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Response to ACNM's Issue Brief on Direct-Entry Midwifery and the CPM Credential

Subject: response to ACNM ISSUE BRIEF 
Grassroots Message for 11/13/97

A list of inaccurate items, by section, with corrected information, follows, with the full text of the ACNM's Issue Brief (as received by e-mail, and believed to be a true copy of the original document) included at the end for reference.

1. The ACNM Credentialing Process

The Issue Brief states that "The ACNM Certification Council (ACC) has opened its national certification exam to graduates of midwifery education programs approved by our Division of Accreditation (DOA), which in turn is approved as an accrediting agency by the U.S. Department of Education." While it is true that the DOA is an approved accrediting agency for nurse-midwifery education programs, the above statement fails to disclose the fact that the DOA has an application pending, but has not been approved to expand its scope of recognition to include non nurse-midwifery education programs. In other words, the DOA has not received USDE approval to accredit the one and only CM program in the U.S. Therefore the downstate CM program does not have the same accreditation standing with the DOA as other ACNM nurse-midwifery programs. The Issue Brief statement could be corrected by adding the following sentence, which is taken verbatim from the CM column of the jointly-approved CM/CPM comparison chart: "An application for expansion of the DOA's scope of recognition to include midwifery education programs is anticipated in 1998."

2. The Home Birth Option

The Issue Brief states that "Nevertheless, ACNM continues to support education and practice by CNMs and CMs in all settings and recently published a Handbook on Home Birth Practices to guide our students and members on safe home birth practices." While the ACNM may support practice by CNMs and CMs in home or out-of-hospital settings, there are no CNM or CM educational programs that require, and we are unaware of any that include, a home-birth clinical component. In fact, completion of a DOA accredited educational program by itself does not prepare graduates to attend home births because they have had none of the specialized training or clinical experience necessary to effectively and responsibly practice in that setting. The statement would be accurate if the words "education and" were omitted from the above sentence.

3. Standards for Practice

"We want to make sure that women have the assurance that all practitioners who call themselves midwives meet minimum standards of academic and clinical preparation consistent with the World Health Organization definition." This statement implies that only ACNM certified midwives conform to the WHO definition of midwives. However, the WHO is not specific about minimum standards of academic and clinical preparation. Rather, as stated in your Issue Brief on page 2, "the World Health Organization (WHO) has defined a midwife as a person who has completed a prescribed course of studies in an education program that is fully recognized in that country, and acquired the requisite qualifications to be legally licensed to practice midwifery." By that definition, LMs and many CPMs clearly qualify. They have completed a recognized and approved course of education and training which is the basis for their licensure and/or certification. The WHO definition of midwifery was never intended to limit recognition only to those midwives who complete a formal, prescribed course of studies resulting in a college degree. There are many midwifery credentials throughout the world and many fine, competent practitioners who are not nurse-midwives, have not received their midwifery education and training in affiliation with a degree-granting institution, and who practice primarily in out-of-hospital settings, but who fit the WHO definition. This sentence should be either omitted or followed by a second sentence explaining that ACNM-credentialed midwives are not the only ones who meet the WHO definition.

4. Other Midwifery Credentials

This entire section is completely inaccurate and should be omitted or re-written.

