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About CNMs and the ACNM

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Date: Mon, 07 Jul 1997 23:16:25 -0400
To: djz@efn.org
From: Susan Hodges 
NOTE: I wrote the original version of this letter to a small group of direct entry midwives and midwifery advocates around the country. In the "what you can do" section I have now added some ideas especially for CNMs who are concerned about the actions of the ACNM. I want to clarify that the aim of Citizens for Midwifery (CfM) is to promote the Midwifery Model of Care in all settings, provide public education about midwifery and related issues, and encourage consumer action to increase the availability of the Midwifery Model of Care; CfM recognizes that a variety of practitioners, including nurse midwives and direct entry midwives, may provide that kind of care. CfM does not support actions or positions that serve to limit the availability of skilled midwifery care in the full range of settings.


After attending the ACNM Convention, and reading the last few Grassroots Network messages, I felt compelled to put into words a clear (I hope) statement about the implications of the ACNM's recent positions and actions, what we need to be aware of, and what we can do on the state level.

THE PROBLEM: The ACNM is now graduating "Certified Midwives" (CMs) from their new non-nurse "direct entry" midwifery program in New York (and a number of other programs are about to open in other states), but CMs are not legally recognized in any state statutes. CMs are not nurse-midwives, so they do not fall under state statutes for nurses or for nurse-midwives. Furthermore, the CM program requirements alone do not meet midwife licensing requirements in any state with the possible exception of New York. Like CNMs, CMs are not required to have any out-of-hospital birth experience, so the programs do not prepare them for home birth practice; however, the CM credential is not a recognized medical credential either, so CMs are unlikely to get hospital employment.

It is important to understand that the ACNM is using the words "direct entry" in a very narrow sense, meaning simply not requiring nursing first. Their meaning has nothing to do with out-of-hospital midwifery practice or the "kind of care" we associate with home birth midwifery. Their educational philosophy differs dramatically with educational philosophy of MANA, MEAC and NARM. The ACNM's original intent was to provide an ACNM-controlled pathway for other medical practitioners who were not nurses (such as physician's assistants) to obtain ACNM midwifery credentials without having to go through nursing school. Confusion arises when people see the ACNM using "direct entry" and think that they mean what most of us mean by this term: learning midwifery through educational pathways based primarily outside the hospital (including apprenticeships as well as midwifery schools), leading to the midwifery model of care, the kind of midwifery most easily practiced outside the hospital. This is NOT what the ACNM means.

THE CHALLENGE FOR THE ACNM Is to get the CM legally recognized in all states. The ACNM has been working on a strategic plan for statutory recognition of the CM credential for several years, and we must assume will work aggressively for new laws and for changes in existing licensing laws. We can assume that wherever possible they will take advantage of existing laws. We should also assume that these new laws and changes will NOT be friendly to "traditional" direct entry midwives, licensed or otherwise, if the ACNM has anything to say about it.

The ACNM leadership has been very clear in recent position statements, publications and actions that only ACNM credentials (all requiring university-based, degree-granting programs approved by the ACNM) are acceptable to them, that any other credential, especially any that include apprenticeship learning, are totally unacceptable, and that they intend for the ACNM to monopolize and dominate midwifery in the U.S. We can expect that they will work not only to establish the legality of their CM credential, but also to exclude all other credentialing and licensing processes that are not based on the CM/CNM credentialing requirements. According to the ACNM, virtually all licensed and unlicensed midwives in the US who are not CNMs or CMs are merely "traditional birth attendants" and not to be referred to as "midwives" (Kraus, Nancy. What's In a Name: Defining the Profession of Midwifery. J Nurse Midwifery 1997;42:69-70).

The ACNM appears to be unconcerned about the ramifications of these policies and intentions, for midwives or for consumers, and particularly unconcerned about the availability of midwife-attended home birth -- only about 3% of CNMs attend home births, out-of-hospital birth experience is not required and often not available to nurse-midwife students (home birth experience is virtually unavailable in ACNM programs), and increasing home birth practices does not appear to be a significant priority for the ACNM leadership. In fact, until relatively recently the ACNM opposed home birth, and I believe even fewer CNMs would be practicing in the home setting were it not for traditional direct entry midwives who have provided the knowledge base and experience for out-of-hospital birth practices. Out-of-hospital birth, particularly home birth, is really the basis for the Midwifery Model of Care and for the Mother-Friendly Childbirth Initiative. MANA, NARM, MEAC and CfM are really out to protect and preserve the out-of-hospital model of midwifery practice and that option for consumers, and they share deep concern that the ACNM is strongly moving away from this model. The problem is not that the ACNM has established the CM credential; the problem is that they have gotten themselves into an all or nothing position-- if the ACNM credential is excellent, it must mean that all others are inferior-- rather than being able to accept the idea that there can be more than one effective and desirable way of doing a good job at preparing midwives for practice.

