Why the ACNM needs more CMs

I never had a chance to post much about my experiences in Chicago at the ACNM Annual Meeting in May, mostly because I was finishing up my semester at school, and graduating, and then studying for my board exams, and blogging was not a high priority. But I’ve been thinking a lot about my time at the convention, and there are still a lot of posts which need to be written about it. This is one of them. Where to even begin? The entire topic is enormous, highly political and daunting.

I get lots of e-mails from people who are very excited about becoming midwives, but aren’t sure how to go about it. They’re not sure which path to midwifery is the right path for them, and they’re confused about all the different options available to them. And rightly so: it’s highly confusing stuff! It took me years to get a basic understanding of all of this, especially many of the smaller nuances which you miss when you’re first learning about your educational options. And if we, the midwives and future midwives of America are confused about this stuff, just imagine how our clients feel, let alone your average American who’s surprised to learn that midwifery still exists as a viable modern profession.

Part of this confusion stems from the fact that in this country right now, there is no one standardized definition of a midwife, nor are there standardized credentials or certification processes. Instead of one standardized educational route for all midwives, there are two main routes you can take, and myriad ways to obtain differing degrees and qualifications. Instead of one professional title to designate you as a midwife, there are three legally recognized titles: CNM, CM and CPM. Instead of one national accrediting body for midwifery educational programs, there are two: ACNM and MEAC. Instead of one national board exam, there are two different exams administered by two different organizations: the AMCB (which administers the board exam to qualify as a CNM/CM) and NARM (which administers the board exam to qualify as a CPM). The acronyms alone are enough to make your head spin.

Just to give a quick overview (because I’m sure there are still many folks who’re confused about all of this), it works like this: the ACNM (American College of Nurse Midwives) is the professional organization of Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). Most of the members of the ACNM are nurses who then go on to obtain advanced degrees in midwifery (either a Masters degree or a certificate….usually a Masters), and are then credentialed through the ACNM. However, there are some members of the ACNM who are direct-entry midwives (i.e. do not have any prior nursing education or experience), who attend ACNM accredited midwifery education programs, and when they graduate are then credentialed through the ACNM and become CMs. In contrast, Certified Professional Midwives (CPMs) obtain certificates through midwifery-education programs which are accredited by the Midwifery Education and Accreditation Council (MEAC), and when they graduate, they are credentialed through the North American Registry of Midwives (NARM) and become CPMs. Like CMs, CPMs are direct-entry students, with no prior nursing education or experience. And because CPMs are not nurses, nor are they credentialed through the ACNM, they aren’t allowed to join the ACNM.

The professional organization which represents the interests of CPMs is the Midwives Alliance of North America (MANA), which seeks to represent the interest of every type of midwife in North America, including CNMs/CMs (even though their interests are already being respresented by the ACNM). While some midwives (well, CNMs/CMs) belong to both organizations, I think the majority of midwives tend to pick one or the other, if they even join at all (and just think how much further the profession as a whole could get if every midwife in the country actually joined their professional organization and paid dues, which could then be applied to projects and lobbying which actually benefits midwives and our profession. Sadly, of course, membership is never even close to 100%, which is just stupid. Membership in the AMA is just about 100%—I have never known a doctor who was not also a member—and just look at what a powerful and influential organization the AMA is—i.e., look what happens when a professional organization actually has money! Ahem.)

Now, there are so many problems with this I don’t even know where to start. Someone looking in from the outside could very sensibly say: well, don’t you think you’d have more power and more political clout and be better understood by the public and by other professions if all of you midwives just got together and decided on ONE standard definition, ONE standard credential and ONE professional organization to represent you? And of course, the answer to that would be a resounding YES! In countries around the world where midwifery has a very strong professional presence, and where midwives are not only highly respected but also deliver the majority of the babies in that country, invariably you will find that there is one unified professional organization for all of the midwives of that country, one standardized educational track and one credential. British midwives who are reading this, please correct me if I’m wrong, but I’m pretty sure that if you’re in England and you say “I’m a midwife”, no one needs to ask if you’re a nurse-midwife or a direct-entry midwife or if you have a Masters Degree or a Certificate. The profession of midwifery there has one standardized definition of what midwifery entails, one qualifying board exam, one credential, one professional organization and one standardized scope of practice. I’m sure this must really simplify things, and allow the profession of midwifery to move beyond issues of sorting out its own mess and instead tackle larger goals and issues and missions which are important to the entire profession, as a whole.

