Not In Our Name: Midwifery Turf Battle?

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.


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, RH Reality Check 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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  • invalid-0

    Thank you for taking the time to write this so clearly.

  • invalid-0

    The American College of Nurse Midwives is right to point out that CPMs (direct entry or lay midwives) are undereducated and undertrained. Indeed CPMs have less education and training than ANY midwives in the industrialized world. They would not qualify for certification as midwives in Europe, Canada or Australia, precisely because of their lack of education and training.

    The issue is very simple. The US already has midwives. Why should the US license a second class of midwives who would not meet the standards in any other industrialized country?

  • invalid-0

    Oh no, not Dr. Amy again. When will this woman give it up? Doesn’t she even read research? Maybe she doesn’t UNDERSTAND research. When statistics look at PLANNED homebirths with Certified Professional Midwives, our statistics are similar to hospital-based, low-risk women. This shows that women who choose home birth with a CPM are at no greater risk than if they had chosen a hospital birth. However, they are much less likely to have a C-Section, forceps, vacuum or epidural interventions in their births.
    Dr. Amy, go get a life.

  • invalid-0

    The Certified Professional Midwife credential is accredited by the National Commission for Certifying Agencies (NCCA). The NCCA is the accrediting body of the National Organization for Competency Assurance (NOCA), the same accrediting organizations that authorize the Certified Nurse-Midwife credential as well as those for dozens of allied health care providers.

    To claim that the CPM is somehow an illegitimate credential makes a mockery of our national accrediting organizations and calls into question the credentials held by CNMs as well. After all, they do not undergo clinical training in out-of-hospital settings, and many of them were trained via certificate programs that did not require a university degree. So perhaps we should call on Congress to remove federal recognition of CNMs?

  • invalid-0

    Thank you so much for a great article. I have worked with Certified Professional Midwives for over 20 years, attending births at home and in birth centers. When I was pregnant myself, I chose an apprenticeship-trained CPM and received world class care.

    Midwifery care, by CNM’s and CPM’s and other midwives provides unsurpassed safety, impressive outcomes, stellar patient reviews, and impressive cost savings. We need more midwives in all settings. Health professionals tend to stay where they are trained. We desperately need more CPM’s in rural areas, so we will have to continue to train them there, especially since the science supports their training and their care.

    Unity among midwives. I’m working for that every day. May it be so.

    Elizabeth Allemann
    Family Physician
    Columbia, Missouri, USA

  • invalid-0

    Amy Tuteur, MD – The US should license CPMs because they offer midwifery care out of the hospital environment, where doctors and liability insurance influence the opportunity for women to achieve a non-medical birth.
    Go back to the statistics – “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.”
    If CPMs experience the same outcomes, how can you or anyone else make the argument that they are undereducated and undertrained?
    ACNM is under the influence of the AMA because CNMs live in the world of doctors. This division isn’t about any valid question of CPMs qualifications, it’s about the medical community continuing to attempt to control childbirth in America. But birth isn’t a medical procedure. Let it go.

  • invalid-0

    “When statistics look at PLANNED homebirths with Certified Professional Midwives, our statistics are similar to hospital-based, low-risk women.”

    Actually, all the existing scientific evidence, as well as national statistics show that PLANNED homebirths with CPMs have almost triple the neonatal mortality rate.

    The Johnson and Daviss BMJ 2005 paper, which claims to show that homebirth is as safe as hospital birth actually shows the opposite. Johnson and Daviss compared planned homebirth with a CPM to a bunch of out of date papers extending back more than 25 years. That’s because when you compare planned homebirth in 2000 with low risk hospital birth in 2000, planned homebirth has almost triple the neonatal mortality.

    Why would Johson and Daviss compare planned homebirth to a bunch of out of date studies instead of the correct comparison group? Johnson is the former Director of Research for MANA (Midwives Alliance of North America), and Daviss, his wife, is a homebirth midwife. They simply neglected to mention that in the paper. Moreover, the study was conducted with MANA and funded by a grant from a homebirth foundation.

    More disturbing still is the fact that MANA is withholding its OWN safety data collected from 2001-2008. The data has been processed and analyzed and MANA has publicly offered the data to members of midwifery organizations who can demonstrate that they will use it for the “advancement of midwifery”. Even then you must sign a legal non-disclosure agreement promising not to share the data with anyone else.

    It does not take a rocket scientist to suspect that MANA’s own statistics almost certainly show that homebirth has an increased rate of neonatal death. Otherwise, why hide them from the general public?

  • invalid-0

    Certified Professional Midwives are the ONLY midwives who are trained and credentialed to assist women who choose to give birth at home or in freestanding birth centers.

    While the previous comment is correct that the US already has midwives, it does not have a legally recognized type of midwife in all states to attend the cohort of women who choose to give birth at home. In many states, nurse-midwives must practice under the supervision of obstetricians, and often have difficulty obtaining authorization to attend homebirths. Nurse-midwives are educated in universities and train in hospitals.

    Midwifery advocates should continue to ensure that all midwives are rigorously trained to provide safe, evidence-based care in the setting where they practice: Certified Professional Midwives (CPMs)attend births at home, therefore, they train through evidence-based apprenticeship in birth at home.