1. "The Midwives Alliance of North America (MANA), another association of midwives, has created its own credential, the certified professional midwife (CPM)." The inaccurate information in this sentence has been published by the ACNM on more than one occasion and will hopefully be clarified by the facts stated below.
1. MANA is an umbrella midwifery organization that represents a variety of midwives, including a substantial number of CNMs. It did not create its own credential, and has no plans in the immediate future to do so.
2. NARM, a wholly separate entity, created the Certified Professional Midwife (CPM) credential. NARM is the sole certifying body for the CPM.
3. While most CPMs belong to the Midwives Alliance of North America, MANA is not, and has never claimed to be, the trade association for CPMs. In fact, MANA is not a trade association for any single category of midwife. As noted above, it was formed to embrace all midwives and support the practice of midwifery, whether by CNMs, CMs, CPMs, direct-entry midwives, indigenous midwives, Canadian midwives, Mexican midwives, etc.
2. "MANA has also created an accrediting body, the Midwifery Education and Accreditation Council (MEAC), for midwifery education programs." Again, MANA did not create MEAC. MEAC is a wholly separate entity formed by midwives interested in establishing an accreditation process for direct-entry midwifery education programs.
3. "With MANA's support, the North American Registry of Midwives (NARM) has been established as a certifying body to administer an exam for persons wishing to be certified by NARM as midwives." Not true. Here are the actual history and facts:
1. At one time NARM administered a written exam and midwives who passed that exam were listed on a registry. However, NARM never issued certifications based on this exam.
2. In 1995 NARM hired a professional testing company which designed and conducted a thorough Job Analysis, revised NARM's written exam, added a skills assessment component, and created an extensive application and documentation process. Candidates who complete and pass all aspects of the process are awarded the Certified Professional Midwife (CPM) credential by NARM.
3. Finally, NARM certifies CPMs, NOT midwives.
4. "NARM permits experienced midwives who have not completed a MEAC accredited education program to take its exam." This is entirely misguided on several counts.
1. While NARM works closely with MEAC, and all graduates of MEAC accredited programs are prepared to sit the NARM exam, NARM was not created to credential only graduates from MEAC accredited programs. While the ACNM maintains and is familiar with the one-to-one model that characterizes degree-based education (graduates from DOA approved programs sit the ACC exam in order to receive the CNM credential), it is not the only model and is not applicable to NARM's competency-based, many-to-one model (graduates from many educational routes, who meet NARM requirements, sit the NARM exam in order to receive the CPM credential).
2. NARM's mission is to validate the knowledge, skills and experience of midwives who have received their education and clinical experience in a variety of settings. The term for this type of education is competency-based education. It has an underlying philosophy which is fundamentally different from that of university-based education. However, it is not considered second-class or inferior by professional educators, although the ACNM is guilty of implying this in its references to NARM and the CPM credential.
3. A copy of Dr. Catri's excellent summary of competency-based education is available from NARM, as well as her review of the NARM's CPM process. Dr. Mahlman's review of NARM's exam process is also available from NARM.
4. A summary of certification and education requirements as stated in the CM/CPM comparison chart, which was approved by both NARM and ACNM in July, 1997, is listed here: --------------------------------------------- Certification and Education Requirements for the CPM
• Seven categories that require various combinations of the NARM written exam (W), skills exam (S), and documentation (D). Entry Level--W,S,D; MEAC Accredited Schools--W,S; CNMs--D of 10 out-of-hospital birth; State Licensed or Certified Midwives--varies from state-to-state, but all areas pre-approved must be professionally equated with NARM exams; Grand Midwife--W,D; Internationally Educated--W,S,D; Special--W,S,D.
• Education content must incorporate: MANA Core Competencies, NARM Task List, NARM Skills List, NARM Examination Bibliography.
• Accept MEAC accredited programs, apprenticeship, self-study, classroom learning or any combination of the above that prepare the student for mastery and validation of midwifery knowledge, skills, and experience.
This approved language, which the ACNM was certainly aware of when preparing this Issue Brief, was apparently ignored for the above section. Note that NARM "accepts MEAC accredited programs" as well as other educational programs, including ACC certification. Note further that the experienced midwife category, a temporary, start-up category, was already past when the comparison chart was prepared, and had no relation to MEAC accredited education programs.
5. "Potentially then, there could be many categories of midwives practicing in a particular state: CNMs, CMs, CPMs, midwives with a state credential, and lay midwives without formal credentials." The above sentence is correct except in reference to states which have their own licensure procedure. These states confer licenses, not credentials, and these midwives are often referred to as Licensed Midwives. The licenses are generally recognized only by the state issuing the license.
6. "Clearly, this may cause confusion for consumers, health care institutions and state regulators alike." This sentence is particularly offensive to women and consumers because it implies that the average consumer is not capable of evaluating a variety of practitioners. The only confusion for consumers, policy makers, and health care institutions occurs when they must sort out inaccuracies and mis-information, such as those presented in this Issue Brief.
1. CNMs, CMs, LMs, and CPMs have different acronyms, and represent practitioners with different educational backgrounds, underlying philosophies, qualifications, skills, and practice settings.
2. Any person of average intelligence is capable of discerning the difference between these practitioners and making a decision based on his/her needs.
3. A general public that is capable of discerning the difference and appropriateness of health care providers as diverse as Medical Doctor (MD), Physicians Assistant (PA), Registered Nurse (RN), Licensed Nurse (LN), Certified Nurse Practitioner (C.P.), Doctor of Osteopathy (DO), Psychiatrist, Psychologist, Masters of Social Work (M.S.W.), and the list goes on, is certainly capable of evaluating the strengths and weaknesses of each of the current midwifery credentials—CNM, CPM, and CM.
4. As for health care institutions and state regulators, they are in the business of evaluating these credentials and making health policy decisions regarding practice by each. While these decision makers may favor one practitioner over another, it is doubtful that they are confused once presented with factual information concerning each credential. Moreover, it is their job to learn the differences between each of these practitioners, much the same as they must distinguish among all the other health care professionals such as those listed above.

