Planned Home Birth 
• American Academy of Pediatrics: Guidelines for Planned Home Birth 
• American College of Nurse Midwives: Statement on Planned Home Birth

Considering Home Birth? Check out these recommendations...

The debate as to whether home birth is safe, and just how safe has been ongoing in the US for some time now.   The only thing it's safe to say is that home birth is not for everyone in every circumstance, nor is it meant to be attended by just anyone who wants to call herself a "midwife".  The safety of home birth is directly related to several key factors, each of which must be carefully considered.  Important national organizations are expressing their positions on the matter.

Exactly what factors undoubtedly impact the safety of OOH birth? 

• Consistently reliable educational standards and training; ie AMCB certified midwives.

• A defined scope of practice (including consistently valued, research-based assessments, and risking out criteria to ensure only truly low-risk pregnancies are taking place OOH).

• Midwifery practices that function within a fully integrated model of maternity care, for smooth consultation, collaboration, and transfer of care.

In addition, SMM also believes that consistent informed consent, philosophy, malpractice insurance, a balanced board for oversight, and reporting outcomes in the form of data are key elements that directly impact safety.  
 

So what do the national and international maternity organizations have to say about home birth? 


 

ACOG Planned Home Births

•  "Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery."

• "Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth." 

• "Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes."

• "The recognition and regulation of certified professional midwives and lay midwives varies tremendously from state to state. At this time, for quality and safety reasons, the American College of Obstetricians and Gynecologists does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board."
 

AAP's Recommendations for Planned Home Births 

• "The AAP concurs with the recent statement from the American College of Obstetricians and Gynecologists (ACOG) that the safest setting for a child’s birth is a hospital or birthing center, but recognizes that women and their families may desire a home birth for a variety of reasons."

• "Pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board."

• "There should be at least one person present at the delivery whose primary responsibility is the care of the newborn infant and who has the appropriate training, skills and equipment to perform a full resuscitation of the infant. All medical equipment, and the telephone, should be tested before the delivery, and the weather should be monitored."

• "A previous arrangement needs to be made with a medical facility to ensure a safe and timely transport in the event of an emergency.

ACNM Position Statement on Planned Home Birth

• "Every woman has a right to an informed choice regarding place of birth and access to safe home birth services. 

• Certified nurse-midwives (CNMs) and certified midwives (CMs) (ie. AMCB certified midwives) are maternity care professionals who are qualified to provide ongoing assessment of appropriate birth site selection over the course of the antepartum, intrapartum and postpartum periods.

• CNMs and CMs (Again...AMCB certified midwives) are qualified to provide antepartum, intrapartum, postpartum and newborn care in the home.

• An integrated system of health care that includes collaboration among all health care providers is essential and fundamental to supporting a safe, seamless, transfer of care from home and/or out of the hospital setting when necessary.

• Reimbursement from third party payers should be available to licensed maternity care providers for home birth services.

• Professional liability insurance carriers should provide coverage at actuarially appropriate premiums for all licensed maternity care providers who attend home births.

• The characteristics and management of normal birth, including the influence of birth setting, should be the focus of research and evaluation. This research should address outcomes, client satisfaction and experience, markers of morbidity as they relate to birth site, and development of ongoing quality assurance initiatives."

In Summary, guidelines, recommendations, and the way in which out of hospital birth is approached matters a great deal in terms of safety.  We won't preach "do your homework mama", because the vague message doesn't give any tangible guidelines for practice, nor does it help mothers know what to look for.  We will however, highlight (as we've done here) the specific elements that contribute to the safety of out of hospital safety (or lack thereof) in an effort to help women better understand what to look for if they are considering home birth or a birth center birth.  The absence of any one of the above named elements dramatically influences the safety of you and your baby. 

Other opinions on the topic:
Navelgazing Midwife: AAP's New Homebirth Guidelines
Skeptical OB: MANA's Response to AAP's Guidelines 

Science & Sensibility: MANA's Response to AAP Guidelines 
(by Michigan's own Geradine Simkins, CNM, MSN, and director of MANA...posted here in the "opinion" section because this piece is so misleading it deserves it's own blog post rebuttal...coming soon.) 

MEAC - How to Make Accreditation Matter in Midwifery Education

The Midwifery Education Accreditation Council - also known as MEAC - is the organization that accredits programs that train midwives to become eligible to take the NARM exam and become CPMs.  (Note: The MEAC accredited route represents only one path to becoming a CPM.) 

Believe it or not, we have had numerous discussions regarding MEAC-accredited midwifery programs and creating a requirement of graduation from a MEAC-accredited program as a provision for CPM licensure in Michigan.  Florida and California already do this, and it beefs up the educational background for certified professional midwives licensed by these states. The American College of Nurse-Midwives has a position statement regarding midwifery certification in the US, and supports licensure of CPMs who have completed a formal education program. Requiring formal midwifery education goes above and beyond the paltry educational requirements set forth by NARM and perhaps even fulfills the education requirements set forth by the International Confederation of Midwives.

In our discussions we've come to the conclusion that MEAC does not do enough to ensure high-quality midwifery education, and though it is an improvement over NARM's rudimentary standards, it is not sufficient for licensing independent midwives.

Why doesn't Safer Midwifery for Michigan endorse the MEAC-graduate CPM as holding the minimum requirement for Michigan licensure?

