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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  1. kgallionexum
    Posted October 2, 2007 at 5:10 pm | Permalink

    Great post! You’re right, too many pathways, too many certifications, too much range in scope of practice…all similar to NURSING! LOL

    I would want to add though that are many CNM students who would have loved to be simply midwifery students, it’s evident in our class that most people didn’t care about nursing one way or the other…or did care, meaning NEVER wanted to be a nurse in the first place. It’s going to be a hard sell to get people to bypass the CNM (and I guess CM) for CPM or LM because of the differences in what you can do with these certifications. If I could work as a CPM or LM IN A HOSPITAL (which is where the population that I seek to serve births *their* babies) then I would not have gone this route. But most hospitals don’t allow that. And, in fact, the hospitals in my state barely allow CNMs in, and I am almost positive that the only reason they do is because of their degree backed education!

    Also, what about the money involved. Do CMs make as much money as CNMs? Also, if you propose that the entry requirements be changed from master’s degree to no prior education, then I hope we do something about all of the people who will be paying back these loans we made them take out for 6+ years of college to get the CNM degree…especially if once you lower the entry requirements to zero, the salary tanks as well. It’s like the CNA -> LPN -> RN thing, those differences in level of education = differences in level of pay, and I don’t think anyone is going to pay someone with no degree what CNMs make now…maybe that’s why the CM designantion isn’t taking off too fast? Similarly, I don’t think we (CNMs and CMs) as PRIMARY CARE PROVIDERS will able to continue to provide these non-gyn related services (same services as family docs; ie HEENT, DERM, some PSYCH, etc) at the rate we do if we don’t have any advanced education that is proven by/tied to an advanced degree.

    Otherwise I am all for a unified professional organization that accepts all midwives, and even a name change, but I don’t think that we all do the same thing….can PAs join the AMA? I ask because the level of education is different between them, too, and I think they have separate orgs also…

    A lot to think about. I’ll chew on this some more….

  2. The Midwife
    Posted October 2, 2007 at 5:48 pm | Permalink

    You’ve got a good point about salary and cost of education. Just to clarify a few things: CMs are coming into the program with a Bachelors, it’s just not in nursing. Usually it’s public health or sociology or biology or *something*, but not nursing. They also have to have a lot of basic prerequisites to join the program, like biology and anatomy and physiology and chemistry etc., and then once they’re in the program they take other classes to catch up on the nursing education they don’t have, such as a class on basic health skills which teaches them how to take a blood pressure and start an IV and draw blood etc. So they’re not starting from nothing–they have a Bachelors, and then they can go on to earn their Masters (in my program, CMs earn their Masters in Midwifery). They’re only called “direct-entry” because they are entering their midwifery education directly, without first obtaining a nursing degree. Also, CMs make as much money as CNMs do. One of my good friends from midwifery school is a CM, and she actually started at a job where she makes a little bit more money than I do, by a few thousand dollars, even though I’m a CNM; she just got lucky and found a job that paid a bit more than the job I accepted. CNM/CM is synonymous: it’s the same credential, the same board exam, the same certification, the same advanced degree, the same level of education and the same scope of practice. The reason the CM designation isn’t taking off too fast is two-fold, as far as I can tell: 1) There are very few educational programs which have a direct-entry track (because they can’t, because they’re housed within a school of nursing), and 2) there are only 3 states where CMs can legally practice, so the desire for people to become CMs is small if they live in a state where they can’t legally practice as a CM.

    My understanding of the CPM credential, though, is that it is a certificate program which can accept students without requiring that they first have a degree (if I am incorrect about this, please let me know!). And you’re right: because of the cost of education, it’s important for students entering midwifery programs to know that they’re going to be able to pay back their loans, and their future salaries have to be able to justify their educational expenditures. This is one of the issues facing future advanced practice nursing and midwifery students if the whole DNP thing becomes a reality in 2015: in order to practice, students are going to have to pay for a doctorate, and I’m not sure that the minimal increase in salary for a doctorate compared to a masters is going to justify the extra year and half of school and loans.

    And yeah, there is a *huge* difference in what the different credentials allow you to do. Prescription privileges in some states if you’re a CNM v. not even being allowed to legally deliver babies if you’re a CPM. It all just varies state by state–another huge hurdle to making any kind of real change on these issues.