In America, because of all of the different credentials and the differing legal status of midwives from state to state, we’ve got an enormous range in our scope of practice. CPMs most often work in birth centers or homes, while CNMs/CMs can work in hospitals, birthing centers and homes. Depending on what state you live in, a CNM/CM may or may not be able to prescribe drugs, or admit private patients to a hospital. CNMs/CMs are required to work with a collaborating physician in order to practice legally (is this also true for CPMs? To be honest, I’m not sure. CPMs who are reading this, please let me know!). The scope of practice for CNMs/CMs can range from primary care to family planning to birth control to hormone replacement to basic gynecology. To be honest, I’m not sure if CPMs can do all of this as well (CPMs who are reading this, can you? Or is that a state by state thing, too?). In other words, it’s a hodge-podge mess. And maybe that’s just the nature of the game, given that America is a conglomerate of states, and because each state wields so much independent power, laws vary considerably from state to state.

However, the chance of MANA and the ACNM actually getting together and coming up with one unified plan for midwifery in this country seems very, very, very slim. And while there is a MANA/ACNM Bridge Committee that is working to keep a dialogue open between the two organizations, I doubt very seriously that I will see these two groups joining up in my lifetime. Part of the problem is that the interests of these two groups are too distinct and it’s hard to find the common ground, but I also believe that part of the problem is that there’s an undercurrent of disdain between members of both of these two groups, which harms every midwife in the country, collectively. I think that CNMs/CMs have a tendency to look down on CPMs as being under-educated, unacademic, tradition-based rather than evidence-based, and not very clinically well-informed, while CPMs have a tendency to look down on CNMs/CMs as being too interventionist and technocratic, too quick to view pregnancy from an medical/obstetrical lens, too eager to suck up to the AMA and/or the ANA, and having lost touch with the heart and soul of midwifery. The term “med-wife” gets bantered around a lot in reference to midwives who have apparently lost their soul and become too medically-minded, too quick to turn to drugs, induction, or pitocin, too much a part of the system. And of course, since CPMs don’t work in hospitals or have to manage hospital-based deliveries, “med-wife” is most often used to describe CNMs/CMs. There’s really no point in arguing which point of view is right; they’re both flawed, and so long as this continues, the profession of midwifery in America will continue to struggle.

However, this post isn’t really about the differences between MANA and the ACNM, and why the fervent dream of someday having just one professional organization in this country is most likely going to remain nothing but a dream. Instead, since I am a CNM and a member of the ACNM, my chief concern resides with issues within my own professional organization at this time. We’ve got to clean up our own house first before we can even think about moving forward. (Some of you may be wondering why I’m not also a member of MANA, and to be honest…that’s a really good question! I should be. More thought on this to follow).

When I was in Chicago this Spring, I was acting as the student representative from my midwifery program, and I had been charged by the direct-entry students in my program to make sure that the concerns and issues facing CMs were given a voice. I took this duty seriously, and when we were brainstorming ideas for topics to include in our student statement, I proposed that we ask the ACNM to make the recruiting of direct-entry students a bigger priority, and to encourage the development of more direct-entry educational tracks in existing ACNM accredited midwifery programs. This was met with a lot of resistence from the other students, and ultimately, this was dropped from our list of proposed topics (granted, there were more than 20 items on our brainstorming list, and many of them were dropped). Because there are so few CMs within the ACNM (at the moment, there are only a little over 50 CMs in the entire U.S.), the other student representatives felt that the student statement needed to focus on the issues of the majority. The consensus seemed to be that since CMs could only practice legally in three states (NY, NJ and RI), what was the point in encouraging more direct-entry educational options, especially in states where CMs aren’t legally recognized in the first place? To that I can only say: which comes first, the chicken or the egg? Legislative change is very slow, and it requires large numbers of people pushing for something in order to make it a reality. Until we educate and graduate more CMs, we will never have the numbers needed to actually demand that the CM be recognized in more states.

I was really surprised to learn that I was the only student there who came from a midwifery program which had direct-entry students, and which graduated CMs in addition to CNMs. Only a few of the other students even knew what a CM was, or were aware of the fact that there were ACNM-credentialed midwives who weren’t also nurses. There are only a handful of midwifery education programs in the country which are housed under a department other than nursing, such as a college of health-related professions or a department of allied health professions, and in these programs, since there is no need for a nursing prerequisite, direct-entry education is an option. Every other student in that room came from a midwifery program that graduated CNMs only, and most of these midwifery programs were housed within the school of nursing or were a part of the nursing department. And for the most part, these students didn’t see any problem with this. After all, they were all nurses, and were now going on to become certified nurse midwives. Why should it bother them if their midwifery program exists as part of the school of nursing? What’s the big deal? And why do we need more direct-entry routes of education anyway? If a direct-entry student wants to be a midwife so badly, why can’t s/he just go to nursing school and then on to midwifery school, just like they did? If you’re already a nurse, with boundless midwifery education options open to you, it just doesn’t seem that important.

