Judith Rooks speaks out on homebirth midwives (CPMs)

Rooks quote

Sara Snyder, of Safer Midwifery for Michigan, has produced an excellent series on the education of homebirth midwives around the world. Part 3 was published on Monday and is especially timely.

Sara invited Judith Rooks, CNM, MPH, who recently reported on the hideous death rates of licensed Oregon homebirth midwives, to share her thoughts about the CPM credential. Those thoughts are eye opening.

On the education of homebirth midwives (CPMs):

… the PEP [portfolio process] route to certification as a “professional” midwife isn’t deep enough educationally. The floor is too low, some of them are dangerous …

The PEP route to becoming a CPM seemed reasonable when it was started, but I thought it would only be used to provide an opportunity for very experienced OOH birth attendants, and that new educational programs along the lines of the Seattle Midwifery School—a direct-entry professional midwifery school based on the curriculum used in The Netherlands, would be started to provide educational opportunities for young women who wanted to start preparing themselves as midwives from scratch…

To my great disappointment, many young women who want to become midwives seem to think it is too much bother, time or money to complete an actual midwifery curriculum and think it is enough to just apprentice themselves to someone for a minimal number of births, study to pass a few tests, and become a CPM that way. (emphasis in the original)

On the licensing of CPMs:

… [M]any have inadequate knowledgeable, manual skills and clinical judgment. Some DEMs/CPMs say that it is the responsibility of a pregnant pregnant woman to choose her midwife wisely, but that is very hard to do.

I count on the state to not license inadequately trained health care providers. I can’t assess the skills of every professional I use. I would not hire an electrician to change the wiring in my house without someone knowledgeable exercising due diligence to assure me that the person I hire has achieved some minimal level of relevant education and prior experience (an apprenticeship). Attending lectures or reading some books isn’t enough…

On the credential itself:

The International educational standards should be the long term goal…

I thought the CPM would be short-term; we have lived with it now for a long time. The data from Oregon, shows that it’s not working. The CPM credential was a stop-gap measure from the next-to-the last decade of the 20th Century. We are now in the 2nd decade of the 21st Century.

Rooks gets to the heart of the matter:

The lingering questions then become why are the minimum standards so low, especially in comparison to counterparts around the world? Why is it acceptable for midwives to aim for the cheapest, quickest route instead of striving to be their best? Why are the “certifying” bodies (ie NARM/MANA) keeping the bar so low…as in only requiring a high school diploma as of 2012 instead of requiring a college level education to deliver our babies?

Why are the minimum standards so low? Because the CPM isn’t an academic credential; it’s a public relations ploy designed to falsely reassure women that CPMs meet the same international standards as midwives in the Netherlands, the UK, Canada, Australia and all other first world countries. It’s been an incredible success as a public relations ploy, but it is been a horrific failure by the measure that really counts: safety. CPMs have presided over so many preventable perinatal deaths that their own organization (MANA, the Midwives Alliance of North America) refuses to release their own death rates.

This has been known for a long time in both obstetrics and nurse-midwifery. Obstetricians have been speaking out about preventable deaths at homebirth for years; Ms. Rooks is to be commended for bravely doing the same.

  • Mary Herrington, RN, IBCLC

    So glad to see this on the Safer Midwifery for Michigan website. Thanks for bringing it to my attention. I will be sharing this on FB for others to see. I suffer from living in Texas where lay midwives are licensed by the Dept of Health midwifery board and so many laypeople are completely clueless as to their lack of professional standards/education. Of course, I was one of those ignorant women years ago, so I try to be gentle, yet steadfast, in my efforts to enlighten the women in my “natural” birth network. I certainly am puzzled by all the CNMs here in Texas that continue to support CPM’s instead of striving to distinguish themselves as the true midwifery professionals and out CPMS/DM’s as substandard dangerous practitioners. A Certified Nurse Midwife needs nothing from a CPM/DM. Let them sink or swim alone, I say.

  • It boggles my mind why there isn’t more outrage from women about the inadequate protection from under qualified care providers and the health and well being of themselves and their babies. If health insurance providers were pushing less effective and less safe treatments to save money in any other area of care there’d be an outcry!

    • Antigonos CNM

      The average woman thinks she knows a great deal about obstetrics, but doesn’t, really, because she doesn’t know what she doesn’t know. My own daughter, who’s been the recipient of far more than average knowledge about matters obstetric and gynecologic [dinner table conversation as well as volunteer work with me in hospital], just asked me the other day, after seeing the “Downton Abbey” episode where Sybil dies from eclampsia, “if the disease still occurs”.

      We expect outrage because we know “too much” but most women do not. Today, the average woman thinks birth is perfectly safe. If anything, all those medical “interventions” aren’t REALLY needed. The idea that we know what prevents obstetrical tragedies in most cases and therefore do preventative procedures to eliminate the chances of complications happening does not really register. We might not yet know the cause of toxemia but we do know how to avoid pre-eclampsia progressing to eclampsia. We know that labor, prolonged beyond a certain time, is likely to result in brain damage and hemorrhage, so we don’t let labor go on indefinitely. And so on. But, of course, when a birth [with interventions] takes place, and everything’s OK, retrospectively it is so easy to declare the IV or the pitocin “unnecessary”. Do any of you have a friend or relative who died in childbirth? While the deaths of both babies and mothers have declined radically, maternal death is really rare nowadays.

      • AmyM

        Yes, it is just like some of the anti-vaxxers: they have no idea how bad measles can be because they have never seen it. They don’t understand that modern medicine (vaccines) are the reason they’ve never seen it.

        • Happy Sheep

          They swear up and down it wasn’t the vaccines, it’s nutrition and sanitation1!11! they truly have no thinking skills

      • Eddie

        I think the average American, and likely the average Westerner, believes that medicine is simultaneously better and worse than it is. For example, that doctors know how or should know how to predict exactly which interventions were necessary, and that if everything is OK then the intervention wasn’t necessary, just as you said. And by similar reasoning, that bad outcomes are necessarily failures of the system.