    Having just re-read my post, I’m beginning to realize it’s so naive and optimistic of me to think that we’ll someday have one professional organization, or one credential for midwifery, or that we’ll even someday have midwifery education in this country that’s seperate and distinct from nursing education. Oh sigh!

  3. Posted October 3, 2007 at 3:24 am | Permalink

    Hiya, very new to your blog, but just wanted to say…. It can be done! In the 1980’s midwifery was nearly dead in New Zealand, with no insurance, no way of getting paid without charging the mother direct, when she was entitled to free care, and midwifery a subset of nursing. Now, we have our own midwifery council (instead of a nursing council supervising those crazy midwives), pay parity with doctors, the ability to prescribe for pregnancy and birth, access hospitals or offer birth at home, get paid by the government, and give women choices!
    The save the midwife campaign was hard fought and harder won, and it took till 1990 to get legislation to support us, and it wasn’t till 2004 that we got our own council…. But we did! I qualified in DE training with a bachelor in Health Science majoring in midwifery last year… and now I am an independent midwife, caring for the women of mycommunity, in their homes, in my clinic or in the hospital dependant on their needs. I just wanted to remind you guys, there is always hope where midwives and women work together, in partnershi, to create a demand that the lawmakers and doctors can no longer ignore… you have my support in your striving for change.

  4. kgallionexum
    Posted October 3, 2007 at 8:13 am | Permalink

    I am a “direct entry” midiwfery student who came into school with an unrelated bachelor’s degree, and I’m at a school of nursing earning a Masters in Nursing for CNM. So schools of nursing definitely have direct entry tracks…Yale, Columbia, Emory, Vanderbilt all come to mind. Based on your post, a CM sounds like a CNM who rejects the nursing identity of her education. In other words, she took all the classes required for nursing credentialing, but doesn’t want to call herself a nurse. I can understand this, because I never say “Hi, I’m your student NURSEmidwife” I say “I’m your student midwife.” And I do it on purpose because I resent having to become a nurse before a becoming a midwife to practice in all 50 states. BUT I am honest with myself about it! Do you think this might be the case for CMs?

    Anyway, yeah I’ve been spewing off at the mouth in the middle of the night trying to get crap out of my head and on paper (screen). I feel like half the time I’m the only one who sees things the wasy I do, but then I realize, no, you’re wide awake, and this is happening- you’re just far away from people who have experienced the same things you have. It’s so isolating. So much more to say, so little time and energy.

  5. The Midwife
    Posted October 3, 2007 at 10:58 am | Permalink

    Kgallionexum: You’re in a program like the one I started out in, at Columbia. I started that program coming in with a bachelors in English, of all things (hence the desire to write, write, write about everything). There was a year-long fast track for nursing, and then we were supposed to go on immediately and begin our midwifery education. The first year of the program was nothing but nursing: nursing theory, nursing policy, nursing skills, nursing nursing nursing, and at the end of our first year, we graduated with a bachelors in nursing, and then took the NCLEX and became registered nurses. At that point in my career, I then decided to drop out of the fast track because I felt like I knew nothing, and I worked for 2 years as a nurse in L&D before heading back to get my masters in midwifery through a different midwifery program (not Columbia, which only offers a MSN), but even if you continued straight on through, you would have a nursing education under your belt before you began the midwifery.

    Maybe your program is structured a little bit differently so that you’re doing the nursing and midwifery simultaneously, but the end result is the same. You entered your program with an unrelated bachelors degree, but along the way, you’re qualifying as a nurse before qualifying as a midwife, and ultimately, your final degree will be a masters in NURSING (MSN) with a concentration in midwifery.

    The CMs in my program never have the option of rejecting their identity as nurses because they never qualify as nurses. It’s not that they’re fooling themselves. They do learn *some* nursing skills and take classes which teach them *some* of the things you learn in nursing school, but they never take the NCLEX and they never become RNs. They never study nursing theory and nursing policy, they never do all of that nursing stuff that you need to get a degree in nursing. Instead, they study midwifery theory and midwifery policy. They take midwifery research instead of nursing research. When they graduate they are Certified Midwives, but they’re not nurses. Their degree is a Masters in Midiwfery, not a Masters in Nursing, and they can’t go on to further docrorate of NP study because they’re not nurses.