This raises a lot of other issues as well. So long as midwifery programs are housed under the umbrella of nursing in this country, direct-entry educational tracks will not be widely accessible. But the larger issue is more of a philosophical one: if you’re a nurse who then goes on to become a nurse-midwife, what is your core identity? That of a midwife, or that of a nurse? How can midwifery fall under the jurisdiction of nursing, when as a midwife you are in a much different role from that of a nurse—the midwife diagnoses and makes management decisions and writes orders, which are then carried out by the nurse. How can nursing supercede midwifery? Is the profession of midwifery seperate and disctinct from that of nursing, with its own philosophy and culture and educational tenets? I would say, unequivocally, YES. And if that’s the case, is it possible to be a midwife without first being a nurse? Again, unquestionably, YES. While midwifery utilizes skills which are also used by nurses, the profession of midwifery predates the profession of nursing. When you look at other countries with a large and successful midwifery profession, you will see that there is either a direct-entry route which doesn’t first require a nursing degree, or else midwifery education is entirely seperate from nursing education, and you go to school to either become a nurse, or a midwife, but not both—and one is not a prerequisite for the other.

At the ACNM meeting this year, one of the very first suggestions made on the floor during the business meeting (i.e. the really big annual meeting where hundreds of members get together and vote on the really important stuff) was to change the name of the ACNM from the American College of Nuse-Midwives to the American College of Midwifery. This motion was tabled, but only after 10 minutes of pretty heated and strenuous debate (you could tell it would be a powder keg, if it was actually put forth as a motion), and this is not the first time that members of the ACNM have tried to change the name in such a way. It just goes to show that even within the ACNM itself there is a huge debate and very mixed views on this issue. Personally, I would be very happy with the credential of CM, instead of CNM. I wonder what would happen if more CNMs simply changed our credential to CM? After all, we are certified midwives, even if we are also nurses. Why should the nursing come before the midwifery?

The issue is coming to a head at the moment due to a new proposal made by the American Association of Colleges of Nursing (AACN), which has suggested the Doctorate of Nursing Practice (DNP) as the new entry to practice for advanced practice nursing by the year 2015. In other words, starting in 2015, if you want to be an advanced practice nurse (i.e. nurse-practitioner, nurse-anesthestist, and yes, nurse-midwife), you’ll have to obtain a Doctorate in Nursing Practice, rather than simply getting your Masters. As a student, this raises untold concerns, but from a professional point of view, it’s just as tricky. Since nurse-midwives are advanced practice nurses, will all CNMs starting in 2015 have to get a DNP? What if you’re a midwife, but you don’t want a doctorate in nursing practice? What if you’d prefer to get your doctorate in research, or international relations, or health policy? And where will that leave direct-entry CMs, who can’t obtain a DNP since they’re not nurses in the first place? What about the profession of midwifery itself, which is trying to move away from the shadow of nursing?

Requiring all future midwives to get a doctorate in nursing doesn’t seem to be the right way to go about this. Instead, I believe that the answer lies in midwifery education which is seperate and distinct from nursing education. The degree I obtained was a Masters in Midwifery, not a Masters in Nursing. I chose this route because I view myself as a midwife, period, not a nurse-midwife (even though yes, I am a nurse). Unfortunately, there are only a handful of midwifery education programs in the country right now which can offer a Masters in Midwifery rather than a Masters in Nursing, but I do think that Midwifery education would really benefit from this approach. Once obtaining a Masters in Midwifery is more widely available, more direct-entry students will be able to become midwives. From a self-preservation standpoint alone, this makes a lot of sense to the future of the ACNM.

Which brings me back to the MANA/ACNM divide. If the ACNM continues to ignore the direct-entry route and doesn’t work harder to provide more direct-entry options for students, where are all of those talented, bright, committed future midwives who aren’t already nurses going to go? Will they take the long way around, and go to nursing school in order to then go to midwifery school, or will they go to midwifery school right off the bat, via the more widely avaiable direct-entry route provided by MANA, and ultimately become CPMs rather than CNMs? There is obviously a large market for direct-entry midwifery, and many interested and talented women who are becoming amazing midwives without bothering to become a nurse first—and why should they? But it means that MANA and the ACNM are going to become even more polarized as the “direct-entry” professional organization versus the “nurse-midwife” professional organization, and so long as we have two seperate professional organizations, the profession of midwifery as a whole won’t get very far in this country. At a time when our country so desperately needs more midwives, period, and the ACNM itself is noting a shortage of qualified candidates for nurse-midwifery education, ignoring direct-entry students and not providing more direct-entry routes of education seems like shooting yourself in the foot. Direct-entry midwifery is the only way to get our profession out from under the foot of nursing, but so long as the ACNM continues to emphasize the nurse in nurse-midwife, our professional organization is never going to grow…and neither will the profession of midwifery in this country.

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