        I remember after hurricane Katrina, a news reporter was interviewed and said essentially 1) the federal government has the ability to save people. 2) people died, 3) therefore, that meant that the government didn’t care, didn’t really try to help people. At that time, I encountered that belief across the media, on the radio, on the internet. Essentially, that the unfortunately outcomes meant that the government didn’t care, because the all-powerful government had the ability to prevent the bad outcomes and clearly didn’t.

        This doesn’t quite get to the level of conspiracy thinking, but I think the reasoning is very similar. I see this same reasoning over and over when it comes to the medical system, but oddly NOT with the alternative one. It starts with a vast oversimplification, and then reasons backwards from those assumptions.

        A FOAF sued his wife’s doctor for malpractice when she died quickly of an unknown illness. From what I heard about it (3rd hand), I didn’t hear any malpractice. I just heard about a terribly unfortunate situation where a women went to the hospital with a rapidly progressive illness that they couldn’t figure out in time. Too many people seem to think that these things can be 100% prevented in young otherwise healthy people.

        Isn’t it funny that any hospital death is a failure of the system, but an alternative medicine (and US homebirth largely falls into that category) death is just part of life as death is part of life?

        • Antigonos CNM

          Before science became the new religion, there was Religion. Religion had all the answers: bad things happened to you because you were bad somehow, even if you thought you were being good. Science is SUPPOSED to have all the answers, and when it doesn’t, people feel let down [to say the least]. And, unlike an angry deity, you don’t know how to propitiate Science. Sacrificing something or someone just doesn’t seem effective. Since blaming oneself leads to more stress and anxiety, it’s a lot easier to blame the system for “letting you down”.

        • Antigonos CNM

          People aren’t rational. It should seem obvious that a medication/treatment/substance/whatever which is beneficial will inevitably have some form of side effect which is less than beneficial, yet the proponents of “natural” want to have their cake and eat it: they want the benefit yet think that something so powerful as to effect change won’t have a downside.

          • Bombshellrisa

            THIS!
            I have seen this so much with people who seek a “cure” for cancer using natural remedies. They will site the side effects and risks associated with chemotherapy and radiation treatments (since doctors discuss risks openly with patients, something naturopaths don’t do) and believe that because there are side effects and risks, that makes the treatment “bad”. So they seek natural/herbal therapies, since the side effects and risks are not well known (neither is the survival rate for those who choose to rely on these methods), believing that their herbalist/naturopath/doctor at the Mexican cancer treatment clinic has discussed everything with them. We have gone through this with friends and family, who believe that medicine is a huge conspiracy to “hide the cure for cancer”.

      • Like you Antigonos, I had my children a l o n g time ago. And I was laughably ignorant about obstetrics. I still am, but I have learnt quite a lot here. When my daughter had an ectopic pregnancy, her doctor’s attempts to explain the biological details had me fairly bewildered as the inner working of the reproductive system in general and birth in particular somehow do not stick with me. But I knew the one thing that matters – that birth, while frequently mundane, is not to be trusted. It sometimes goes wrong, even in the confidently low risk, and when it does you had better be around people who know what they are doing.

        I am pretty well informed on pre-eclampsia now. (Didn’t know I had it till I was told, though – but I spotted it more easily than the midwives in my daughter) And on the uses of ultrasound and EFM. But when anyone asks about the cause of my daughter’s difficulties, and I try to explain pre-eclampsia, I am met with blank disbelief usually. Aren’t problems with swelling and blood pressure just a variation of normal? Surely they could not have such serious consequences?

      • I don’t know anyone who died in childbirth, but a few of my mom’s friends came very close and only survived because of modern medicine (my friends and I aren’t having babies yet).

        The woman who contracted a massive uterine infection after birth. The woman who hemorrhaged so badly that she had to be cut open and her uterus removed and massaged outside her body to stop the bleeding (post c-section hemorrhage). Her husband said that he was watching through the OR glass and wondering how he was going to cope with a newborn all by himself, that’s how bad it was. Oh, and my cousin with pre-eclampsia who got a c-section.

        All of them would have died without modern medical care, and some of them nearly died even with it. The close calls are scary enough- does anyone not know people who have nearly died?

        • An Actual Attorney

          Before any of my friends were having kids I took a class in college and believed most of the NCB dogma. I think I’m lucky that the first close friend to have a baby did have the docs come to her and say: if we take the baby now it might not survive, but if we don’t take the baby now you probably won’t. Woke me up to how dangerous this reproduction thing really is.

          (p.s. that was 14 years ago and everyone is doing great)

        • Eddie

          I have a SIL who had GD (not controllable with diet) and high blood pressure, lots of related problems during pregnancy overall, who delivered at 32 weeks for the first kid. She was induced. Don’t remember if it escalated to C-Section or not. The kid would have died for sure, and likely her without the induction. Then she had an ectopic pregnancy. She would have almost certainly died without that being fixed. Then for pregnancy #3, child #2, same problems as the first pregnancy but better controlled until she got toxemic at 31 weeks. They waited until the first day of week 32 and induced. Again, don’t remember if she had a C-Section or not.

          That’s three different times she would have died without modern medicine, and neither of her children would be alive without it either. Both kids are special needs. There was apparently some brain injury but I don’t know (have never asked and don’t know if my brother or his wife would really know) if it was due to the problems of her pregnancies or from the very early delivery. Physically, both are healthy. The firstborn is on the autistic spectrum, and I can see how someone without a scientific mindset could think it was an event during childhood that caused it.

          I also had a friend who experienced a miscarriage caused by some trisomy defect, and the fetal cells — no longer a fetus — continued to divide inside of her. They were days away from starting chemo when the hormone numbers started to drop instead of climb. No modern medicine needed, but it was close.

        • Elaine

          A friend of my husband’s had a seizure when she was 8 months pregnant. She had a C-section and she and the kid are both fine now, but absent modern medicine odds are they both would have died.

