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. 

Roundups Politics

Campaign Week in Review: Clinton Criticizes Trump’s Child-Care Proposal in Economic Speech

Ally Boguhn

Hillary Clinton may be wooing Republicans alienated by Trump, but she's also laying out economic policies that could shore up her progressive base. Meanwhile, Trump's comments about "Second Amendment people" stopping Hillary Clinton judicial appointments were roundly condemned.

Hillary Clinton may be courting Republicans, but that didn’t stop her from embracing progressive economic policies and criticizing her opponent’s child-care plan this week, and Donald Trump suggested there could be a way for “Second Amendment people” to deal with his rival’s judicial appointments should she be elected.

Clinton Blasts Trump’s Child-Care Proposal, Embraces Progressive Policies in Economic Speech

Democratic nominee Hillary Clinton took aim at Republican nominee Donald Trump’s recently announced proposal to make the average cost of child care fully deductible during her own economic address Thursday in Michigan.

“We know that women are now the sole or primary breadwinner in a growing number of families. We know more Americans are cobbling together part-time work, or striking out on their own. So we have to make it easier to be good workers, good parents, and good caregivers, all at the same time,” Clinton said before pivoting to address her opponent’s plan. “That’s why I’ve set out a bold vision to make quality, affordable child care available to all Americans and limit costs to 10 percent of family income.”

“Previously, [Trump] dismissed concerns about child care,” Clinton told the crowd. “He said it was, quote, ‘not an expensive thing’ because you just need some blocks and some swings.”

“He would give wealthy families 30 or 40 cents on the dollar for their nannies, and little or nothing for millions of hard-working families trying to afford child care so they can get to work and keep the job,” she continued.

Trump’s child-care proposal has been criticized by economic and family policy experts who say his proposed deductions for the “average” cost of child care would do little to help low- and middle-wage earners and would instead advantage the wealthy. Though the details of his plan are slim, the Republican nominee’s campaign has claimed it would also allow “parents to exclude child care expenses from half of their payroll taxes.” Experts, however, told CNN doing so would be difficult to administer.

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Clinton provided a different way to cut family child-care costs: “I think instead we should expand the Child Tax Credit to provide real relief to tens of millions of working families struggling with the cost of raising children,” Clinton said in Michigan on Thursday. “The same families [Donald Trump’s] plan ignores.”

Clinton also voiced her support for several progressive policy positions in her speech, despite a recent push to feature notable Republicans who now support her in her campaign.

“In her first major economic address since her campaign began actively courting the Republicans turned off by Donald Trump, Clinton made no major pivot to the ideological center,” noted NBC News in a Thursday report on the speech. “Instead, Clinton reiterated several of the policy positions she adopted during her primary fight against Bernie Sanders, even while making a direct appeal to Independent voters and Republicans.”

Those positions included raising the minimum wage, opposing the Trans-Pacific Partnership trade deal, advocating for equal pay and paid family leave, and supporting a public health insurance option.

“Today’s speech shows that getting some Republicans to say Donald Trump is unfit to be president is not mutually exclusive with Clinton running on bold progressives ideas like debt-free college, expanding Social Security benefits and Wall Street reform,” said Adam Green, the co-founder of the Progressive Change Campaign Committee, in a statement to NBC.

Donald Trump: Could “Second Amendment People” Stop Clinton Supreme Court Picks?

Donald Trump suggested that those who support gun ownership rights may be able to stop Democratic nominee Hillary Clinton from appointing judges to the Supreme Court should she be elected.

“Hillary wants to abolish, essentially abolish the Second Amendment,” Trump told a crowd of supporters during a Tuesday rally in Wilmington, North Carolina. “By the way … if she gets to pick her judges, nothing you can do, folks. Although, the Second Amendment people—maybe there is. I don’t know.” 

Trump campaign spokesperson Jason Miller later criticized the “dishonest media” for reporting on Trump’s comments and glossed over any criticism of the candidate in a statement posted to the campaign’s website Tuesday. “It’s called the power of unification―Second Amendment people have amazing spirit and are tremendously unified, which gives them great political power,” said Miller. “And this year, they will be voting in record numbers, and it won’t be for Hillary Clinton, it will be for Donald Trump.”