    I hope this doesn’t sound too pedantic. I’m not meaning to be an asshole about this, I’m just trying to explain the difference between true direct-entry midwifery education, versus entry-to-practice programs which give you a nursing degree along the way, even if you never use it. I had to explain this a lot to the other students at the convention, and that’s sort of my point right there: how can the ACNM more forward on direct-entry education if your average midwife in the ACNM doesn’t really understand what direct-entry education is in the first place, or what the difference is between a CM and a CNM? And if there are only 50+ CMs in the whole country, most of the other CNMs in the country can write it off as just sort of a New York/New Jersey phenomenon, and not something they need to worry about.

    Anyway, does that make more sense? Some of my favorite midwives and student midwives are CMs, and it’s something I obviously feel pretty strongly about and am eager to advocate for (maybe because, if I could do it over, I probably would have been a CM and not bothered with all the nursing education first). But I am definitely beginning to wonder: is my midwifery education program….the only program in the country that has a CM track???

    I understand all too well the so-little-time-and- energy thing. Midwifery school is HARD!!!! It’s hard enough just getting through it and getting all of your homework and studying done without also trying to blog about it. And yet, when you blog, and keep abreast of current issues, and read all about other women’s opinions in the blogosphere, it really makes you a much more informed, well-rounded midwife, in the end. You’re not alone. You’ve got other crazy lunatic midwifery bloggers who are late to dinner parties (like I was, last night) because they’re so busy answering comments on their website! Keep your chin up. You’re going to be such an amazing midwife.

  6. The Midwife
    Posted October 3, 2007 at 11:03 am | Permalink

    Trin: That’s a truly inspirational story, and something we could learn from. We’ve got similar issues here in the states, in a micro version. Since our country is so big, the regulation of midwifery falls under individual states for the most part, rather than the federal government. In most states, midwifery is regulated by th Board of Nursing. However, in some states, like NY, there is a Board of Midwifery in addition to a Board of Nursing, and midwifery regulation is managed by that. I wonder if establishing a Board of Midwifery was the first step that was needed in order to make the direct-entry/CM option available to students in NY? It seems like creating more Boards of Midwifery is probably the first place to start with regards to getting out from under the nursing umbrella, and then direct-entry education would follow. Easier said than done, of course, but it’s very exciting to know that similar feats have been accomplished in other countries! There must be some way to get your national leaders in touch with our national leaders, sit them down together in a room, and let them share their experiences.

  7. hannah banana
    Posted October 7, 2007 at 10:36 am | Permalink

    Hey there,
    I’m currently in the process of applying to schools and so I’m pretty familiar with the program options out there – I can say with a fair degree of certainty that your program is indeed the ONLY program in the country to offer the Masters of Midwifery/CM option.
    As somebody from a non-nursing background the CM option is incredibly appealing, the only downside being that it would leave me fairly geographically restricted – something that I’m trying to avoid. That is a huge factor in my decision but it’s pretty much the only negative that I’ve found for the program (well that and now the whole DNP 2015 issue, which my understanding is that as a CM I would be in a less than optimal position to navigate that mess). So likely I’ll apply to both entry to practice nursing programs and the SUNY CM program and make the decision in a couple months (assuming the application process is successful enough to allow for that). Nurses are great but I don’t want to be a nurse, I’ve never wanted to be a nurse, but I do want to be a midwife (now try to turn that into an appealing essay for a nursing school application)and right now becoming a nurse first just might be the best way to accomplish my goal. It took me a long time but I’ve made some degree of peace with the idea.
    It is my entirely personal opinion that being a nurse-midwife is not the factor that makes one a better midwife. Other countries with incredibly vibrant and successful midwifery care have demonstrated this to be true – I could be wrong but it seems that all of Canada, Australia, New Zealand and most of Europe have separated the profession of midwifery from the profession of nursing with excellent results. This can be done and in order to get it done maybe we need people in the field who are optimistic and naive enough (i.e. YOU and other midwives with similar beliefs like, hopefully someday myself) to pursue it and encourage that change for future generations of midwives. Already you’ve hit on some key ideas – a state Board of Midwifery separate from the Board of Nursing is a great place to start (surely easier said than done but still a great place to start). And you never know, maybe the whole DNP thing will actually help to contribute to a push within the field for change. One way or the other it’ll happen.