MIDWIVES AND MIDWIFERY ADVOCATES IN EVERY STATE NEED TO BE ALERT TO THE INTENTIONS OF THE ACNM AND RELATED ISSUES, WHETHER THERE ARE LICENSING LAWS OR NOT. The ACNM is very clear that they want ONLY their standards and credentials to be legally recognized. Direct entry midwives and advocates need to have an understanding of the issues in order to proactively guide any regulatory activity in their state. Any statute designed by the ACNM will include the requirement of a baccalaureate degree with clinical training in a hospital setting. This would assuredly eliminate the apprenticeship model and even academic models such as the Seattle Midwifery School and Miami Dade Program as well as many other programs around the country.

Imposing ACNM requirements and educational and practice philosophies on all of midwifery would virtually give the doctors complete control over where, how and if all midwives might practice (not just CNMs), would greatly curtail the availability of community-based midwifery education, would greatly increase the cost of midwifery education, and would make it extremely difficult for most student midwives to get any out-of-hospital, especially home, birth experience. In addition, of midwives, only CNMs are acceptable teachers in ACNM programs, so experienced direct entry midwives, no matter how respected and experienced, would be ineligible to teach in these programs. Is this what we want for all of midwifery??

THE CHALLENGE FOR MIDWIVES (DIRECT ENTRY, LICENSED, ETC.) AND ADVOCATES is to make sure that direct entry midwifery and home birth remain alive and growing in our country. That is, direct entry midwifery as we understand it, as expressed by the Certified Professional Midwife (CPM) credential, recognizing a variety of educational modalities with training and experience in techniques for woman-centered, out-of-hospital practice, rather than the strict European definition of simply not requiring nursing first.

Another part of the challenge is that the ACNM has a lot of recognition and respectability --much more than direct entry midwifery does in many states. They have established a widely recognized credential based on an educational model that is easy for people to understand and widely acceptable. Direct entry midwifery is not well-known, out-of-hospital birth is rather suspect in many circles, and the educational process known as apprenticeship, while effective, is not widely used and is perceived to be difficult to evaluate. So, a degree-based "direct entry" credential from the ACNM may be very acceptable to legislators who do not understand the issues. We have a great deal of educational work to do with legislators and government officials, and if we wait until an ACNM bill is in the legislative process, we are likely to be too late.

[here is the section with changes. You can replace from this "heading" to the end of the piece with following]

WHAT CAN STATES AND INDIVIDUALS DO? Here are several things that have been thought of, but I'll bet you will come up with more ideas -- please share them! If you believe in the Midwifery Model of Care, if you want to protect the choice of midwife-attended out-of-hospital birth and to work for independent professional midwifery, these are things you can do to help.