This section (Other Midwifery Credentials) should either be omitted or completely re-written to provide correct information. Furthermore, any re-write should be submitted to the identified entities to confirm accuracy.

The intent of this e-mail message in its entirety is to encourage better communication between midwifery organizations to insure that consumers, midwives, policy makers, and health care institutions do get accurate information and facts regarding midwifery. Women and families benefit most when they can freely choose from a variety of birth settings and maternal care practitioners trained to practice in those settings. There is no one setting or practitioner that is best for every woman.

AMERICAN COLLEGE OF NURSE-MIDWIVES

ISSUE BRIEF

RECENT DEVELOPMENTS IN MIDWIFERY CERTIFICATION IN THE U.S.

The purpose of this document is to provide a brief overview of the midwifery profession in the United States, with particular emphasis on nurse-midwifery and the recent decision by the American College of Nurse-Midwives (ACNM) to accept, as members, certified midwives who do not have a nursing credential.

BACKGROUND

Midwifery is an ancient profession, with a proud tradition of providing care for women during pregnancy and childbirth. In the United States, midwives have been attending births since colonial times. During the 1920s, a combination of the nursing and midwifery professions, modeled after nurse-midwives practicing in the United Kingdom, led to the formation of the Frontier Nursing Service in Kentucky and the Maternity Center Association in New York. American nurse-midwives trace their history to rural and urban settings where mothers and their babies frequently had little access to health care. From the beginning, nurse-midwives were able to provide that primary care to women and their families. These early experiences provided the first documented evidence in the U.S. that nurse-midwives could reduce the rates of maternal and infant mortality and improve the health of women, especially among vulnerable population.

Nurse-Midwives Today

Over the past 70 years, nurse-midwives in America have continued that tradition. Nurse-midwives practice in collaboration and consultation with other health care professionals, providing primary, gynecological and maternity care to women in the context of the larger health care system. Our partners in providing care include Ob/Gyns, family practice physicians, nurse practitioners, physician assistants, midwives, nurses and doulas. In 1995, nurse-midwives attended more that 200,000 births in the U.S. ACNM is the national organization representing more that 6000 certified nurse-midwives (CNMs) and certified midwives (CMs) from all 50 states and most U.S. territories. ACNM is proud of our twin heritages of nursing and midwifery. We also recognize that this dual preparation is not a basic requirement to provide competent midwifery care to women and their families.

Midwifery in Other Countries

In Europe and many countries throughout the world, midwifery care is the norm for birthing mothers and only high-risk or complicated pregnancies are referred to physicians for medical intervention and management. In those countries, there is uniform agreement on appropriate educational preparation and professional credentialing for midwives and prior nursing preparation may be but is not always a prerequisite. Indeed, the World Health Organization (WHO) has defined a midwife as a person who has completed a prescribed course of studies in an education program that is fully recognized in that country, and acquired the requisite qualifications to be legally licensed to practice midwifery. Studies have documented the quality of care provided by midwives who meet the WHO standard in both industrialized and developing nations.

The ACNM Credentialing Process

Because ACNM believes that a nursing credential is not the only avenue of preparation for midwives to deliver safe and competent care, we have recently moved to develop education programs for midwives who do not wish to earn a nursing credential. The ACNM Certification Council (ACC) has opened its national certification exam to graduates of midwifery education programs approved by our Division of Accreditation (DOA), which in turn is approved as an accrediting agency by the U.S. Department of Education. These "certified midwives (CMs)," as they will come to be known, are educated to meet the same high standards that certified nurse-midwives (CNMs) must meet. These are the standards that every state in the U.S. has recognized as the legal basis for nurse-midwifery practice. CMs, like CNMs, must earn at least a Bachelor's degree. CMs must also complete core science requirements similar to those required for a nurse, and fulfill core midwifery requirements that have always been a part of our education programs. CMs take the same ACC exam as CNMs and study side by side with nurse-midwifery students in some education programs.