  8. Posted October 7, 2007 at 10:39 am | Permalink

    For me, I am quite similar to Kgallionexum as I entered my program with a BA in Women’s Studies. And while I find it somewhat inconvenient that I have to get a nursing degree prior to starting my midwifery education, I felt compelled to become a CNM because I want to get an education/certification that I can use in all 50 states. I want to be able to prescribe which (ironically) you can do in every state except GA. I originally came from a state (VA) where the only midwives who can practice legally are CNMs — we didn’t have CMs or professional midwives. And moreover, I felt that a nursing degree can open doors to other opportunities further down the line that I don’t think would be there without this education.

  9. Posted October 9, 2007 at 10:45 pm | Permalink

    Congratulations on all the great changes in your life, midwife! I just wanted to say this is a fantastic post and so timely a subject considering the presentation that Robbie Davis-Floyd just gave at the Gentle Birth Congress. It is such a good post I sent her a link to it. Anyhooooooo, to answer your questions as the CPM on the thread:

    1. Depending on the state the CPM is legal, she may or may not require physician supervision. Example, I was previously in a state where I had autonomy but my guidelines for scope of practice were pretty narrow but at the same time open for interpretation (some say purposely designed that way). In the state I am currently in we must practice with physician supervision, however, the malpractice policies of physicians expressly prohibit their participation in our practice so it’s a Catch-22. I am in a practice with a CNM who has a collaborative doc who signs off on both of us.

    2. Again depending on the state we are in we may or may not be able to do well-woman care. I am a MEAC grad, a CPM, and a LM. My MEAC education prepares me for this but it is not a competency required of entry-level CPMs, but my current state grants me the scope to provide that care. So I do normal well-woman gyn, paps, breast exams, etc. Rx for contraception are written through the CNM if desired. In my last state of practice well-woman care was not addressed and was readily considered a gray area; some provided it, most did not.

    Did you know that the ACNM wanted to name their DEMs “CPM”? Davis-Floyd told a story about the inception of NARM and a landmark MANA meeting where the titles of CM and CPM were tossed around before CPM was settled on. The only thing left for ACNM was CM and that was adopted at their next meeting. The contention between ACNM and MANA runs deep. Her book Mainstreaming Midwives chronicles the events of the most important meetings between the two organizations that she was either a part of or a moderator for during heated conventions.

    The CNM I work with had an ADN, a BS in Nursing Admin, and a direct-entry CNM through an old community type of program designed to get “lay midwives” off the streets and into respectable titles back in the day. Her CNM is the last of their kind. I’d love to have that pathway. I’d really appreciate the nursing education, but don’t want to be a nurse and that is a huge stumbling block to proceeding with a CNM path.

    Happy midwifery week! I appreciate the ACNM not calling it nurse-midwifery week and I think we have Kitty Ernst to thank for that.

  10. The Midwife
    Posted October 10, 2007 at 6:08 am | Permalink

    Yeah, Kitty is fantastic. I can’t believe she’s president of the ACNM again. What stamina!

    I’ve heard a lot about Mainstreaming Midwives, but I haven’t read it yet. I will definitely get on that ASAP, especially since I am such a fan of Robbie Davis-Floyd.

    Thank you so much for responding to my questions! I am much more familiar with the nurse-midwifery track, obviously, because that’s the path I took, but I have so much respect for my CPM colleaugues. One of my really good friends in Kentucky is thinking of becoming a CPM at the moment, and I’m really looking forward to following her progress through her education. Strangely enough, for all its forward progress in direct-entry midwifery, CPMs are not actually legal in New York State, only CMs, so when I was debating my educational options, CPM didn’t even occur to me, sadly.

    Sounds like you have a really good practice situation set up, though. And I’m really glad to hear that you can do well-woman gyn care too.

  11. Posted October 10, 2007 at 11:37 am | Permalink

    What might be interesting to you is I know there are at lease 2 grads from my MEAC program who are practicing as CMs in NY. It’s been a while (5 years?) since I read the announcement in an email congratulating them but it seemed to me they had they had the BS, did the entry-level ASM with CPM at my school, then through their portfolio were allowed to sit for the ACMB exams. So they are CM-CPMs although obviously NY doesn’t recognize the CPM part of their paths.

