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Month: June 2018

Midwifery in America

Midwifery in America

I’ve gotten a lot of questions the last few months from fellow students and other midwives here in the UK about exactly what midwifery is like in America. There is a fair bit of confusion about the roles. Some people I’ve encountered think that midwives in the US don’t do any actual baby catching, but they’re confusing the role of US Labor & Delivery nurse with that of the US midwife.  It IS confusing because in the UK, L&D nurses don’t exist. Instead, the UK midwife does both the US L&D nurse’s job AND the US midwife’s job.  I also think the role of the midwife and scope of practice varies a great deal between the US and UK as well, and midwifery in general in the US is so confusing because there are two different standards of midwifery care there (CNM v. CPM). So in conclusion, a post to explain US midwifery and the differences I’ve noticed so far between the US and UK seems like a good idea!

First, here in the UK, a midwifery degree is an entry-level degree (i.e. a Bachelors degree) and the majority of midwives are direct-entry midwives (meaning that their degree is in Midwifery, without first having to obtain a nursing degree before becoming a midwife). Granted, there are some people here who come to midwifery after having obtained a nursing degree first (and there is a handy 18-month program which allows them to become midwives fairly easily), in which case they are both a nurse and a midwife after they qualify (and will have a Bachelors in Nursing and a Bachelors in Midwifery). Crucially, though, the practice of nursing and midwifery are separate fields of study here, and separate qualifications (although there is a lot of overlap in the subject matter, such as basic health skills). The labour wards here in the UK are staffed by midwives (and if there are staff members who are both midwives and nurses working there, they would be working on labour ward in their midwifery role and not in their nursing role). Labour & Delivery nurses do not exist in the UK (although there might be a few specialist nurses who do work on the labour ward occasionally in a nursing capacity) and the majority of the work done on the ward is done by midwives. After completing her midwifery education here, a midwife qualifies and joins the register through the Nurse and Midwifery Council (NMC) and has the title of Royal Midwife (RM). There is ONE standard for midwifery care here, which is defined, set and monitored by the NMC, and there is only one main professional organisation which supports midwives in this country (the Royal College of Midwives) versus two in the US (see below).

In contrast, in the US there are two different routes to midwifery, and three legally recognized titles that you can practice under as a midwife: Certified Nurse-Midwife (CNM), Certified Midwife (CM) and Certified Professional Midwife (CPM). Instead of one national accrediting body for midwifery educational programs, there are two: the American College of Nurse Midwives (ACNM) and the Midwifery Education and Accreditation Council (MEAC). Instead of one national board exam, there are two different exams administered by two different organizations: the American Midwifery Certification Board (AMCB), which administers the board exam to qualify as a CNM/CM, and the North American Registry of Midwives (NARM), which administers the board exam to qualify as a CPM. The acronyms alone are enough to make your head spin!

The ACNM (American College of Nurse Midwives) is the professional organization of Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). Nearly all of the members of the ACNM have a Bachelors level nursing degree first, then go on to obtain an advanced degree in midwifery (usually a Masters degree), and are then credentialed through the ACNM. A very small subset of this group are “direct-entry” midwives, meaning that they don’t have any prior nursing education before beginning their midwifery training, although they do have a Bachelors already, usually in a related field like public health or sociology or biology or chemistry; a direct-entry student goes through the exact same program as her nursing compatriots, and when she graduates she takes the exact same board exam, and is credentialed as a CM, rather than CNM (both CNMs/CMs are credentialed through the American Midwifery Certification Board (AMCB)).  In this pathway, midwifery education is a Masters level degree, and when they graduate, a CNM/ CM is a a mid-level provider. They work autonomously are able to practice in all 50 states, prescribe medications in many of them, and are able to work independently as autonomous providers (although in some States they have to have a written practice agreement with a doctor in place in order to be able to practice legally).

