Certified Professional Midwife Credential

Some may read our blog and draw the conclusion that we do not "like" or support Certified Professional Midwives."  Please know that is not the intention.  We do not aim to be inflammatory or derogatory toward CPMs.

For Safer Midwifery for Michigan, the bottom line is a clear, an appropriate standard for education and training is absolutely critical.  Research from around the world points to a high level of education as one of the key factors in positive birth outcomes outside the hospital.  You can visit recent posts about the Education of Midwives Around the World, Part I, and Part II to further understand this research, and how it highlights glaring disparities between educational standards for midwives in other countries as compared to the US.  Notice in these links that other first world countries have much higher standards, most requiring a university level education for the women delivering their babies.  What about the USA?   The minimum standard for a CPM's education is only recently (2012), a high school diploma.

The problem with the CPM credential lies in credibility and severe inconsistencies among providers who carry the credential.  While there may be some CPMs who are highly educated, there are far, far too many who are not, and they are all thrown in the pot together.  Scope of practice is undefined at best, purposefully leaving it up to the midwife herself to determine along the way.  For example, check out NARM's "Shared Decision Making Statement".  The end result is a variable pool of midwives, some who are highly educated, and those that are not with a smattering of skills in between.  Some are even rushing through the training with a careless preceptor so they can be "grandfathered in" when licensing legislation does pass.  For a little history lesson about the CPM credential, and the importance of educational standards, visit our recent guest post by Judith Rooks, CNM.

The American College of Nurse Midwives said it well in a letter sent to members of Congress in 2009: 

     "Until the CPM community has developed a uniform process to ensure that all 
      CPMs have graduated from an accredited program, Congress should not recognize 
      this class of provider in its entirety."

 
We sincerely understand the desire and need for a credential that offers reliable care for the out-of hospital client, but in what world is an apprenticeship process acceptable for delivering babies?  Especially when there are other routes to professional midwifery credentials that require a graduate level of education, like the CM credential, or the CNM.  Or what about states that provide provisions and appropriate licensing for all three credentials like the state of New York? 

Education Requirements for Licensure in NYS:

All midwives, regardless of credential or educational background must meet certain criteria to be eligible for licensure in NYS:

-- Bachelor's degree (doesn't matter what subject) -- which you already have.
-- Midwifery education at a NYS approved midwifery school*
-- Can demonstrate competency in particular areas relating to well-woman care and pharmacology (see http://www.op.nysed.gov/midwif.htm check under education)

All midwives must take and pass the AMCB certification exam which is designed for CNMs or CMs, but which all midwives in NYS must take (the NARM exam is not accepted here).

** Several MEAC schools have been deemed acceptable by NYS. CPMs using the PEP process can become licensed, but they must then go to a midwifery school and have a bachelor’s degree. Several CPMs have become licensed in NYS by attending the distance learning program at the National College of Midwifery and obtaining a BS in midwifery.

(These guidelines and standards for education are in line with ACOG and AAP's recent statements on planned home birth.)

Some are uncomfortable with any kind of comparison among credentials, CPM, CM, and CNM.  I would ask them, how is a healthy conversation about the safety of midwifery, and educational standards possible without discussing the difference among them?  Somehow that is misconstrued as breaking the sisterhood, or damaging the image of midwifery.  I have to say, nothing is more damaging to midwifery than continued unsafe practices, preventable deaths, and injuries that are ignored, and the multitude of issues that continue to go unaddressed ~ even outright ignored.  

Our advocacy group believes that women and families deserve transparency.  They deserve to know, discuss, and understand the differences between these credentials, and how it impacts their care.  Lines between these credentials have been purposefully blurred to the public, allowing dangerous midwives to practice under the same hat as those who practice responsibly.  Need an example?  MANA's "What is a Midwife?" leaves out all the important details about educational standards and the differences in scope of practice among various types of midwives.  They make it seem as if their training is on par with the rest of the world, even citing an International definition of "midwife"...all while the minimum standards for CPMs don't even meet International educational standards. It's misleading, confusing, and leaves women feeling scammed when the unthinkable happens.  

It's time for frank discussions about what our standards should be for education and practice of all midwives in this country and state, and the public deserves to have a say.  It's not about leaving anyone out, insulting any one body of midwives, or being divisive.  It's about establishing a minimum bar for education and standards for practice that are appropriate, with safety and outcomes at the forefront.  It's about supporting midwives in reaching that bar if they aim to provide excellent care for mothers and babies in any environment, home or hospital.  It's about taking the time to get a sound education and offer women choices they can rely upon.  We've said all along, the state of midwifery cannot improve if it cannot accept and address its shortcomings.  