          Then there was the woman from my childbirth class whose son wasn’t tolerating labor in any position. They did a C-section and there was a knot in the cord. He too probably would have died without the C-section.

  • Antigonos CNM

    Unfortunately, judging by this post on Science-Based Medicine, it might not just be about untrained midwives in the near future:

    http://www.sciencebasedmedicine.org/index.php/dr-who/

  • A sensible CNM

    As a CNM who does offer births in the home setting I am so happy to be reading what I already know is true. CNM’s are the only acceptable midwives that should be allowed to be licensed and practice in the USA. I am amazed at the excuses I hear from people (cpm) about why they should have to do so little before they can get a license and I think back to what I had to do in terms of education and work etc…. Being a midwife is an enormous responsibility and these women and babies deserve to be cared for by people who actually know what they are doing. Let’s hope we can prevent any more states from allowing this poor excuse of a midwife to get any further and tarnish nurse midwifery…

    • Susan

      Hi sensible CNM. Nice to see your post. I had a homebirth with two CNMs. I no longer would choose that but I am really glad there are well educated midwives like you for those that do choose it. I worked with CNMs too and have great respect for them. I am curious if with you bring a pulse oximeter for the baby and O2 blending capacity to the home? The CNM’s I had brought intubation equipment and that was back in the early eighties. What else do you bring to a homebirth? Are there two CNMs or do you hire a nurse? Just interested. I was trying to imagine handling a baby that needed compressions and epi at home, I know it’s really rare, but how would you do that without a third person.

      • A sensible CNM

        I am glad you ask this question. I am on a number of homebirth boards and it’s like watching a circus as far as the midwives with all differ backgrounds in an uproar about the recent statement by the AAP and homebirth. Is this any shock that they felt the need to do this? Except for the fact that I do not do the HepB shot at home(they can go to the peds for that) I follow their guidelines. All of the women I take care of at home meet the guidelines for healthy and low risk or it’s a NO at home and we do the birth in the hospital. As far as post dates moms I do FMC from 36 weeks on and at 41 weeks NST and AFI and 41+3 we add BPP and again at 41+6. At 42 weeks we are in the hospital. I believe this adheres to the state and safety guidelines. I bring all the equipment you mentioned as well as another CNM and trained midwifery assistant to the birth because it’s always better to have more not less help. Living in a state where the CPM is allowed I am always amused when the general public comes to see me for an interview. They really have no idea that the CPM they also met with are any different.

        • Susan

          I imagine a homebirth with you might cost more, and it SHOULD, than a CPM. I am really impressed, and relieved, you can answer yes to all of my questions and even add more ways you don’t blow off risk factors as variations of normal.It sounds like you did these things because you knew it was what was right before the AAP guidelies. I can’t imagine how frustrating it would be to have to be.

          I have another question. I was perusing the Karen Strange NRP for homebirth course. Do you have an opinion on it? I like the idea that it uses NRP but I am concerned about some of the apparent non science links on it. I also noticed that providers are only asked to do part 1-4 and then the last (ethics) part of NRP. How can anyone justify not doing the entire course especially when they may be the only, or one of only two or three people, at a birth? Are you familiar with this? Are these the people saying they meet AAP guidelines ( that’s not a “full resuscitation” ) Wouldn’t homebirth mean you need more skill not less? Is that common for some midwives to think the whole thing doesn’t apply to them?

          Thanks for your answers to my previous questions and hope to see you post again.

          • A sensible CNM

            Over the years I have tried to charge a fair and affordable rate that I could earn a living while paying the other CNM, malpractice and other expenses that go with have a private practice. I have been frugal in that I have a separate office attached to my home so I don’t have to pay additional rent and my children all went to state colleges. I make what I would make as a CNM working for a doctor or hospital. I was shocked a few years ago when I found out that the CPM’s in my community were charging and billing the insurance companies 3-5 thousand dollars more than I was! I am not kidding. I was charging 5,500 for all of the care for everything and they were charging 8,500 and billing up to 10,000 for a birth. We have a cpm here that actually only got a GED, never went to college, took the A&P and micro online through National College, took 5 years to get through this easy program, failed the Exam 2 times and charges 10 grand! How do you like them

          • A sensible CNM

            Apples???? I kid you not. She also from what I understand can’t put an IV in to save her life, let alone anyone else’s but hey she doesn’t do fear so what if she loses a mother who bleeds out in the bath tub cause apparently she doesn’t even bother to get them out of the tub until they have lost over a 1000 cc’s. I could not make this stuff up and the horror stories go on and on. Based on this blog, a group of CNM ‘s that all do homebirth, are getting together to compose a well crafted letter to the board in our state (with recent studies including ) asking that the midwifery board or the medical board at a minimum better regulate the CPM’s in our state before they kill someone. I will address the Karen question at a later point but I have met her and do like her as a person and Thank God the CPM ‘s are at least doing something to learn more because it is scary what they don’t know and of course there are exceptions ….

          • A sensible CNM

            Don’t even get me started on these online CPM courses where the teachers hmmm tell the students that you never need to carry Pitocin or Methergine etc…and that if you and the mother are doing things right you will never ever need these things? They need to be stopped from spreading this information and risking more lives……

          • An Actual Attorney

            ASCNM – Please make that letter public so that other folks can point to it. I think it would have a lot of weight. I bet even some press would be interested in it.

          • Susan

            Thanks Sensible CNM I am fascinated! I didn’t mean to pick on the Karen thing… she was in my town and I read over the site and considered going. I saw good stuff on her website and stuff that made me wary. I have a worked with a number of CNMs who started out as lay midwives too. I also had a lay midwife in my nursing class who truly didn’t understand Rh factor or ABO incompatibility. So that gave me pause. But this was pre CPM license I believe none of them were. You have a refreshing perspective. And those are some bad apple stories 😉 Where I live there have been CNMs at the hospitals working with local doctors for 30+ years. I never worked in anything but an LDR setting where the labor nurse recovers mom and baby together. Normal has always been skin to skin for first hour trying to get baby to breastfeed before ever goes over to warmer. So I have a harder time seeing why moms here feel they need to have homebirths, but many do. No CNMs doing homebirth here all CPMs I think apprenticed. One is a naturopath or something too. I’m not big into woo. I find the way you look at it a lot like the CNMs who delivered my daughter ( in Miami in the early eighties). They were extremely cautious. I am sure they would get called medwives by the mothering brigade but if they were all like them I think Dr. Amy would have to stick to the lactovists and anti vaxxers and those who force their birth values onto those who have no interest!