In contrast, Certified Professional Midwives (CPMs) obtain certificates through midwifery-education programs which are accredited by the Midwifery Education and Accreditation Council (MEAC), and when they graduate, they are credentialed through the North American Registry of Midwives (NARM) and become CPMs. Like CMs, CPMs are direct-entry students, with no prior nursing education or experience. And because CPMs are not nurses, nor are they credentialed through the ACNM, they aren’t allowed to join the ACNM. The professional organization which represents the interests of CPMs is the Midwives Alliance of North America (MANA), which seeks to represent the interest of every type of midwife in North America, including CNMs/CMs (even though their interests are already being represented by the ACNM). While some midwives (well, CNMs/CMs) belong to both organizations, I think the majority of midwives tend to pick one or the other, if they even join at all (and just think how much further the profession as a whole could get if every midwife in the country actually joined their professional organization and paid dues, which could then be applied to projects and lobbying which actually benefits midwives and our profession. Sadly, of course, membership is never even close to 100%, which is really disheartening. Membership in the American Medical Association is much higher—I have never known a US doctor who was not also a member—and just look at what a powerful and influential organization the AMA is—i.e., look what happens when a professional organization actually has money! Ahem.)

Are you confused yet?

Now, there are so many problems with this I don’t even know where to start. Someone looking in from the outside could very sensibly say: well, don’t you think you’d have more power and more political clout and be better understood by the public and by other professions if all of you midwives just got together and decided on ONE standard definition, ONE standard credential and ONE professional organization to represent you? And of course, the answer to that would be a resounding YES! In countries around the world where midwifery has a very strong professional presence, and where midwives are not only highly respected but also deliver the majority of the babies in that country, invariably you will find that there is one unified professional organization for all of the midwives of that country, one standardized educational track and one credential. Here in the UK when you say “I’m a midwife”, no one needs to ask if you’re a nurse-midwife or a direct-entry midwife or if you have a Masters Degree or a Certificate. The profession of midwifery has one standardized definition of what midwifery entails, one credential, one professional organization and one standardized scope of practice. I’m sure this must really simplify things, and allow the profession of midwifery to move beyond issues of sorting out its own mess and instead tackle larger goals and issues and missions which are important to the entire profession, as a whole.

In America, because of all of the different credentials and the differing legal status of midwives from state to state, we’ve got an enormous range in our scope of practice. CNMs can legally practice in all 50 states. CMs are legally licensed in 5 states at the moment, and CPMs are legal in 33 states. CPMs most often work in birth centers or homes, while CNMs/CMs can work in hospitals, birthing centers and homes. Depending on what state you live in, a CNM/CM may or may not be able to prescribe drugs, or admit private patients to a hospital. In some states, CNMs/CMs are required to work with a collaborating physician in order to practice legally, in others they can practice autonomously (is this also true for CPMs? To be honest, I’m not sure. Any CPMs who are reading this, please let me know!). The scope of practice for CNMs/CMs can range from primary care to family planning to birth control to hormone replacement to basic gynaecology. To be honest, I’m not sure if CPMs can do all of this as well (CPMs who are reading this, can you? Or is that a state by state thing, too?). In other words, it’s a hodge-podge mess. And maybe that’s just the nature of the game, given that America is a conglomerate of states, and because each state wields so much independent power, laws vary considerably from state to state.

One of the biggest differences I’ve noticed, though, is the difference in power and influence that the profession holds in each country. Prior to the turn of the 19th century in America, there were thousands of traditional, apprentice-taught midwives practicing in America, and most births were still attended at home by midwives as they always had been. “Native American midwives continued to attend women in their tribal groups, as did colonial midwives among the white settlers, Hispanic midwives in their southwestern communities, immigrant midwives accompanying their ethnic groups, and black granny midwives in the American South” (Davis-Floyd & Johnson, 2006). However, starting in the early 1900s, doctors began to move into the lucrative birth business in droves and launched a comprehensive smear campaign against traditional midwives, stereotyping them as dirty, ignorant, uneducated and careless. This was happening at the same time that birth was moving out of homes and into the hospitals, which were portrayed as clean, modern, hygienic, progressive and cutting-edge. In this regard, patriarchy also played a part; it made sense to accept male dominance and authority in obstetrical matters when the cultural norm already viewed men in this role, and male inventors had ushered in the modern age through new technologies such as electricity, railways, cars, telephones, etc.–chloroform in hospitals and forceps deliveries felt like the future in this context (Davis-Floyd & Johnson, 2006).  Mainstream cultural pressure and assimilation also made giving birth with private physicians fashionable and trendy, while cultural, socioeconomic and language barriers made it nearly impossible for traditional midwives of different ethnic groups to join together to collectively fight the physician’s propaganda against them. The end results was a complete decimation of midwifery as a profession in the US; in the 1800s, midwives attended the majority of all births, but by the mid-1900s, midwives attended a tiny minority of births, often illegally (Davis-Floyd & Johnson, 2006).