“This is simple—what Trump is saying is dangerous,” said Robby Mook, Clinton’s campaign manager, in a statement responding to the Republican nominee’s suggestion. “A person seeking to be the President of the United States should not suggest violence in any way.”

Gun safety advocates and liberal groups swiftly denounced Trump’s comments as violent and inappropriate for a presidential candidate.

“This is just the latest example of Trump inciting violence at his rallies—and one that belies his fundamental misunderstanding of the Second Amendment, which should be an affront to the vast majority of responsible gun owners in America,” Erika Soto Lamb, chief communications officer of Everytown for Gun Safety, said in a Tuesday statement. “He’s unfit to be president.”

Michael Keegan, president of People for the American Way, also said in a Tuesday press release, “There has been no shortage of inexcusable rhetoric from Trump, but suggesting gun violence is truly abhorrent. There is no place in our public discourse for this kind of statement, especially from someone seeking the nation’s highest office.”

Trump’s comments engaged in something called “stochastic terrorism,” according to David Cohen, an associate professor at the Drexel University Thomas R. Kline School of Law, in a Tuesday article for Rolling Stone.

“Stochastic terrorism, as described by a blogger who summarized the concept several years back, means using language and other forms of communication ‘to incite random actors to carry out violent or terrorist acts that are statistically predictable but individually unpredictable,’” said Cohen. “Stated differently: Trump puts out the dog whistle knowing that some dog will hear it, even though he doesn’t know which dog.”

“Those of us who work against anti-abortion violence unfortunately know all about this,” Cohen continued, pointing to an article from Valerie Tarico in which she describes a similar pattern of violent rhetoric leading up to the murders that took place at a Colorado Springs Planned Parenthood.

What Else We’re Reading

Though Trump has previously claimed he offered on-site child-care services for his employees, there is no record of such a program, the Associated Press reports.

History News Network attempted to track down how many historians support Trump. They only found five (besides Newt Gingrich).

In an article questioning whether Trump will energize the Latino voting bloc, Sergio Bustos and Nicholas Riccardi reported for the Associated Press: “Many Hispanic families have an immense personal stake in what happens on Election Day, but despite population numbers that should mean political power, Hispanics often can’t vote, aren’t registered to vote, or simply choose to sit out.”

A pair of physicians made the case for why Gov. Mike Pence “is radically anti-public health,” citing the Republican vice presidential candidate’s “policies on tobacco, women’s health and LGBTQ rights” in a blog for the Huffington Post.

Ivanka Trump has tried to act as a champion for woman-friendly workplace policies, but “the company that designs her clothing line, including the $157 sheath she wore during her [Republican National Convention] speech, does not offer workers a single day of paid maternity leave,” reported the Washington Post.

The chair of the American Nazi Party claimed a Trump presidency would be “a real opportunity” for white nationalists.

NPR analyzed how Clinton and Trump might take on the issue of campus sexual assault.

Rewire’s own editor in chief, Jodi Jacobson, explained in a Thursday commentary how Trump’s comments are just the latest example of Republicans’ use of violent rhetoric and intimidation in order to gain power.

Analysis Politics

Experts: Trump’s Proposal on Child Care Is Not a ‘Solution That Deals With the Problem’

Ally Boguhn

“A simple tax deduction is not going to deal with the larger affordability problem in child care for low- and moderate-income individuals," Hunter Blair, a tax and budget analyst at the Economic Policy Institute told Rewire.

In a recent speech, GOP presidential nominee Donald Trump suggested he now supports policies to made child care more affordable, a policy position more regularly associated with the Democratic Party. The costs of child care, which have almost doubled in the last 25 years, are a growing burden on low- and middle-income families, and quality options are often scarce.

“No one will gain more from these proposals than low- and middle-income Americans,” claimed Trump in a speech outlining his economic platform before the Detroit Economic Club on Monday. He continued, “My plan will also help reduce the cost of childcare by allowing parents to fully deduct the average cost of childcare spending from their taxes.” But economic experts question whether Trump’s proposed solution would truly help alleviate the financial burdens faced by low- and middleincome earners.