          • Karen in SC

            The IRS has a form you can send in if you suspect unreported or underreported income. You can remain anonymous.

            http://www.irs.gov/Individuals/How-Do-You-Report-Suspected-Tax-Fraud-Activity%3F

          • Bombshellrisa

            That is HORRIFYING. That is exactly the type of midwife Dr Amy wants to raise awareness about.
            There are midwives who call themselves “traditional birth attendants” in the Eastern part of WA state (all of whom are being investigated right now, and thank GOD it’s about time) who accept barters of silver and gold to help make up their fee. Who else will let you trade a Husquvarna riding lawn mower towards the birth of your child?

          • Eddie

            But of course it’s hospitals and OBs that are out to get your money. (/end sarcasm)

            On the other hand, with as few births per year as they handle, how can they make any money at it without charging an arm and a leg? I really don’t understand that business model. And why is it that they attend so few births? Is it by choice, or are there just too many of them?

          • Bombshellrisa

            Depends on the area they are practicing and how many midwives they are practicing with. The midwives I knew best took case loads that assumed 3-4 women delivering a month and there were three midwives in each practice (now there are 3 in one practice and 5 in the other). Too hard to attend more births than that, since the majority will be birthing at home and they still have office visits to cover during the week as well as being on call and covering weekends. There are only three birthing suites at their birthing center with lots of midwives having privileges there. They seem to do well, these midwives own homes and some even land in the most affluent areas (three in particular in “wine country” where all the Washington tasting rooms are). The midwives in the Eastern part of the state are willing to trade gold, silver and riding lawn mowers and most of them have horses and will accept hay as partial payment. I should add that most of the ones who accept barter are “working towards” a CPM, and use the title traditional midwife so their accepting barter is a way to work around the law that someone wishing to practice midwifery without a license cannot accept payment.

          • AmyP

            “hay as partial payment”

            Now I’ve heard everything.

            This is all taxable income by the way–let the IRS audits begin!

          • Eddie

            their accepting barter is a way to work around the law that someone
            wishing to practice midwifery without a license cannot accept payment.

            Except that should it come to a court of law, barter counts as payment. But I imagine they’re hoping to skirt that point. As others have said, there will always be those on the fringes. What surprises me is that enough of the population is into woo to be willing to pay these undertrained folks.

          • Bombshellrisa

            Too bad I am not in Spokane next week, she has a workshop there. Since you have looked at the classes, can you tell me what an oxytocin bath is and what giving one to a client during each prenatal visit is supposed to do?

          • Susan

            LOL that’s about when I stopped looking. Was tempted though almost for entertainment value. It isn’t like I could have gone in stealth mode though.

          • Bombshellrisa

            I guess I will have to get my Google University degree in it!

          • Bombshellrisa

            http://chicomidwife.blogspot.com/2011/03/first-breaths-of-life.html This is a homebirth CNM who attended the Karen Strange course

            ” the baby was born. She was floppy like a rag doll and a mottled purple and white color. She was not grimacing or sneezing or trying to breathe. I quickly dried her with a warm flannel blanket and rubbed her up to stimulate her. While doing so I placed my fingers on the skin where her umbilical cord inserts and felt a normal heart beat. “Good heart beat” I said. But still no effort to breathe at all. And limp. Amber had the oxygen tank and ambu bag ready.” (Amber is her assistant)

            ” I lifted the baby to my face, placed my mouth firmly over her nose and open mouth, and carefully, slowly gave the baby an “inflation breath.” With mouth-to-mouth, I can literally feel her lungs’ alveoli inflate, and her lungs expand to take in oxygen. I am so connected to the baby’s life force. A newborn baby’s alveoli must inflate so she can take in oxygen through her lungs. In the womb, the alveoli are collapsed and the lungs are filled with water. That is why the baby’s first, big breaths are so important. I pulled her away a bit to look at her. She opened her eyes and looked at me. But didn’t breathe. “Okay baby, lets breathe” I said, and gave her four more mouth-to-mouth breaths. By the fourth, I felt her suck in on her own, she mewed, and then gave a good cry. She turned a rosy pink from head to toe, and her arms and legs bent into normal position. She was breathing fine. Her heart rate was fine. Her tone was strong. She was a little more than a minute old. I had been working on the baby right beside Talia, with the cord intact and pulsing away, providing oxygen to the baby even while she wasn’t breathing. In the hospital, if the baby is not breathing, they cut the cord right away and take the baby across the room to work on her. At home we leave the cord, which is still bringing oxygen to the baby via the placenta for several minutes, and work on the baby beside the mother. I would like to see hospitals learn to do things that way – it is definitely to the baby’s advantage. “

          • Susan

            I noticed the mouth to mouth mention on her site and an apparent belief in the validity of oxygen transfer via an intact cord after the birth. Disturbing.

  • I was not aware that the PEP process was created as a bridging program for experienced OOH attendants, not for students just starting out. I’ve gotten into discussions about what to do with the experienced CPM’s if (when) CNM’s become the only accepted OOH attendants and the most popular idea is a bridging program. But we already have one and it’s been abused and warped, now I’m not so sure a bridging program is appropriate anymore.

  • staceyjw

    Where are out parachuters, coming to tell Dr Amy she is mean and HB MWs are awesome?
    Right, they NEVER show up on posts like this.

