Not In Our Name: Midwifery Turf Battle?

Amie Newman

In health care reform, Certified Professional Midwives (CPMs) are seeking federal recognition of their vocation. But will the leadership of the Certified Nurse Midwifery (CNM) advocacy organization be their main obstacle?

It hasn’t been an easy road for Certified Professional Midwifery thus far. Certified Professional Midwives (CPMs) are fighting, across the country, simply not to be considered criminals; more than that, CPMs are looking for federal recognition of their vocation, and for acknowledgement that midwifery is actually a tonic for much of what ails pregnancy and childbirth care in the United States.

So it is that campaigns like The Big Push for Midwives and MAMA (Midwives and Mothers In Action) are pushing amibitious agendas. In the case of these two campaigns, under health care reform, their current fight is for federal recognition of CPMs. In concert with a host of advocacy and professional organizations including the Midwifery Education Accreditation Council, the Midwives Alliance of North America, the International Center for Traditional Childbearing and others, these campaigns are working the halls of Congress and the streets of America to expand access to safe care during childbirth, through midwifery and out-of-hospital birth options. 

Both campaigns are rooted in the foundational idea that the Midwifery Model of Care can provide critical relief from a series of serious (and, honestly, unforgivable) maternal and newborn downward health trends in this country:

  • The United States has the worst newborn death rate in the developed world and  one of the highest maternal mortality rates of all industrialized nations.
  • Cesarean sections are the most common operating room procedures in this country and have also increased by 50% over the last ten years. 
  • Escalating rates of preterm and low-birth weight deliveries are widening racial and ethnic disparities in birth outcomes and increasing the costs associated with long-term care.


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Clearing the path for more women in this country to have the option to birth with a CPM, at home or at a free-standing birth center is a remedy for many of these disturbing statistics.
There is an opportunity, under health care reform, to expand prenatal and childbirth options for all women. Ensuring federal recognition of Certified Professional Midwives would mean Medicaid coverage for low-income women who could not otherwise afford to chose a CPM or out-of-hospital birth. Midwife-in-training, Rewire reader and diarist, Alison Cole explains certified professional midwifery in a distinctly non-medical context, "For most healthy women, birth doesn’t need to be a medical event, and
what they need is primarily someone to safe-guard and support the
healthy choices they will make when given good information." 

So you’d think that midwives, across the board, would be supportive of the efforts, under health care reform, to ensure greater access to the midwifery model of care.

Not so. 

The American College of Nurse-Midwives (ACNM) leadership, the professional organization for CNMs (Certified Nurse Midwives) has come out in opposition to federal recognition of Certified Professional Midwives. In a letter to Congress, sent last week, Melissa D. Avery, President of the ACNM writes:

It has come to our attention that members of Congress will be asked to consider an amendment providing for federal recognition under the Social Security Act (SSA) of Certified Professional Midwives (CPMs). On behalf of the American College of Nurse-Midwives (ACNM), I am writing to inform you that ACNM opposes this recognition because individuals holding the CPM credential lack a unform minimum standards of accredited academic education.

ACNM’s problem with this federal recognition is that, as of yet, there is not one accreditation standard for the education of all CPMs; that is, some CPMs graduate from an educational program accredited by the Accreditation Council for MIdwifery Education and others train solely via apprenticeship. However, to be considered a Certified Professional Midwife, all midwives must gain certification through the North American Registry of Midwives (NARM). 

The decision by ACNM to rally Congress against the work that CPMs have been engaged in, under health care reform measures, has not been met with support by all Certified Nurse Midwives, however. 

Encouraged by the fourteen-member Midwives of North America (MANA) board (five of whom are Certified Nurse Midwives themselves), Geraldine Simkin, a Certified Nurse Midwife herself, a member of ACNM and President of the Board of MANA wrote a response, angrily shooting back:

"…Your position to me is indefensible. For an organization of professionals that values evidence, I find it inexcusable that you have chose an action that the evidence does not support.

  • There is no evidence to support your claim that the majority of CPMs are not properly qualified to practice.
  • There is no evidence to support the position that CPMs in general have poorer outcomes than CNMs or CMs.
  • There is no evidence to support the position that CPMs trained through apprenticeship and evaluated for certification through the Portfolion Evaluation Process (PEP) of NARM have different outcomes than CPMs trained in MEAC-accredited schools.
  • And there is no evidence to support the notion that a midwife with a Master’s Degree has better outcomes than one without that level of higher education."

Simkin takes issue with the "lack of vision" the stance represents and makes a passionate plea for unity around the change all maternal health care advocates have been working towards:

"The health care debate has been in progress in Washington DC for over a decade, but never before has the possibility of real change been as promising as it is now. Now is the time when we may have a real opportunity to effect unprecedented changes in maternal and child health care…Women deserve high quality maternal care, affordable care, and equal access to care…Vulnerable and underserved women deserve to have disparities in health care outcomes eliminated, and they deserve to have barriers removed that limit services, providers and reimbursement for maternity care." 

Katherine Prown, The Big Push for Midwives’ campaign manager, is also bothered by ACNM’s letter, “Midwifery educational requirements are determined by the
states, not by the federal government—what Congress needs to consider is the
Certified Professional Midwife credential itself and the outcomes associated
with it, which are excellent," Pronwn tells me. "Research consistently shows that babies born to
low-risk women receiving care from Certified Professional Midwives experience
the same outcomes as babies born to low-risk women receiving hospital-based
care, but with far fewer costly and often preventable interventions, including
a five-fold reduction in cesarean section."

Prown says it’s "no surprise that there is strong
and growing support in Congress for including Certified Professional Midwives
in health care reform to ensure that all women, including those on Medicaid,
have access to this model of care.”

ACNM’s stance, according to a special alert sent to its members, was formulated in part based on the fact that the leadership of ACNM and the MAMA campaign could not reach a mutually agreeable compromise that both organizations could support. Simkin does not buy it:

"…There was one phone conversation in which the ACNM representative said there was only one concession they would accept: federal recognition only of graduates of MEAC-accredited programs; this is not a compromise."

ACNM’s goal is unity amongst midwives – though from the sound of things it does seem more about common ground being found on ACNM’s terms rather than any sort of real concession that CPMs may have much to offer based on the evidence thus far.

"ACNM looks forward to the day when there is one unified
profession of midwifery, with unified standards for education and
credentialing, working toward common goals.  This has been the model for
success in all other developed countries in which midwifery care is the
dominant model of maternity care.  We welcome the CPM community to join us
in working to achieve this goal," says ACNM’s Executive Director, Lorrie Kaplan.

Ultimately, however, The Big Push and others seem to hold the leadership of ACNM responsible for the split – not CNMs themselves.

"As we saw happen within the AMA (American Medical Association) during the debate on the
public option, the leadership of the ACNM is out-of-step with its membership on
issues related to Certified Professional Midwives and health care reform, " says Prown. "The
majority of rank and file Certified Nurse-Midwives—the providers who are out
there in the trenches actually working with CPMs—are very supportive…We have many examples of CPMs and
CNMs working together on legislative initiatives in states like Massachusetts,
Illinois, Wisconsin, and North Carolina who are much more focused on promoting
maternity care policy that benefits women and babies than they are in fighting
petty turf battles that policy makers, frankly, have no interest in."

Here’s to an end to the "turf battles" and a focus on what really matters – the evidence-based maternal care that ensures the health & safety of women and newborns. 

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