Nurse-midwifery in its modern incarnation first appeared in the US in the mid 1920s, after Mary Breckenridge, a public health nurse, travelled to the UK and trained there as a midwife, returning to rural Kentucky to found the Frontier Nursing Service (FNS), which brought the UK midwifery model of care to isolated and deeply impoverished Appalachian communities. This model of care was also adopted in New York City through the establishment of the Lobenstine Clinic in 1930, which began to train nurse-midwives to care for the underserved communities in Harlem, Hell’s Kitchen and the Bronx, tending to “populations in dire need that physicians were not attending [to], and did not wish to attend [to]” (Davis-Floyd & Johnson, 2006). During the World Wars, nursing had established itself as a profession and organised itself as a professional body, and America’s earliest modern midwives were able to use the legitimacy of the nursing profession to overcome the negative stereotypes surrounding midwifery; in this way, modern midwifery in the US has been associated with nursing from the very beginning, despite the fact that midwifery is its own profession, separate from nursing. The growth of nurse-midwifery was very slow through the fist half of the 20th century as nurse-midwives still had to fight against the negative stereotypes of ignorance and unprofessionalism, but little by little, gains were made. The first graduate-level midwifery education program was opened in 1956 in Yale’s Department of Nursing (again linking midwifery to nursing in the US), and the ACNM was formed in 1955 after nurse-midwives were unable to create their own niche within the newly created American Nurses Association (ANA). The post-war baby boom also opened up new opportunities for nurse-midwives as over-stretched hospitals in New York and Baltimore began to rely on them to cope with the increasing numbers of women giving birth (Davis-Floyd & Johnson, 2006). This resulted in nurse-midwives moving into hospital-based practices in greater numbers, which decreased their autonomy but increased their knowledge base and ability to deliver care to a larger number of women. However, nurse-midwives’ adaptation to hospitals and adoption of hospital norms was so complete that by 1973 the ACNM actually issued a Statement on Home Birth which declared that giving birth in a hospital was the preferred location due to increased safety (in 1980, ACNM retracted it’s original statement on homebirth and instead endorsed nurse-midwifery practice in all settings, but to this day, the majority of CNMs still practice in hospitals) (Davis-Floyd & Johnson, 2006). The ACNM continued to develop a national certification process and education programs, and by the end of the 1970s there were 19 nurse-midwifery education programs, nurse-midwives could legally practice in 41 states, and combined they attended a little bit more than 1% of all births in the US (Davis-Floyd & Johnson, 2006).