  • Bombshellrisa

    Not sure why she supports the program at SMS/Bastyr. There is SOME classroom time, but the majority of the classes can be taken online, it’s still largely apprentice style and it’s not as if the credits you take at Bastyr transfer to any other school.

    http://www.bastyr.edu/academics/areas-study/midwifery-degree-programs/master-science-midwifery#Low-Residency-Model
    “One of the most exciting aspects of our program is its low-residency model. This hybrid delivery system allows students to remain in their communities and commute to the Bastyr campus three times each quarter. When not physically on campus, students use the Internet classroom to correspond with classmates and instructors, post discussions, turn in homework, and take tests…….When not attending the Bastyr campus, students are engaged in learning activities in the virtual classroom using our online learning system as a guide and point of interaction. Learning activities include extensive reading, watching videos, research projects, worksheets, quizzes and online discussions. Students need to be self-directed, self-motivated and have strong time management skills to be successful in the low-residency program.”

    • auntbea

      Because Netherlands.

      • Bombshellrisa

        Oh yes, the Netherlands. But she fails to connect the dots-those midwives in the Netherlands are part of a system where homebirth is an option, meaning they have concrete plans for when things go south and how to transfer. And they still don’t have such great stats for homebirth outcomes.

        • Antigonos CNM

          I think it needs to be remembered that in countries like the UK and the Netherlands, midwives also work in hospitals.There aren’t any “labor and delivery nurses”. When I was in the UK [admittedly a long time ago], district midwives — those who operated outside of hospitals and did homebirths — were integrated with the hospital system and not independent of it. Their equipment and supplies came from the local hospital, etc. Registers of all births are a legal requirement. This keeps midwives “up to snuff” in matters of midwifery practice, and under a form of supervision. In the US, one of the salient points of all non-CNM midwifery is the apparent desire for avoidance of supervision, so each midwife can do whatever her particular ideology requires.

          • Bombshellrisa

            That is a very good point!

          • Susan

            So when a patient comes into the hospital the midwife does all the work the labor and delivery RN would do in the US? I wasn’t aware of that. Did I understand you correctly? Are there nurses who are not midwives in the rest of the hospital? If the patient needs OB care do the midwives assume the roles a labor nurse would have here? They must be quite exhausted midwives….

          • Antigonos CNM

            It varies somewhat from country to country, but here are my experiences:
            In the UK, a woman goes to her GP for a pregnancy test. When it’s positive, he calls the local midwifery service and the district [now called “community”] midwife calls on the woman at home, opens an antenatal file, assesses her and her home [which must meet certain very basic criteria] for suitability as a homebirth candidate. Even if she isn’t, the community midwife will visit according to an antenatal protocol [monthly until 7 months, every two weeks until the 9th month, weekly until completion of the 40th week] to do the usual antenatal checks. Twice, assuming everything otherwise is normal, she visits the local OB’s surgery or the hospital [this has undoubtedly changed since my time since ultrasound was invented] for lab tests and a consult from a doctor.
            There are several different methods of delivering in the UK, depending upon situation and the area of the country. But on an average, when a woman feels labor has begun [or if she needs hospitalization], she goes to the hospital where she is taken care of entirely by midwives who have great autonomy BUT once certain “red lines” have been crossed, MUST involve the medical staff and from then on, they act in much the same way as L&D nurses do in the US. In the event labor progresses normally, the staff midwives, who work shifts, deliver the baby, etc. Staffing ratios are quite high compared to the number of L&D nurses. There are also specialist nursery nurses who attend deliveries for the baby. In C/S situations, either the midwife scrubs or specialist OR nurses are present. Once the patient returns home after delivery, the community midwife stops in at least once a day until the 10th postpartum day, to check both mother and baby.

            In Israel, midwives work more in the hospital L&D setting, have less autonomy, but still a great deal, and will do the actual delivery. We have “well-baby clinics”, staffed by both doctors and midwives, for both antenatal and postpartum care, including free vaccinations and periodic exams. There isn’t any home visiting by a district midwife as in the British system, but pregnant women do not pay for any maternity care. All midwives in Israel MUST be RNs who have done postgraduate courses in midwifery, pass exams, and be licensed by the Ministry of Health as midwives. Home birth is not illegal, but the demand is very small — possibly as few as a couple of hundred a year. However, in view of a couple of recent catastrophes, the Ministry is re-evaluating the situation and it would not surprise me if legislation to restrict or abolish home birth was eventually passed.

            Other wards of a hospital are staffed, in both countries, by registered nurses, or the equivalent. In both countries, a woman can take a private doctor for a delivery, but since birth is free otherwise, there’s little call for it. Most women who do want a private doctor in Israel either are ex-Americans who think “midwife” is an untrained person and can’t imagine not having a private doctor, or who have a bad OB history, require an elective repeat C/S, etc. and want the extra security. In those situations, the staff midwives act like L&D nurses, although the OB is more likely to rely on their observations during labor and only show up for the actual delivery.

          • Susan

            Thanks Antigonos that’s fascinating. Very different system.

          • RockSci

            Not sure if you have access to it where you are, but there are UK and US versions of the show “One Born Every Minute”, and when they showed the US one here I was quite surprised how different the systems are.

          • Becky05

            I live in the US and even I was surprised at the routine shown in the US version of One Born Every Minute! I got a lot more support from my L&D nurses than those women had.

          • Antigonos CNM

            When trying to explain the differences in medical systems to American tourists, I often say that, when two women are discussing birth, the American one might say, “Oh, old Dr. X delivered all my babies!”, to which a European woman might respond, with sympathy, “What went wrong?”
            Historically America became oriented to the private doctor for deliveries at a time when the private “accoucheur” was coming into vogue among the aristocrats of Europe [middle of the 18th century]. It was a matter of status more than any greater knowledge. The only real difference in practice between doctors and midwives then was that some doctors — not all that many — knew how to use forceps and had them. Otherwise, as Semmelweiss showed, in many cases, midwives had lower infection and death rates than doctors of the period before general anesthesia and certainly before antibiotics.