  • invalid-0

    There is no evidence to support the allegation that a different path to midwifery results in poorer outcomes. The CPM credential has rigorous standards and requires demonstrated knowledge including physiology, definitions, signs and symptoms, differential diagnosis for Risk Assessment, stabilization and treatment, follow-up, referral, and transport. The candidate must train under a qualified preceptor and assist at 20 births, and then attend 20 births as the primary midwife, along with some 75 prenatals, 40 post partums, and 20 newborn exams. There are specific reequirements as to how many of these must serve out of hospital clients, and how many must be continuous care — that is, seeing the same woman from conception through post partum. Compare this to a CNM, who is required to attend only 20 births as the primary, receives no training in out of hospital birth, and has no requirement for continuous care.

    Before being issued the CPM credential, the candidate must pass a rigorous skills-based exam and then an 8 hour, 350 item test. It takes 3-5 years to complete training and education for the CPM credential. The training and education are different, but the rigor is comparable. The training and education is different, but the outcomes are comparable. And CPMs are the only midwives required to gain experience in out-of-hospital settings, and complete their education at considerable cost savings, often going on to serve areas that desperately need health care access such as rural counties.

    As a homebirth mother, I am upset that ACNM would squander this opportunity to increase the availability of midwives in favor of promoting a narrow-minded view of training.

  • invalid-0

    When individuals make claims that studies found to be of stellar quality, like the Johnson and Daviss BMJ study, are less than valid, it’s easy to recognize these as erroneous claims cloaked in seemingly scientific terms.

    The fact is the British Medical Journal is the most esteemed and rigorous journals in the entire world, rivaling (and some say surpassing) even JAMA. If the BMJ publishes a study, you can be sure it’s been thoroughly vetted. When consulting with actual epidemiologists, they all recognize the findings that for healthy women, home birth with a CPM is perhaps safer due to its much lower injury and infection rates and statistically same mortality rates. That shakes the nearly trillion dollar industry of American obstetrics to its core. If the American obstetrical community’s dirty little secret got out (that home birth with a certified professional midwife is safer for the baby and mom), imagine how many millions of dollars they would pour into a smear campaign.


  • invalid-0

    I guess you are unaware that Johnson and Daviss have already acknowledged on their own website that they used the wrong comparison group.

  • invalid-0

    I am a CNM who is supportive of CPMs and agrees that they can be excellent providers. We need more midwives in this country, and there are multiple valid paths to becoming a midwife. However, there is is no precedent for extending federal recognition under the SSA to a class of health care providers who lack a formal education from an accredited health care program or institution. Supporting an exception to the current standards has the potential to damage the credibility of the midwifery profession.

    • invalid-0

      The idea that Certified Professional Midwives do not undergo a formal, accredited educational and training process is misinformation, pure and simple. The CPM credential is accredited by the National Commission for Certifying Agencies (NCCA), which is the accrediting body of the National Organization for Competency Assurance (NOCA), the very same bodies that accredit the Certified Nurse-Midwife credential. The educational route a health care provider takes to earn a nationally-authorized credential is determined by state law, not by the federal government. Some states require Certified Nurse-Midwives to have master’s degrees in nursing, while others only require CNMs to be certified while still others require no certification whatsoever. So if you want a single set of educational requirements to apply to all midwives in the U.S., you need to begin in the states and by standardizing the educational requirements that apply to nurse-midwives first.

  • invalid-0

    Women don’t pay out of pocket for second class care. We don’t travel passed hospitals for second class care. We don’t hire CPMs because we are poor, uneducated, and have no other choice.

    For a woman to go against the grain and choose a CPM assisted birth is the result of education. It is not the easiest thing or the most popular. Women don’t make these decisions lightly. CPMs are experts in normal birth. To call them second class is to accuse women who hire them of accepting substandard care. It is a low blow and not very professional.

    The fact is we need more CPMs and better access to them.

  • invalid-0
  • invalid-0

    The addition of CPMs to the federal medicaid healthcare bill will allow states that license CPMs to receive matching federal funds for reimburement. The requirements for licensure are established by the state, though most accept the CPM credential as meeting the eligibility criteria for licensure. Regardless of how opponents feel about home birth or CPMs, those issues are not in question here. CPMs are already licensed in many states; practice and outcomes are overseen by the state and have been found to be excellent. This amendment will allow mothers on medicaid to have the same maternity care options as mothers with other types of funding (self-pay, insurance, etc). This is about EQUAL treatment for medicaid mothers by states that already license CPMs.

  • http://www.w invalid-0

    So, just for kicks, I’m starting a new post. Something I saw on here yesterday made me think of the TP Chicago Meetup last summer :) – what fun that was . . .

  • invalid-0

    Health care options should not be a game of competition. However, I would pit my midwifery skills and many of the CPM’s I know against Dr. Amy’s any day. When was the last time you rubbed a laboring moms back for two hours? CPMs are experts in normal birth. My skills include keeping that woman normal. Yours usually just recognize abnormal and treat. Lets look at the MANA stats project and see just how well CPM’s are doing. What is your real beef with CPM’s? It can not honestly be the safety or efficacy of care given………