Turf Wars

That’s probably the best description for ACNM’s response to a proposal that the federal government recognize CPMs, in the form of reimbursing them for Medicaid (and whatever other government programs fall under federal purview… and since most forms of insurance [assuming there will be any private insurance worth talking about once Congress is done with “health care reform“] reimburse for what Medicaid reimburses, this could be a huge positive for CPMs) for attending births. ACNM outlines their response in a letter to their members here.

Essentially, they say that since many CPMs are trained through apprenticeship, rather than sitting in school all day, that their education is less than that of CNMs, who have a degree in nursing plus another in midwifery (if I’m remembering correctly, it’s a Bachelors in Nursing for the RN degree, and then a masters in midwifery for the CNM degree). They pay lip-service to CPMs…

ACNM leaders appreciate that this is a challenging and even emotional issue for many ACNM members who value the passionate energy that CPMs have helped to generate for midwifery and out‐of‐hospital birth. We understand that many of our members work with CPMs directly or in other ways.

We strongly support the right of women to have choices in childbirth and that the current maternity care system does not always meet their needs. In many venues on the federal and state level, ACNM works to support these choices and to improve the maternity care system and enhance the availability of high‐quality midwifery care to all women in all settings.

… but that’s not enough. It almost comes across like deliberately sticking your foot out to trip a racer, and then saying, “Oh, but I was hoping you’d win!” Incongruous. Nice sounding words, but the actions are antagonistic.

“We strongly support the right of women to have choices in childbirth” — as long as that choice is between an OB and a CNM… and since many CNMs are hamstrung by state legislation requiring them to practice in ways against the principles of midwifery, or against the way they’d wish to practice (i.e., they must have a back-up doctor, and the back-up doctor requires them to transfer care at 41 weeks, or requires them to enter the hospital at 24 hours after the amniotic sac has broken if they practice out-of-hospital births, or requires them to practice in-hospital due to birth politics, etc.), then that leaves only CPMs and unassisted birth to provide women with “choices in childbirth.”

I was able to read and/or be part of a few conversations amongst various levels of birth junkies, including CNMs and non-midwives, on the topic of whether CPM training and education was really “second class” like Dr. Amy frequently says. One midwife (either British herself or familiar with British midwives) said that while there are two different groups of midwives in England, both groups attend hospital births, and nurse-midwives are actually the ones looked down upon. Another midwife said that CPM and CNM training is very close if not identical, except that CPM training was better if you were planning on attending home births, because that is what you are trained in, rather than all the hospital stuff. On one thread, when I posted a link to the requirements of CPM training and credentialing, one midwife said that CPMs had to see, participate in, and manage more births than CNMs did in order to graduate and/or be credentialed.

While there is value in “brick and mortar” schooling, there is also value in apprentice-type training. And from what I know of CPM training, there is education involved, and it’s not just peering over a senior midwife’s shoulder while she catches babies and takes blood pressure. Quite frankly, I’d rather have a midwife who had attended 20 births but hadn’t sat in a classroom for any of her education, than to have a midwife who had attended no births but had all the education schools had to offer.

CNMs, having become registered nurses before their education in midwifery, can do all the nurse-related hospital things, and I’m sure that some part of their education is taken up with training (especially as an RN) for a lot of medical-related things that have little or nothing to do with pregnancy, labor, birth or postpartum; and also that a good portion of their training is taken up with information and practical knowledge that is useful only in a hospital setting (how to assist at C-sections, for example). It might be nice, if you have a CNM who attends home births and also has hospital privileges, to be able to have the midwife of your choice attend you at home and at the hospital should you need to transfer. And should you need an OB (for example, to perform a C-section), your CNM would still be with you, perhaps even assisting with the operation. That would be continuity of care! A CPM can’t do that. But, then, neither can most if not all CNMs, since most have to make the choice of being strictly home-birth or strictly hospital-birth. Birth politics prevents those who would attend home births from also having hospital privileges.

In my own personal experience, I had a CNM for my first birth and a CPM for my second. I couldn’t point out any major differences between the two, except my CNM used a Doppler and performed vaginal exams every week towards the end of pregnancy; while my CPM used a fetoscope (at my request — she also used Doppler… and actually, my CNM might have used a fetoscope as well, if I asked — but at the time, I didn’t know to ask… or even what a fetoscope was) and said that she would only do vaginal exams if I really wanted her to, but she didn’t like to disturb the cervix during pregnancy unless it was necessary or beneficial to do so (and since you can’t tell when you’re going to go into labor by performing a VE, and if the information you gain from a VE doesn’t change the way you handle a woman [which is almost always the case in pre-labor VEs], there is almost never a necessity and only rarely a benefit from having a vaginal exam). That’s about it. They both did the urine checks, weight checks, palpations, blood work, offered but did not stress prenatal tests, had backup doctors, etc.

So I don’t think that “book-l’arnin'” is all it’s cracked up to be. Some years ago, “online school” or “internet education” was somewhat looked down upon by [insert snooty voice here] brick-and-mortar educators [end snooty voice]. Yet, these are now mainstream. In fact, I heard recently that most if not all brick-and-mortar schools have at least some classes that are internet-only classes, even though their students attend some physical classes. Things change. Self-directed study can be even more valuable than forced education — that is, education in which you are forced to go at someone else’s speed (perhaps too fast or too slow), or to learn things according to their little paradigm (which may not resonate with you, and may leave you floundering in some areas, not quite understanding what they’re saying).  Isn’t it better to really understand what you actually need to know, even if you’re not sitting in a desk somewhere listening to a teacher at the front of the room?

One of the things the ACNM letter brought up is that not all CPMs have the same education (contrasting “education” with “apprenticeship”, which I don’t think is a really accurate contrast, since it is possible to learn far more valuable information through an apprenticeship than through reading words on a page or hearing a lecture), and it is the lack of a single, unified standard that they are objecting to. If it is shown that CPMs who earn their certification through apprenticeship are really substandard, then the best way to remedy their ability to legally attend births (and be reimbursed by them either currently or in the future), would be to show that this manner of certification is actually sub-par, and to work to decertify them on the state level, or to ask that certifcation only apply to women who meet X criteria. But if it is shown that CPMs are equally qualified, regardless of their manner of education (since I call apprenticeship a form of education, and I rather wonder at those who would sneer at it), then ACNM needs to back off and not worry so much about their ivory tower.

I’m disappointed in ACNM’s stance, but I don’t wish to make this into a turf war, nor to extend the battle, if it already is one. I hope that ACNM members who disagree with their decision would let the leadership know their disapproval. And I hope that there can be unity among midwifery, and indeed among all who want what is best for mothers. After all, isn’t that the goal?

My thanks to Gloria Lemay for bringing this to my attention.

Update: Gloria also has an excellent letter written by Geraldine Simkins, CNM, here. Although I wrote my blog post prior to reading this letter, it fits like a hand in glove, with Ms. Simkins similarly questioning the value of formal education as THE criterion for quality, demanding evidence showing whether CPMs have worse outcomes than CNMs, and whether CNMs are shown to be better or more qualified by virtue of their having gotten a Master’s Degree. Everyone needs to read this.


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