          • Dr Kitty

            They are several models of antenatal care offered in the UK.
            Caseload midwifery led (where each MW sees clients throughout pregnancy and aims to manage their delivery wherever it may be).
            Shared care (Antenatal appointments either with GP or MW at the GP surgery, delivery by whichever midwife is on duty).
            Obstetric led (all antenatal appointments at hospital with doctors and midwives- usually for multiples or other high risk).

            You can opt for a homebirth with either caseload or shared care models.

            Regardless- all women have a dating scan at 12 weeks and an assessment of risk at that point and have a big scan at 20 weeks and another risk assessment with an OB.

            If you make it to 41 weeks you see an OB to discuss induction or CS.
            If you have previous CS you discuss at booking if VBAC is desired, and discuss VBAC or CS again at 34 weeks with an OB.

            Bloods are done at 12 weeks and at 34 weeks and more frequently if needed. Anti D usually twice before delivery and once afterwards if needed. BP and urine are checked at every antenatal visit and women are prescribed urine sticks to dip their urine weekly at home from 28 weeks. Everyone gets folic acid, iron, vitamin D and calcium supplements.

          • Antigonos CNM

            I know the system has changed greatly since my time at Cambridge in the early 70s [what has not ? :-)]. For one thing, there is now direct entry midwifery, which did not exist back then. The criteria for home delivery now include primips too [I think that is a mistake, btw].

            But the point was to show how a midwife-led system can work, when properly constructed so patients who are suitable candidates for midwife care and/or home birth delivery are chosen not by midwife preferences, but by an established protocol, and how midwives are integrated into a system which includes other medical personnel. Because the guidelines I work/worked under were so clear, when I brought in a doctor, he knew his expertise was needed, so we collaborated, rather than confront each other. There was mutual respect. I find the paranoia of the American pseudo-midwives very disturbing, frankly, because what we are supposed to be doing is supporting the woman through her pregnancy and birth, and making it as safe as possible, not making her feel that everyone is against her and that we are deliberately doing things to harm her and her baby.

          • Dr Kitty

            Very true.
            In a typical day I get a call from a MW on a postnatal home visit, she’ll tell me she thinks the woman has endometritis or mastitis or a wound infection. I’ll assume she is competent to make the diagnosis, ask a few questions to double check, and write an appropriate prescription.
            Or a MW will ask me to see someone with possible PPD, or ask me to double check if they think a baby is breech at term, or refer someone with SPD to physio.

            99% of the time the midwives are right on the money, and I have no issues treating them as professionals and collaborating. It isn’t a competition, it s about doing the right thing for the patients.

          • AlexisRT

            Having given birth in both and seen the midwife shortage in the UK (and had many friends give birth since) I think US staffing is superior now–it certainly is on postpartum units.

            In a consultant unit, the doctors are nominally in charge even though the midwives have a great deal of autonomy. For a low risk pregnancy it is quite possible now to never see a doctor at all–you can even self refer for antenatal care. I am unusual in having all my appointments aside from initial booking with an obstetrician (I was shifted to consultant led care at booking due to hypertension).

            There have also been cuts in community midwifery and postnatal visiting. I got regular visits as I had a CS with complications, but they were not daily, and I have heard that the PCT was cutting visiting further (my first was born 6 years ago).

          • Antigonos CNM

            I’ve watched the deterioration of the NHS from afar for some years now, and think it’s a damned shame. Back in the early 70s, everyone complained about over-administration, etc. but the maternity services were really excellent. In “THE” textbook for student midwives, known affectionately as “Maggie Myles” there was a statement in the introduction that the production of midwives trained to the highest level was a “major British export” and indeed, women came from just about everywhere to study in the UK back then. When I went up to London for my viva, the majority of the candidates were from the Commonwealth, Africa, or Asia. There used to be a blog by a British community midwife that I read, but she eventually got so burned out she retired early and stopped writing.

          • Dr Kitty

            Yes- the NHS MWs do all the nursing duties too, with the help of nursing auxiliaries. They do the medication rounds, help with dressing changes, bed baths etc.
            Nurses in the rest of the hospital, but midwives only on L&D wards- no nurses.

            The community midwives (who do antental, postnatal care and occasional homebirths) also have to work for 8 weeks in the hospital labour ward once every so often so that they can be supervised as part of a team.

            It is a very, very different system to the USA.

      • Bombshellrisa

        http://seattlehomebirth.vpweb.com/Meet-The-Midwives.html

        These are two midwives who are graduates of that program. The first one has “attended over 120 births since 2010”. The other has a master’s in midwifery from Bastyr and has attended 115 births. That is barely enough experience to be an L&D nurse, let alone a midwife who does homebirths.

        The instructors for the courses at SMS/Bastyr are CPMs. So sure, the credits you earn say pharmacology, genetics, embryology, biology or whatever, but they are not taught by people who have degrees in these subjects nor are they graduate students who are earning degrees in these subjects. They are just CPMs of varying education levels who teach the classes.

        • RM

          While it is true that some of the instructors are CPMs in the Bastyr program, there are many who are CNMs, PhDs, and many guest lectures done by Neonatologists, Obstetricians, Perinatologists, Registered Midwives, and other Medical Doctors. Also, the first graduating class from the Bastyr Program proper (not the combined SMS program) was in 2012, so technically the midwives who graduated prior to that point did not complete the same program. Also, there are many reputable programs in many disciplines (including medicine) that use online classrooms combined with hands on clinical experience. Just because a school uses an online component does not make it sub par.

          • DiomedesV

            Guest lectures do not make up for instructors whose knowledge of a subject is weak, and who don’t even realize it. I have given guest lectures, attended them, and provided them in a course I was teaching. At worst they are filler, at best they’re a stimulating view onto a complex field that is no substitute for regular, dedicated study.

            Finally, the fact that you have to bring up the distinguished “guest lecturers” at all as evidence that the material is taught rigorously by people who know what they’re doing is… pathetic.