  1. If you are a CNM join the Midwives Alliance of North America (MANA), to collaborate with your sister midwives working for woman-centered care and independent midwifery. and participate in MANA's regional network of direct-entry and nurse midwives.
  2. If you are a CNM and you disagree with the positions or actions of the ACNM, write directly to the ACNM Board members. Tell them you want them to acknowledge the CPM credential and existing state direct-entry midwifery credentials. Encourage representatives from your state ACNM chapter to participate in a dialogue between the Midwives Alliance of North America and the ACNM.
  3. If you are a direct entry midwife, get to know many CNMs in your state. If you are a CNM, reach out to direct entry midwives. Find common ground. Find ways to respect and honor each other's work. Remember, many individual CNMs do not really comprehend what the ACNM is trying to do and its implications, and when they do, many do not support it. Our job is to make sure as many CNMs as possible understand, and encourage those who disagree to communicate vigorously with their leadership. Encourage CNMs to join MANA, so they can hear about CPMs and other direct entry midwives from the source, instead of only through the ACNM.
  4. If you are a midwife of any kind, CNM, licensed or unlicensed direct entry, etc., consider getting your CPM credential if you have not done so already. (If you do not know much about it or what the requirements are, contact the North American Registry of Midwives, Public Education, 1033 Woodlawn, Iowa City, IA 52245 or .)
  5. If you are a midwife of any kind, a childbirth educator, a doula, or work in some capacity with pregnant and laboring women, talk to your clients about the politics of childbirth and encourage them to join Citizens for Midwifery (contact us at 1-888-CfM-4880, toll free, or , brochures are available,. and membership brings an informative quarterly newsletter).
  6. Set up a legislative watch (CfM has a how-to paper on this topic) so you can be aware of potentially harmful legislation. This is most easily done with a group of people, but a single dedicated person can accomplish a great deal.
  7. Organize a phone tree to activate the "constituent power" capacity in your state on short notice. Constituent phone calls in significant numbers (hundreds or thousands in just a few days) can stop a bill and cause elected officials to wish they had never sponsored it.
  8. Look for bills that would change terminology (definition of a midwife, for example), change requirements (educational, protocols, scope of practice, etc.), or change who has authority to regulate midwives or midwifery education, etc., especially if such bills are proposed by anyone other than the direct entry midwifery community members. Be prepared to stop ACNM-exclusive legislation.
  9. Beware of any bill that would set up one midwifery licensing board for all midwives as was done in New York. No matter how nice it sounds, no matter how much you like the local CNMs or others who might propose it, realize that the ACNM leadership intends to get rid of non-ACNM credentialed midwives. Beware even of bills to combine licensing of CMs and other DEMs-- the same thing holds true. The danger is the intent of the ACNM to exclude from legitimacy all midwives but its own. Having a single board opens the door to ACNM-credentialed midwives and friends dominating the board and acting by means of rules and regulations to exclude other midwives, again as has occurred in New York. If such a board becomes the only politically feasible plan, it is imperative that the composition of the board is specified and includes substantial proportions of direct entry midwives and consumers, and that there is a provision for unlicensed midwives to sit on the board during the initial phase (until some reasonable time after licenses are available). A problem in NY was also that you must be licensed to sit on the board of midwifery, and only CNMs initially had licenses; no direct entry midwives have sat on the board during the critical rule-writing phase.
  10. Persuade "all" direct entry midwives and CNMs in your state to become CPMs. The more CPMs there are, the harder it will be for the state or anyone else to get rid of CPMs. The CPM credential was developed for midwives by many midwives, including both CNMs and a broad spectrum of direct entry midwives. The act of voluntarily meeting national requirements for certification can help direct entry midwifery achieve respect and be taken seriously by state officials. Also, recognizable, measurable standards for certification and accountability are important to public officials and legislators who see their role in terms of protecting the public health.
  11. Start a MEAC-accredited midwifery school in your state. The more schools there are, the harder it will be for the ACNM or state legislatures to do away with American direct entry midwives. Having a MEAC-accredited school can be a strong selling point to legislators-- a midwifery school is a tangible, observable educational entity, much more "concrete" and understandable to legislators than "apprenticeship", even though the school program may actually be based on an apprenticeship model.
  12. Especially if you are a "consumer", and have not already been doing this, start visiting legislators now just to tell them about midwifery and out of hospital birth as consumer issues. Many state legislatures are not in session during the summer, so this can be a good time to get acquainted with your state representatives and senators etc., make friends with them and start informing them about the issues, even if you already have a bill in the legislative process at this time and especially if you do not. (Do a little research about the individual rep's interests and accomplishments in the legislature so you can start off by acknowledging his or her work and contributions; everyone responds to being appreciated and you'll be more likely to start off on the right foot.)
  13. Finally, even if you think your state does not want licensing, draft a licensing bill NOW so you are ready with a viable counter proposal when an ACNM bill is introduced. Even better, be proactive and get your bill introduced (and educate your legislators and relevant state agencies) BEFORE an ACNM bill is introduced! Contact CfM for Organizing Packet items about issues to address in a midwifery bill (and other aspects of grassroots organizing work and navigating the legislative process), and contact Debbie Pulley, MANA Legislative Chair () for examples of midwifery laws if needed.
The ACNM does not need our friendship and is committed to advancing CNM and CM professionals, period. While it is unfair to lump together all CNMs (they are not one homogenous group), I think we need to respectfully but firmly and persistently stand our ground, that the ACNM does not represent all of midwifery, that CNMs do not and cannot meet the needs of all childbearing women for a variety of reasons, and that ACNM educational philosophy does not adequately prepare midwives for out-of-hospital practice and may not even adequately prepare its midwives to practice the Midwifery Model of Care.

Well, thank you for reading my thoughts on this matter!

Susan Hodges.

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