The Legal Status of Midwifery

Nurse-midwives practice legally in all 50 states and the District of Columbia. In some 19 states, midwifery is a regulated profession and no registered nurse (RN) credential is required. In eleven more states, midwifery practice by non-nurses is legal, but unregulated. In at least seven states, the legal status of midwives other than CNMs is in dispute. And finally, in 15 states, one must have an RN credential in order to legally practice as a midwife. Midwives without a prior nursing credential are sometimes called "direct entry," "lay," "licensed" or "professional" midwives and their practices usually provide home birth or birth center options for women. The scope of practice for these midwives is frequently more limited that for nurse-midwives. ACNM's decision to certify midwives whose education does not include nursing is consistent with the expanding interest, at the state level, in providing students with alternate paths to midwifery education and with increasing consumer choice as to type of midwife and place of birth.

The Home Birth Option

ACNM respects the desire of women for a natural, normal birth at home. A small percentage of our members provide home birth care, but there are many barriers to doing so. It is difficult and expensive to obtain professional liability coverage for home birth services. It often can be difficult to find physicians who are willing to be on call in case a birth becomes complicated. And, women who live too great a distance from hospitals may not be good candidates for a home birth. Consequently, the majority of CNM attended births take place in free-standing birth centers or hospital birthing rooms. Nevertheless, ACNM continues to support education and practice by CNMs and CMs in all setting and recently published a Handbook on Home Birth Practice to guide our students and members on safe home birth practices.

Standards for Practice

Women who have sought the care of midwives for a home birth are, for the most part, well cared for and studies on home births have confirmed the safety of the planned home birth option for healthy women experiencing a normal pregnancy and delivery. However, in states where midwives are unregulated or illegal, appropriate mechanisms to ensure the safety of birthing mothers and their children, as well as sanctions for dangerous practices, may not be in place. State officials have voiced their concerns about the need for appropriate education and clinical preparation to ensure safe outcomes for women. So has the ACNM. It is for this reason that ACNM carefully developed the curriculum and related requirements leading to a certified midwife credential, based on the 70 year history of nurse-midwifery practice in the U.S. We want to make sure that women have the assurance that all practitioners who call themselves midwives meet minimum standards of academic and clinical preparation, consistent with the World Health Organization definition. Further, we believe that all health care professionals who provide maternity care should meet these standards of academic and clinical preparation.

Other Midwifery Credentials

The Midwives Alliance of North America (MANA), another association of midwives, has created its own credential, the certified professional midwife (CPM). MANA has also created an accrediting body, the Midwifery Education and Accreditation Council (MEAC), for midwifery education programs. With MANA's support, the North American Registry of Midwives (NARM) has been established as a certifying body to administer an exam for persons wishing to be certified by NARM as midwives. NARM permits experienced midwives who have not completed a MEAC accredited education program to take its exam. Potentially then, there could be many categories of midwives practicing in a particular state: CNMs, CMs, CPMs, midwives with a state credential, and lay midwives without formal credentials. Clearly, this may cause confusion for consumers, health care institutions and state regulators alike.

Looking Ahead: The ACNM Agenda

ACNM looks forward to the day when there is one, unified profession of midwifery working toward common goals. In the meantime, we will continue to uphold our standards for academic preparation and clinical practice. Study after study has confirmed the quality of care that CNMs provide, with lower rates of cesarean sections, episiotomies, epidurals and technological interventions among low-risk women, and as a result, utilization of fewer health care resources. Studies have also documented that women and families experience a high level of satisfaction when cared for by CNMs.

As an organization, ACNM respects the rights of its members and chapters to take independent positions on legislation, regulations or other issues relating to the midwifery profession. We support efforts to legally recognize CMs as qualified practitioners granted the same rights and responsibilities as CNMs. We acknowledge that not every practitioner of midwifery will choose to seek a CNM or CM credential. It is then up to consumers and state governments to determine and evaluate the quality of care provided by each type of midwife, and the value that each credential has for ensuring safe, quality care for women and babies.

Approved, ACNM Board of Directors September 1997

For a more detailed and comprehensive packet of materials about CNMs and CM in the U.S. and the various issues raised in this paper, please contact ACNM's Department of Professional Services (202)728-9860.