          • RM

            At no time did I ever say, or even insinuate that guest lectures are a substitute for knowledgeable instructors, nor did I say that guest lectures are evidence that the material is taught rigorously. I cannot comment on that as I did not attend that program (I, for the record, am a Canadian Midwife who attended a Canadian program). I was only responding to the comment that all of the instructors are CPMs, which I know is not true. Please save the name calling for someone else more deserving.

          • DiomedesV

            I was too harsh, RM, and I apologize.

          • Bombshellrisa

            “so technically the midwives who graduated prior to that point did not complete the same program”

            Like Val, Erin and Ali, some of the CPMs who teach there? Who is an CNM? Not even the chair of the program is a CNM (she does have an MPH).

          • RM

            I am not familiar with all instructors, I’m not even sure who Val, Ali, etc. are. As I mentioned above, I did not attend that program, I am a Canadian RM who attended a Canadian program. I have met two CNMs who are (or have been instructors there), at conferences in Canada. One CNM who has a PhD – Karen, and another CNM named Colleen. I was only only trying to point out that not all the instructors are CPMs…Sounds like you have an interesting story though Bombshellrisa, as you are seem rather passionate about midwifery education in the US. I am only vaguely familiar with it, as I come from a very different model. Unfortunately I am familiar enough to understand that most CPMs are grossly undereducated, dangerous, and quite frankly, give the rest of us, who have taken the time to pursue a midwifery education in a real university, a bad name. But, correct me if I’m wrong, it seems as though the CPMs who went to Bastyr/SMS are some of the more educated of the CPMs.

          • Bombshellrisa

            Valerie and Ali are CPMs who own the Puget Sound Birth Center as well as teach at Bastyr. Erin is also a CPM and teaches embryology. Did you meet instructors from the Seattle or California Bastyr?
            I am familiar with both Bastyr and SMS because I attended SMS (before they made the move to Bastyr) as well as attended other classes at Bastyr. The instructors like Val and Ali who teach there also attended that school. I did not end up continuing with my CPM career and ended up becoming a nurse. The CPMs who attend Bastyr are more educated in the sense that they are pursuing a formal education, but the ideology and the woo are what makes them just as bad as any other birth junkie who just wants to catch babies.

          • Susan

            I don’t have any personal knowledge about Bastyr. I did know someone who went through the one year program at this place http://www.maternidadlaluz.com/ but she later went on to be a CNM ( at Yale ) and is currently in the Sudan. She’s kind of amazing really, known her since she was a baby. There definitely is a range among CPMs and I think what we all agree on is that the bar is just too low. I personally would have to see new data to ever believe homebirth is adequately safe to let’s say, give my wholehearted approval to my daughter or daughter in law… both of whom have some interest in it.

    • AlexisRT

      There are also distance-learning CNM options. Philadelphia University also offers its MS Midwifery for non-nurses (CM option–I don’t know much about their program, though, and I’m not even sure PA recognizes CMs) via distance.

      Bastyr, unlike some midwifery schools, requires that you complete science pre-reqs prior to enrollment. If you compare Bastyr to, say, Birthingway in Portland, there are immediate, obvious differences in curriculum.

      What’s sad is that I see wannabe midwives disdaining SMS/Bastyr for being “too medical”, “too lengthy,” and “too expensive.” It’s not cheap, and certainly, at some point cost does become a barrier to entry. But all too often, it winds up sounding like “I want the easy way out.”

    • staceyjw

      It is a crap program, but it is accredited so I am sure its better than most. Still NOT good enough IMO, and I also wondered why she had put it on the list.

      • Bombshellrisa

        Rooks collaborated with Penny Simkin on an article called “The Language of Birth” and the Simkin Center for allied birth professions is at Bastyr (although I am pretty sure that Penny herself now teaches at Seattle Center for Birth).

  • Lost in Suburbia

    Dr. Amy,
    Have you been following the Indiana CPM bill that is waiting to be signed by the governor? It appears to have stronger requirements than most other states that have licensed CPMs. The bill is here (as far as I know, this is the one waiting for a signature) http://www.in.gov/legislative/bills/2013/HE/HE1135.1.html Are the additional educations/ practice requirements meaningful? What I see is that an associates degree at a minimum is required, that it looks like MEAC education is required (not just PEP), 20 additional births beyond what the CPM requires, 20 directly supervised by a doc, malpractice insurance, written collaborative agreement, reporting to the state yearly each birth attended, and some more things I’m not catching on a quick read through. Do you think this is representative of states in general moving towards stricter requirements?

    • Bombshellrisa

      The wording looks like it applies only to those who claim to be certified-which midwives get around all the time by calling themselves traditional birth attendants or traditional midwives.

      • Lost in Suburbia

        Do you mean you think the wording allows non-“certified” midwives to practice without a license or legal consequence? If so, I see provisions above that specifically exclude CNMs and CDEMs from being considered unlawfully practicing medicine, which would suggest to me that midwives who don’t hold those credentials could be considered unlawfully practicing medicine. It also specifies later on that a person may not practice midwifery (the definition of this is given in the bill) unless they hold a certificate issued by the boards specified in the bill (which refers to another part of Indiana law), or is a CDEM with a certificate issued under this law and a collaborative agreement with a physician.

        If you mean something other than this, I’d appreciate some clarification.

        • Bombshellrisa

          I understand that this bill states that someone who wants to practice midwifery must hold a certificate, but so many of the hard core CPMs who refuse to get with the program find a way around it and will call themselves “traditional birth attendants” or claim that they are simply sitting with someone who is attempting a UC. Moreka Jokelar in BC (where midwifery is regulated) does this, she even offers to Skype with patients who are attempting to UC so they have someone to tell them if something is going wrong. From what I understand, CPMs and lay midwives are illegal as it is right now in Indiana and that hasn’t stopped people like Ireena Keesler from calling herself a midwife and attending women. And despite a bill like this one being passed, there will still be women who will seek out those illegal midwives. http://www.jennifermargulis.net/blog/2012/04/midwife-arrested-in-indiana-released-on-10000-bail/

          • Lost in Suburbia

            Certainly those people exist both in states where there are “legal” DEM options, and in states where there is no legal pathway for a midwife. Can’t help them, and I don’t know that practicing medicine or midwifery without a license could be made more illegal to prevent them from putting out a shingle claiming to be a midwife or birth attendant. But my original question was intended to ask if the requirements of the law were meaningful enough to improve outcomes with midwives who seek to be licensed by meeting the requirements, and if this might be part of a trend, or just a one-state deal.