Details of most of Trump’s plan are still unclear, but seemingly rest on addressing child care costs by allowing families to make a tax deduction based on the “average cost” of care. He failed to clarify further how this might work, simply asserting that his proposal would “reduce cost in child care” and offer “much-needed relief to American families,” vowing to tell the public more with time. “I will unveil my plan on this in the coming weeks that I have been working on with my daughter Ivanka … and an incredible team of experts,” promised Trump.

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An adviser to the Trump campaign noted during an interview with the Associated Press Monday that the candidate had yet to nail down the details of his proposal, such as what the income caps would be, but said that the deductions would only amount to the average cost of child care in the state a taxpayer resided in:

Stephen Moore, a conservative economist advising Trump, said the candidate is still working out specifics and hasn’t yet settled on the details of the plan. But he said households reporting between $30,000 and $100,000, or perhaps $150,000 a year in income, would qualify for the deduction.

“I don’t think that Britney Spears needs a child care credit,” Moore said. “What we want to do is to help financially stressed middle-class families have some relief from child-care expenses.”

The deduction would also likely apply to expensive care like live-in nannies. But exemptions would be limited to the average cost of child care in a taxpayer’s state, so parents wouldn’t be able to claim the full cost of such a high-price child care option.

Experts immediately pointed out that while the details of Trump’s plan are sparse, his promise to make average child care costs fully tax deductible wouldn’t do much for the people who need access to affordable child care most.

Trump’s plan “would actually be pretty poorly targeted for middle-class and low-income families,” Hunter Blair, a tax and budget analyst at the Economic Policy Institute (EPI), told Rewire on Monday.

That’s because his tax breaks would presumably not benefit those who don’t make enough money to owe the federal government income taxes—about 44 percent of households, according to Blair. “They won’t get any benefit from this.”

As the Associated Press further explained, for those who don’t owe taxes to the government, “No matter how much they reduce their income for tax purposes by deducting expenses, they still owe nothing.”

Many people still may not benefit from such a deduction because they file standard instead of itemized deductions—meaning they accept a fixed amount instead of listing out each qualifying deduction. “Most [lower-income households] don’t choose to file a tax return with itemized deductions,” Helen Blank, director of child care and early learning at the National Women’s Law Center (NWLC), told Rewire Tuesday. That means the deduction proposed by Trump “favors higher income families because it’s related to your tax bracket, so the higher your tax bracket the more you benefit from [it],” added Blank.

A 2014 analysis conducted by the Congressional Research Service confirms this. According to its study, just 32 percent of tax filers itemized their deductions instead of claiming the standard deduction in 2011. While 94 to 98 percent of those with incomes above $200,000 chose to itemize their deductions, just 6 percent of tax filers with an adjusted gross income below $20,000 per year did so.

“Trump’s plan is also not really a solution that deals with the problem,” said Blair. “A simple tax deduction is not going to deal with the larger affordability problem in child care for low- and moderate-income individuals.”

Those costs are increasingly an issue for many in the United States. A report released last year by Child Care Aware® of America, which advocates for “high quality, affordable child care,” found that child care for an infant can cost up to an average $17,062 annually, while care for a 4-year-old can cost up to an average of $12,781.

“The cost of child care is especially difficult for families living at or below the federal poverty level,” the organization explained in a press release announcing those findings. “For these families, full-time, center-based care for an infant ranges from 24 percent of family income in Mississippi, to 85 percent of family income in Massachusetts. For single parents the costs can be overwhelming—in every state annual costs of center-based infant care averaged over 40 percent of the state median income for single mothers.”

“Child care now costs more than college in most states in our nation, and it is an actual true national emergency,” Kristin Rowe-Finkbeiner, CEO and executive director of MomsRising, told Rewire in a Tuesday interview. “Donald Trump’s new proposed child care tax deduction plan falls far short of a solution because it’s great for the wealthy but it doesn’t fix the child care crisis for the majority of parents in America.”

