Wednesday, September 5, 2012

CPM education: The Bar is Too Low

We'd like to welcome "Ex CPM Student" as our guest blogger today.  A former midwife apprentice shares her insights about educational training of CPMs.  

One reason why the authors of this blog are so adamantly opposed to licensing CPMs in Michigan is because they’ve done their research and understand the paltry requirements for one who wants to become credentialed as a CPM.

There is a lot of gloss on this credential – and proud, public proclamations that CPMs should be legally recognized as “a knowledgeable, skilled and professional independent midwifery practitioner” who “specializes in out-of-hospital birth."

First off, I want to state that I do not believe that all CPMs are poorly trained. I will not paint a black and white picture for sake of creating a tidy, diametrically-opposed argument. But I will say that CPM education requirements are not enough. The bar is set too low. This is what the authors of this blog are saying as parents who have done their research – and this is what I am saying as a former apprentice:

The bar is set too low.

So just what is required of an apprentice who wants to become a CPM?


Appropriate education is allowed “through a variety of routes” and yes, NARM includes “self-study” as an option. (I'm quoting the NARM Candidate Information Bulletin). I kind of cringe when someone says CPMs could have trained by watching YouTube videos, but I can’t imagine how this doesn’t fit into NARM’s education standard that allows education by “a variety of routes” including “self-study.”

Do I even need to say this? This is a pretty low fricking bar for educational standards.


If we separate out the clinical training from the educational requirement, we can see that the clinical aspect of apprenticeship is more clearly defined - and dare I say, more stringent - than the education requirement. The clinical requirement specifies at least 1350 contact hours (and how these clinical hours are tracked and verified is defined by NARM) and states that these hours must take place over a period of time at least one year in length. Disregard the fact that 1350 contact hours could be acquired by working 40 hours per week for a duration of less than 9 months. This is a trifling technicality.

These clinical requirements are verified by the supervising midwife, or preceptor, by signing paperwork and having correlating documentation of the apprentice’s participation in client charts.

Well, let’s look at what the specific clinical requirements are:

Initial prenatal appointments:                20
Prenatal appointments:                            55
Postpartum appointments:                      40
Newborn exam:                                          20
Active Assistant:                                         20
Primary midwife under supervision:     20

Now many apprentices will have had more clinical experiences than what is required here when they sit for the NARM exam. But the point is not what “many” or “most” or “some” CPM candidates have done prior to becoming certified, the point is to show what is actually required. So let’s look at just what that is.

Prior to apprenticing in the role of “primary under supervision,” the student midwife usually will attend births as an “active participant.” (At this point, I really want to add my own personal opinion regarding the clinical responsibilities that should exist for one who is acting as “active participant” at a birth in an out-of-hospital setting like being trained in CPR, NRP, qualified to monitor contraction patterns, perform vital signs and assess FHTs to name a few. But NARM does not specify this, so neither shall I.)

OK – 20 births as “active participant” (Whatever that means, maybe placing cool washcloths on the laboring woman’s forehead.)

Then the next 20 births, could feasibly be the apprentice’s “primary” births. The primary under supervision requirement means the apprentice is managing the labor, making clinical decisions and performing all skills relevant to midwifery under the supervision of a preceptor.

OK – add 20 births required for “primary under supervision.”

We’re up to 40 births.

Now, for the appointments: 55 prenatals, 20 initial prenatals, 20 newborn exams, 40 postpartum exams

All of these requirements could be fulfilled with the 40 women whose births were attended as active assistant and primary under supervision. The routine course of prenatal care, if started in the first trimester, can easily include to 8 to 10 prenatal visits, (8 x 40 = 320 prenatal visits) and midwives typically include 3-5 postpartum visits in the weeks following birth (4 x 40 = 160 postpartum visits). If the apprentice performed the newborn exam for half of the births she attended (20 births = 20 newborn exams), this requirement would be fulfilled as well.

I’m not saying this always happens – only that it could: 

The NARM clinical requirements could be fulfilled 
by participating in care for 40 midwifery clients.

That’s the bar. 40 clients.

If you participate in the care of 40 women having babies in an out-of-hospital setting, and your preceptor signs off on your experience, and this takes longer than one year, you will have completed the clinical requirement for NARM.

Include the (non-existent) educational requirement and a bunch of paperwork, you, too, can sit for the NARM exam and call yourself a CPM offering “expert care" and claim to have gone through “rigorous training” to become a certified professional midwife.

At this point, (THIS IS THE BAR – I’m repeating for emphasis: 40 clients, nary a course in anything, and passing the 350 question exam) NARM considers CPMs "knowledgeable, skilled and independent" care providers for pregnant women having an out-of-hospital birth.

Is this bar high enough for you? For your friend? For your sister? For your daughter? For your cousin? For your neighbor? For the pregnant teenager working at the fast-food joint?

It is an appallingly low standard apparent to those who’ve done their research. Safer Midwifery does not support permitting licenses to individuals who have cleared a bar set so dismally low. It does not assure adequate training or competence and it does not assure safety for women and babies.


  1. If I'm understanding this correctly, it would be possible for someone to become a fully trained CPM without ever having attended a complicated birth. Is this correct? And what are the required standards for demonstration of knowledge of complications?

  2. Yes, it would be possible for someone to become a CPM without ever attending a complicated birth.

    The requirement for understanding obstetrical complications? Well, I can only speak for myself and my own "training" and apprenticeship. (BTW I was enrolled in a MEAC-accredited midwifery program.) But this was often covered during a study group - where we sat around a midwife's kitchen table and we discussed complications such as breech, thick meconium, manual removal of retained placenta... just to name a few.

    I was personally very uncomfortable with having these 'skills' validated by my supervising midwife - when all we did was 'chit-chat' about it. I called my school to ask how it was that I was supposed to be deemed competent in these high risk skills. (Also, the other question that begs to be asked is - which complications should OOH midwives NEVER see, because they are too high risk for planned OOH delivery?) The school confirmed for me that it was perfectly OK to have these skills signed off after a discussion, that they understand that these skills are routinely not encountered during one's apprenticeship, and so these competencies are granted in theory only.

    I hope this addresses your question adequately.