          • Bombshellrisa

            I hope that the requirements DO make a difference. It just seems like if it’s already illegal to practice the way that they are, how will naming all the ways that they are supposed to be practicing make a difference? They are already practicing without a licence.

          • Lost in Suburbia

            Fair enough – clearly there is a set of midwives already willing to break the law. Why would we expect that those same midwives, who are seeking licensure/state recognition, are suddenly going to be all compliant with every letter of the law? It would be reasonable to imagine some will try to find ways around the law, while still maintaining their state certification, or at least the portions they find really objectionable.

          • The Bofa on the Sofa

            If there is a clear law, however, it makes it easier to prosecute.

            And I will say, if some midwife tells the mom that, if anyone asks, she really isn’t a midwife but is a “birth attendant or something,” because the state doesn’t allow her to practice, then I’d have a really hard time agreeing that the mom was being “duped” into believing that the mw was competent.

          • Bombshellrisa

            Bofa, the Jennifer Margullis article I linked to talks about women who seek out the care of these CPMs in Indiana and know that if something goes wrong that they either have to go to the hospital alone or say that the midwife is just a friend.
            I am from WA state, where CPMs are legal and regulated and still you see them taking hbacs and patients who are clearly not low risk. Nobody is prosecuted unless there is a complaint-we know for sure that Beth Coyote has had a baby die within the past year and yet she has never been investigated and there have never been any complaints about her to the board of health.

          • Lost in Suburbia

            Honestly, I think there’s a large group of women choosing homebirth who are well aware of their midwife’s competency, and are not being duped into thinking their midwife is competent, and are in fact, purposefully seeking out midwives the women know are avoiding the law.

  • Susan

    I just read all three of Sara’s articles. She’s done a great job. I learned a lot and I have been reading about this subject for 30 years now. Thank you to Sara and to Judith Rooks! I’d like to read about the BC midwifery school that Rooks references.

  • The Bofa on the Sofa

    That’s an interesting take, that she thought the CPM would merely be a stopgap. IOW, she thought it was a way for old midwives to practice while they go get a proper certification

    Instead, it has become an “alternate” version that is the end, instead of just the means. I still think that the CPM is to midwifery what the “naturopath” or chiropractor is to medicine, i.e. sham wannabees

    • Amy Tuteur, MD

      It’s actually worse. It as if chiropractors and naturopaths started calling themselves “certified medical doctors.”

      • The Bofa on the Sofa

        Well, the naturopaths do claim the “holistic medicine” crap.

      • mollyb

        My medical terminology instructor was a chiropractor that insisted that we refer to her as “doctor”. I was always sort of uncomfortable with it.

        • Susan

          I think chiropractors are more into being called doctors than MDs. Who are secure they are really doctors so they don’t have to make sure no one uses their first names.

          • Eddie

            Yes, this. I have a PhD, but I never ask people to call me doctor (which would sound funny to me). I never include my title anywhere when signing my name. My degree is part of my training and experience but not part of my core identity. It’s an accomplishment, not who I am. In grad school, students typically addressed the professors not as “doctor” but as “professor” or by first name. There were very, very few professors who asked people to address them as “Dr ___” and they were uniformly seen as either egotistical or insecure.

          • slandy09

            My grandfather had a PhD and despised being called doctor too.

          • Dr Kitty

            If I am dealing with something professsional, I want to be addressed as Dr Kitty. At the shops, or the beauty salon or hairdressers, I’m perfectly happy to be addressed as Mrs Kitty.

            What IS rude is if I introduce myself as “Dr Kitty”, because it is relevant to the matter at hand and people insist on calling me “Mrs Kitty”, despite that. But that rarely happens.

          • LukesCook

            In Commonwealth countries not every academic who has a doctorate is a professor – the title is only reserved for the most senior academics (who virtually always have at least one doctorate, but it’s not technically necessary). So there may be a number of teaching academics at university (and sometimes school) level who are “Doctor” but not “Professor”, and in their professional context I think it’s correct to address them as such.

          • Dr Kitty

            Like the UK surgeons who are “Mr” and go ballistic if you call them “Dr”-I think you just have to run with the prevailing culture and the person’s preference.

            In the UK it would not be appropriate to address everyone as “Professor”, because they wouldn’t have earned the title, and “Dr” would be appropriate.

            Of course, my late F-I-L was a professor, and preferred to be addressed by his first name.

          • Eddie

            I find it interesting how much this varies across countries and disciplines. My experience is in physics, which is particularly laid back and informal when compared to many other disciplines. I agree with Dr Kitty when she says just go with the prevailing culture and the person’s preference.

    • Eddie

      Part of this, IMO, is caused by politicians not always being interested in science, believing in wacky stuff with no scientific evidence at all, and being able to decide who gets to practice medicine. If she really believed that the CPM was a stop-gap instead of the end-game, then she was unfortunately naive.

  • Guestll

    The effort by both Snyder and Rooks to shine a light on the clusterfuck that is homebirth midwifery in the US is laudable. Both have exhibited the courage to stand naked in the wind and are worthy of admiration.
    Why are the minimum standards so low? Successful PR campaign is right, and the standard of care for and by women won’t improve until American women insist that they are entitled to better and more. How this movement *ever* got conflated with feminism is beyond me.

  • KarenJJ

    It’s great to see some heroes in this debate. I’ve been baffled at how midwifery organisations have been so quiet on this and seemed to even encourage cooperation with lay midwives and CPMs. CNMs should be proud of their qualification, training and skillset. Proud enough to differentiate themselves and stand up to the lay credentials.