  12. The Midwife
    Posted October 14, 2007 at 10:26 am | Permalink

    I know of a few CPMs who do practice in New York State, they just do so illegally and under the radar. It really sucks that such knowledgeable, highly-trained midwives aren’t recognized in this state, and aren’t allowed to enjoy the benefits of legal practice. That’s definitely something we could work on.

  13. Posted October 14, 2007 at 12:14 pm | Permalink

    I’m in Texas, and have pretty much decided to go with getting a CPM, although the better security of CNM does tempt me now and again. Frankly, I just don’t want to a) spend the money on a nursing degree and b) be as restricted in what kind of births I can attend. I certainly don’t want to have to go back and get a doctorate in nursing a few years down the road either.

    I do wish we could be as sensible as NZ in resolving this, but of course, there is a lot of money and power at stake. It’s not just the nursing schools and the ACNM, it’s the OBs and ACOG who have a stake in who gets to attend birth, and it’s going to be a long struggle to get things in better shape.

    I do wonder if, as looks likely, we’re moving towards more universal healthcare coverage, how that will shake up these power structures. It may be an interesting few decades.

  14. rg
    Posted October 16, 2007 at 3:39 pm | Permalink

    I love your blog so much I finally registered.

    Part of the problem in getting a big umbrella for the midwifery community is the fact that midwifery is still illegal in some states in the US. Those states that are smart enough to not outlaw it still may not encourage it, and CNM is the ice-breaker of midwifery. People are more comfortable with that nurse part in there, and seeing someone who comes from within the sanctioned medical community. Those states that are smart enough to license their own midwives – a licensed midwife or LM – have huge differences in how their LMs are treated in terms of scope of practice, requiring OB supervision, regulation, etc. Midwifery still has a whole lot of fish to fry, and the ACNM can more narrowly focus on issues pertaining to CNMs, like hospital policies, perhaps?

    Also, the medical professional communities do everything to keep their business, such as ACOG statements that home births are dangerous. Midwifery needs a lobby as powerful. It should be more powerful, since midwives should be treating more patients than OBs.

    I’m on the West Coast and some states, like Oregon, are very progressive in what midwives are responsible for. More often it’s a catch-22. They want midwives to collaborate with physicians, but physicians are not willing to provide backup. Or malpractice insurers refuse to cover them. A broader national legislative policy change would go a long way, except I’d hate for it to undermine the few progressive states where midwifery has more of a chance to thrive.

    This whole issue is affecting care for regular people. Not many, but a few of us interested in home birth, or natural birth, or not becoming a c-section statistic. I was only able to see a CPM for my second birth because I paid cash and because she was willing to work without being covered by malpractice insurance. I’m grateful that she did, but she shouldn’t have to put her livelihood on the line to do her job.

  15. k
    Posted November 6, 2007 at 10:24 pm | Permalink

    Sorry, perhaps it is the perpetual state of exhaustion that I live in… but whoa…
    We have Registered Midwives.
    Then we have people who have done the PLEA’s (Previous Learning Experience Assessment or some such thing relating to those words…). These people encompass, form L&D nurses, women who apprenticed with midwives, women who have some university, women who have taken correspondence coursework … you get the idea. They are Registed Midwives as well, once they have completed the exams.
    And then we have the hush hush whispered about women who are attending other women.
    All because we don’t have enough people in the first two realms. Or sometimes it is the choice to go outside the ‘legislated midwifery’, one I can’t speak for… not knowing anyone who is willing to speak about it.
    So…. all this discussion of what letters follow your name, which schooling offers what… is making my head spin.
    I do know that a lot of previously c-sectioned mamas in the USA do seek out midwives with almost any varience after their name… just so that they have a chance at a vaginal birth.
    Going to read this post again one day. Perhaps I’ll be able to make sense of who is who one day =)

    So after all that rambling…
    Congratulations on ALL the letters after your name!
    You have obviously worked very hard for them.

  16. The Midwife
    Posted November 7, 2007 at 8:10 pm | Permalink

    Hi, K! Don’t worry about it making your head spin. It makes my head spin too (it gives me a headache, actually).

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