• MEAC does not assure uniformity in education between accredited programs (some graduates hold master's degrees, others have a 'certificate' in midwifery)
• MEAC does not assure more thorough academic preparation than apprenticeship-only education
• MEAC does not strive to provide an education that is an improvement over the infamous portfolio evaluation process (PEP), but takes care to make certain there is no advantage of MEAC-graduates over apprenticeship-only trained midwives
• MEAC bows to the lowest common denominator, citing that "all pathways" to becoming a CPM are equal,  
• MEAC does not require integration into post-secondary education institutions to assure consistency with American standards for general education requirements. This means if a CPM graduates from a MEAC-accredited program, none of the credits earned will transfer to any real university or college in the US.
• MEAC programs do not require evaluation of the preceptor's teaching methods or efficacy in training student midwives.
• MEAC does not require any hospital-based clinical experience midwifery

What would it take for SMM to endorse the MEAC route to becoming a CPM?

• Regional accreditation as well as specialty accreditation.
• Requiring preceptors to have training and guidance in teaching students.
• Oversight in determining how successful completion/competence is determined by preceptor
• Require clinical experience in a US hospital setting
• Require at a minimum a Bachelor's degree
• Require specific coursework related to health care and midwifery in biology, chemistry, anatomy and physiology, microbiology, pharmacology, statistics, risk screening, assessment, the midwifery scope of practice, ethics, embryology, primary care for women's health, and prenatal, postnatal and intrapartum theory courses.
• Commit to ensuring superior education and training of midwives who are educated through MEAC accredited programs. 
• MEAC should not be branded as a 'separate but equal' pathway to becoming a CPM, but a more rigorous, more thorough, more comprehensive pathway that produces higher-quality midwives.
• MEAC must advocate for accredited programs to be the only valid route to attaining a CPM credential.

Currently, the bottom line for CPMs is that ACCREDITATION DOESN'T MATTER - because graduation from an accredited educational program is purely optional for becoming a CPM. A student midwife could drop out, not graduate or fail every single one of her classes, and as long as her 'skills were signed off on' the student midwife could still take the NARM exam and become a CPM.

A quote from Via Vita Midwifery Midwifery illustrates this point:

http://www.viavitamidwiferyschool.org/

Though this is just one example of the attitude toward accreditation of midwifery programs, we have found it to be common among CPMs. Here's another sentiment expressed in a 2011 newsletter from the National Association of Certified Professional Midwives. (Notice the glaring lack of any statement regarding assuring quality of education):

Why does accreditation matter? It remains the first accomplishment in the midwifery movement where we have fully achieved federal recognition. It is that part of the movement that dips its feet into the mainstream waters. It is the portion of our educational fabric that is easily understood by the mainstream,and easily accessed by students who are looking for an educational experience that they can finance in the mainstream and defend in the mainstream. It is a portal where the radical can slip into the mainstream and stir up a change! ~ Ellie Daniels, CPM, Past President of MEAC

So the rationale for MEAC-accreditation - from the words of a past-president of MEAC - is not to assure competent and highly-skilled midwives, but merely to gain some acceptance in mainstream America?

We believe Michigan families deserve better than this, and this is why SMM cannot support MEAC-graduates as qualified for licensure as midwives in our state.

Willow Tree Family Center Board Replies to our Open Letter

Last week Safer Midwifery wrote an Open Letter to the Willow Tree Family Center Board, stating concerns about potential staffing and/or affiliations with dangerous care providers in the Greater Lansing Area. 

We thought it was important to share their reply, and leave it open to your own interpretation:
 
"Dear Safer Midwifery for Michigan,

Thank you for your recent email to our center and for sharing your
suggestions and concerns.  It is very important to us that we have
integrity in our endeavors, and we share many of your goals.  Your primary
goal of making people fully informed about their care providers and health
choices is of utmost importance to us as well.  We agree that providers
should be transparent with their statistics, and we want to empower
families to ask their care providers the right questions in order to be
fully informed.  We are interested in supporting and working with causes
such as The Birth Survey, whose goal it is to make maternity care
transparent.  Statistics ranging from intervention rates to maternal and
infant mortality rates should be public information for all OBs,
hospitals, and midwives.

It sounds as though you have heard various speculations about the services
we hope to provide at our center.  As far as plans for staff, we do not
have plans or funds to be hiring any staff anytime in the near future.  We
are hoping to have a community center space available soon, however, and
we are in the process of developing policies for rental and use of the
center.  We agree that it is important to have legal and safe regulations
regarding rental of the space, and we are currently in touch with a lawyer
who is helping us to develop these policies and procedures.

In the meantime, we are putting feelers out into the community to receive
input from people as far as their aspirations for a new center and hopes
for potential use.  At this point in the process, we are being as open as
possible to all ideas and suggestions, and later in the process we will
work on narrowing down the concepts presented during this brainstorming
stage.  Right now, we are working to make the initial development process
as inclusive as possible to find value in all perspectives. Because we
value all family perspectives and experiences, we have made sure to create
a Board of Directors diverse in backgrounds (teachers, doctors, business
owners, SAHMs) and even in birth experiences (among us we have a variety
of them - from c-sections to home births and everything in between).

Again, we do care very much about being as objective and forthright as
possible as we advocate for improved care options in Lansing.  We are
excited to work together with programs and activities such as yours that
will empower families and make quality care available to all people.

Thank you again for you valuable input!"


Safer Midwifery for Michigan will keep you posted as we see how the Willow Tree Family Center project develops.  We appreciate that the board has been open to hearing our concerns, and we further hope they are able to build a resource that is safe and reliable for the community they serve.