Rowe-Finkbeiner, whose organization advocates for family economic security, said that in addition to the tax deduction being inaccessible to those who do not itemize their taxes and those with low incomes who may not pay federal income taxes, Trump’s proposal could also force those least able to afford it “to pay up-front child care costs beyond their family budget.”

“We have a crisis … and Donald Trump’s proposal doesn’t improve access, doesn’t improve quality, doesn’t lift child care workers, and only improves affordability for the wealthy,” she continued.

Trump’s campaign, however, further claimed in a statement to CNN Tuesday that “the plan also allows parents to exclude child care expenses from half of their payroll taxes—increasing their paycheck income each week.”

“The working poor do face payroll taxes for Social Security and Medicare, so a payroll tax break could help them out,” reported CNN. “But experts say it would be hard to administer.”

Meanwhile, Democratic presidential nominee Hillary Clinton released her own child care agenda in May, promising to use the federal government to cap child care costs at 10 percent of a family’s income. 

A cap like this, Blank said, “would provide more help to low- and middle-income families.” She continued, “For example, if you had a family with two children earning $70,000, if you capped child care at 10 percent they could probably save … $10,000 a year.”

Clinton’s plan includes a promise to implement a program to address the low wages many who work in the child care industry face, which she calls the “Respect And Increased Salaries for Early Childhood Educators” program, or the RAISE Initiative. The program would raise pay and provide training for child-care workers.

Such policies could make a major difference to child-care workers—the overwhelming majority of which are women and workers of color—who often make poverty-level wages. A 2015 study by the EPI found that the median wage for these workers is just $10.31 an hour, and few receive employer benefits. Those poor conditions make it difficult to attract and retain workers, and improve the quality of care for children around the country. 

Addressing the low wages of workers in the field may be expensive, but according to Rowe-Finkbeiner, it is an investment worth making. “Real investments in child care bring for an average child an eight-to-one return on investment,” she explained. “And that’s because when we invest in quality access and affordability, but particularly a focus on quality … which means paying child-care workers fairly and giving child-care workers professional development opportunities …. When that happens, then we have lower later grade repetition, we have less future interactions with the criminal justice system, and we also have a lower need for government programs in the future for those children and families.

Affordable child care has also been a component of other aspects of Clinton’s campaign platform. The “Military Families Agenda,” for example, released by the Clinton campaign in June to support military personnel and their families, also included a child care component. The former secretary of state’s plan proposed offering these services “both on- and off-base, including options for drop-in services, part-time child care, and the provision of extended-hours care, especially at Child Development Centers, while streamlining the process for re-registering children following a permanent change of station (PCS).” 

“Service members should be able to focus on critical jobs without worrying about the availability and cost of childcare,” said Clinton’s proposal.

Though it may be tempting to laud the simple fact that both major party candidates have proposed a child care plan at all, to Rowe-Finkbeiner, having both nominees take up the cause is a “no-brainer.”

“Any candidate who wants to win needs to take up family economic security policies, including child care,” she said. “Democrats and Republicans alike know that there is a child care crisis in America. Having a baby right now costs over $200,000 to raise from zero to age 18, not including college …. Parents of all political persuasions are talking about this.”

Coming up with the right way to address those issues, however, may take some work.

“We need a bold plan because child care is so important, because it helps families work, and it helps them support their children,” the NWLC’s Blank said. “We don’t have a safety net for families to fall back on anymore. It’s really critical to help families earn the income their children need and child care gives children a strong start.” She pointed to the need for programs that offer families aid “on a regular basis, not at the end of the year, because families don’t have the extra cash to pay for child care during the year,” as well as updates to the current child care tax credits offered by the government.

“There is absolutely a solution, but the comprehensive package needs to look at making sure that children have high-quality child care and early education, and that there’s also access to that high-quality care,” Rowe-Finkbeiner told Rewire. 

“It’s a complicated problem, but it’s not out of our grasp to fix,” she said. “It’s going to take an investment in order to make sure that our littlest learners can thrive and that parents can go to work.”

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