Instead of getting offended, lets get the difficult conversations started, and move toward real progress. 

"Certified Midwives" Examining the CM Credential

What is a Certified Midwife?

A Certified Midwife (CM) is a health care professional who holds a credential in midwifery from the American Midwifery Certification Board. Certified nurse-midwives (CNMs) are the most prevalent type of midwife in the US and are certified by this same board.

The standards for education for CMs and CNMs are identical. Both must be educated in a graduate degree program, are trained in the same competencies, and must pass the same certification examination.

By credential, certified midwives are qualified to independently manage low-risk pregnancies and deliveries, provide routine well-woman care and screenings, diagnose and treat health conditions, and prescribe medications. 

How is a certified midwife CM different than the CPM or CNM?

Educationally, the only difference between CMs and CNMs is that CMs do not have degrees in nursing. It is an equivalent credential to the CNM.

The differences between CPMs and CMs are that CMs must be trained at a graduate level, CMs are integrated healthcare providers working alongside physicians, nurses and other healthcare providers, CMs are qualified to attend births in any setting, CMs are trained in pharmacology and prescribing medications.

The differences are so important, we felt a graph would be helpful:

	CM	CPM
Graduate degree required	YES
Training in medical pharmacology required	YES
Skilled in providing care in all birth settings	YES
Providers of gynecology and well-woman care	YES
Qualified to prescribe birth control and other medications	YES
Trained with in the health care system among physicians, nurses, and other healthcare professionals	YES
Self-purported “experts” in out-of-hospital birth		YES

 
How are CMs and CPMs similar?

• Neither CPMs or CMs are required to have a degree in nursing.
• CMs and CPMs are not licensed in every state. The state of Michigan does not currently recognize either the CPM or the CM through licensing. 

But the differences between CPMs and CMs are vast and striking. Why are so many states 'pushing' for licensure of such poorly-trained midwives as CPMs, when there already is a high-quality, non-nurse credential? Why, when every state already recognizes and licenses CNMs, is it so difficult to enact licensing for the CM - an equivalent credential? Why, when it comes to midwifery licensing, should we reinvent the wheel - and an inferior wheel, at that -and license midwives with minimal training, minimal oversight, and minimal (or non-existent) standards of practice?

What we'd like to see in Michigan:

We would like to see Michigan take the lead on this very important issue, and license only the most qualified and highly-skilled midwives for women and their families, CNMs and CMs. We would like to see Michigan's nurse-midwifery programs, the University of Michigan and Wayne State, create pathways for training midwives who would become CMs in our state, and we would like to see not only the Michigan Affiliate of the ACNM but also the Michigan Midwives Association openly support improving the educational standards of midwives in our state by endorsing and promoting the CM credential.

Considering Home Birth?

Our country affords many freedoms, among them the right to birth where and with whom we choose.  In a state like Michigan where there are currently no regulations or laws surrounding midwifery, that freedom is widely interpreted.  But what about the rights of consumers to be "fully informed", and what exactly does that mean?  It seems that many home birth advocates tell mothers to "educate themselves", and defend their cause when things go awry with reprimands about the mother's responsibility to make an educated choice.  

In a state with no defined scope of practice or licensing measures for out-of-hospital midwives, it's extremely difficult for consumers to access information that would allow them to fully educate or inform themselves before making the choice to have a home birth or birth center birth.  Being fully informed means families are told about the good, the bad, and the ugly as they pertain to home birth.  It means a woman is told by her care provider directly & honestly the benefits of home birth, and the inherent risks that come along with it. 

All too often I meet mothers, usually those whose birth stories don't have happy endings, who were only told about the benefits of home birth.  They feel duped, embarrassed, like they somehow were fooled by an illusion of promises that turned out to be anything but empowering.   These mothers have not been informed, they have been misled. 

There will also forever and always be those mothers who choose home birth despite the risks that come with it, and fully knowing what they are risking.  And there are mothers who do not fully understand the choices, and more importantly the consequences that can be associated with making the home birth choice.  I fully accept a woman's right to choose home birth, but the one caveat is that she deserves to know a few key facts.  Then, if knowing these facts, she still makes the choice for home birth, then the choice and responsibility can truly be her own.  The problem comes when mothers choose home birth with their heads full of misguided information and misleading propaganda...blinded by the woo as some might say.  

And so with these mothers in mind, those who weren't fully informed about the important factors to consider before choosing home birth, here is a list of things to consider...

Facts You Should Know When Considering Home Birth

1. "Planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth." ~ ACOG Statement on Planned Homebirth
   
2. Requirements for licensing vary widely by state.  This includes minimum standards for education, scope of practice, collaborative agreements, and insurance requirements.  Some states have NO regulations, others some, and still others more thorough guidelines.  Know your state laws well, and consider heavily the impact they have on safety in practice.  (MI is a state that has no regulation what so ever.) 
3. Credentials and educational training vary greatly too.  Look for a midwife who is certified by the American Midwifery Certification Board.  The only type of midwives who are AMCB certified are Certified Nurse Midwives and Certified Midwives.  CPMs, DEMs, or lay midwives do not typically meet the educational standards for this important certification. There are exceptions for CPMs in states like NY where state law has required CPMs to further their education and pass the AMCB exam to earn a license to practice.  In other states CPMs are licensed without the added educational requirements.  Certification by AMCB demonstrates a high degree of competency, and is a more reliable hallmark of educational training than licensing alone. 
4. Outcomes for home birth are greatly impacted by several factors.  Among the most critical are a high degree of education and training (In the US that means an AMCB certified midwife), working within a fully integrated health system, and practices regarding consultation, referral, and transfer of care.
5. Not all women are good candidates for home birth.  Risk factors matter a great deal when considering where to have your baby, and they matter even more if you're considering an out-of-hospital birth. Research has shown time and time again that home birth is intended for LOW RISK pregnancies...yet somehow story after story of baby deaths and injuries are surfacing, revealing they were high risk to begin with according to modern medical standards. 
6. Assessments matter in order to ensure your pregnancy is and stays low-risk.  If your midwife disregards important assessments, she is "trusting birth" more than she is assessing and monitoring your risk factors.  A good midwife will value assessments so she can be informed, and she can keep you informed about whether or not your pregnancy becomes high risk at any point.  She should have very clear guidelines for what defines high risk, and what situations "risk out".
7. Not all "birth centers" are safe.  Looking for a birth center?  Look for one that is affiliated with a hospital with licensed, insured midwives providing the care.  At the very least, choose a birth center that is accredited by AABC. 
   
8. Most midwives practicing outside of a hospital DO NOT carry malpractice insurance.  Midwives like to claim that they can't afford it.  Insurance protects both the consumer and the midwife.  The former by providing specific safety guidelines for practice, and protecting those who are victims of negligence.  The latter from lawsuits that could be life altering. 
9. Just because a midwife is covered by Medicaid, does not mean she is a safe care provider. 
10. Just because a midwife tells you home birth is safe, and that she has never been responsible for a baby or mother's death, doesn't mean it is true.  When there is no oversight and no public track record, there is no way to actually know the truth.  You have to decide whether or not to take your chances. 

What Factors Contribute to the Best Outcomes for Out-of-Hospital Birth?

1. An educated, licensed midwife 
2. A low-risk pregnancy and health status of mother and baby 
3. A professional, collaborative relationship between the midwife and local physicians and medical providers 
4. Routine prenatal care and testing in accordance with professional medical guidelines 
5. Informed consent leading to a clear knowledge that certain conditions are more dangerous in out-of-hospital settings - and not indoctrination into 'trusting birth' at all costs. A provider should be honest and open about what cannot be handled in an out-of-hospital setting. If the client is led to believe that all complications are handled better at home with a midwife, or if those 'scary' complications only happen in hospitals, then they are being misled.
   

Other Important Thoughts

1. Cesareans are not the worst outcome.  A baby who is injured or does not survive birth is the absolute worst outcome, especially when that death or injury was fully preventable. 
2. Collaborative Care Models are on the rise.  Want a natural childbirth?  You have options, many of them.  Look for a collaborative care model where midwives work as part of the fully integrated health care system.   This means the midwife delivers in a hospital or in a hospital-affiliated birth center.  (Not to be confused with a freestanding birth center.)  Many collaborative care midwife groups have their own practices.  You'll have the most highly educated midwives in the country, with emergency care seconds away should you need it.  You'll have licensed, insured care providers working within a defined scope of practice.   

Any mother planning a home birth who goes around touting that it is safe or as safe as a hospital birth does not have, or fails to acknowledge the facts.  A mother who claims her unlicensed midwife is safe, cannot really know without the data on her outcomes to back it up.  A  mother who tells you she is educating herself and choosing not to do any of the prenatal assessments because they are unnecessary or harmful has fallen hard for the fallacy of trusting birth.  Whatever your choices may be surrounding birth, take time to understand the benefits, the risks, and their subsequent consequences before making the decision to have your baby at home.