And then along came a midwifery renaissance in the US, spear-headed by one of the world’s most famous midwives, Ina May Gaskin. This renaissance was fueled by the turbulent cultural changes occurring in the 1960s and 1970s through the counterculture and feminist movements, as well as in response to the rampant over-medicalization of birth. Hospital birth from the 1930s – 1960s was increasingly restrictive and technocratic, with women disempowered recipients of authoritarian care, where the doctor was the “expert” and the woman was the”patient”, combined with restrictive practices like routine pubic hair shaving and enemas, routine episiotomies, routine use of forceps and common use of twilight sleep, which was a combination of morphine and scopolamine, a psychedelic amnesiac designed to take away the memory of the birth–which it did in spades, but it also transformed women into wild animals during the delivery (Davis-Floyd, 2003). Women receiving twilight sleep were often out of their minds and hallucinatory, strapped down to beds, left alone to scream, or put in padded rooms, only to wake up afterwards with a baby in their arms and no true memory of the birth experience except for scary flashbacks and nightmares which would haunt them for the rest of their lives (the TV series Mad Men did an excellent job of portraying this in Season 3 when Betty Draper gives birth to their third child). In the 1970s, giving birth became a feminist issue, with women clamoring to reclaim birth and humanise and personalise the birth process (NEWSFLASH–respecting basic human rights during birth is STILL an issue we’re battling today!) and midwifery care became a hallmark of this movement away from a disempowered, technocratic birth experience towards a more natural, woman-centered birth experience (Davis-Floyd, 2003). In the hospitals, the use of twilight sleep died out, routine shaves and enemas were no longer performed, and nurse-midwives in the 1970s and ’80s worked to include partners at births and to begin to remove barriers to natural childbirth like routine lithotomy position, routine forceps and episiotomy, and sterile drapes separating moms and babies, as well as promoting unmedicated birth and breastfeeding (Davis-Floyd & Johnson, 2006). But there was also an increase in the popularity of home births during this time, and more women became interested in providing and receiving midwifery care outside of the hospital paradigm, which increased the number of grassroots direct-entry midwives practicing in the country. These direct entry midwives (also called “lay midwives”), like Ina May Gaskin, Raven Lang and Anne Frye, were apprentice-trained and not formally educated like nurse-midwives, and by the end of the 1970s were also attending approximately 1% of all US births.

At first, these small clusters of lay midwives were unaware of each other, but because of growing interest in their counterculture message, the publication of books like Spiritual Midwifery and The Birth Book, and the media attention this brought, lay midwives began to band together and organise themselves. According to Robbie Davis-Floyd’s (2006) anthropological documentation of midwifery in the United States, there was probably a period of time when direct-entry lay midwives could have been folded into the ACNM, if the ACNM had been willing to drop the nursing requirement from its educational pathway and addressed some of the philosophical concerns of the lay midwives. But instead the ACNM affirmed its belief  that midwifery in the US required formal education and a nursing background (the ACNM later changed its mind about the nursing requirement, and went on to develop its own direct-entry pathway for non-nurses to become midwives, hence the credential of Certified Midwives (CMs)). Therefore, since lay midwives were not welcomed into the ACNM, in 1982 they decided to form their own professional organisation, the Midwives Alliance of North America (MANA), later going on to create the credential Certified Professional Midwife (CPM). As CPMs and MANA continued to evolve, they began to develop their own knowledge base, values and philosophy of care based on their greater understanding of unmedicated birth in homes, and went on to create an educational pathway that would teach and support this knowledge base without being incorporated into the more “medicalised” hospital environment. As it stands right now, CPMs can legally practice in 33 states, and The Big Push for Midwives continues to advocate and lobby for further legalisation in the remaining states (whereas CNMs can practice in all 50 states).

Thus through the history of modern midwifery in the US, we can see why there are two midwifery organisations, two educational pathways, two accreditation programs, and three different midwifery credentials you can obtain! And unfortunately, it seems like the chances of MANA and the ACNM actually getting together and coming up with one unified plan for midwifery in the US are very slim. There have been many attempts in the past to align both groups, most notably during the Carnegie Meetings sponsored by the Carnegie Foundation in the late ’80s through the mid-’90s, and subsequent MANA/ACNM Bridge Committees continue to keep a dialogue open between the two organizations (Davis-Floyd & Johnson, 2006). However, it seems unlikely these two organisations will be joining together any time soon (and I’m sure there are many midwives who would argue that that’s a good thing). Part of the problem is that the interests of these two groups are now quite distinct and it’s hard to find common ground. Many CPMs who are trained through apprenticeship view apprenticeship as a key component of their education, and therefore MANA is unwilling to give up apprenticeship training as a viable route to midwifery, whereas the ACNM has a long history of valuing graduate-level university education and is unwilling to accept apprenticeship as an equal educational pathway. There’s also an undercurrent of disdain between some members of both groups, unfortunately. I think that *some* CNMs/CMs (certainly not all!) have a tendency to look down on CPMs as being under-educated, unacademic, tradition-based rather than evidence-based, and not very clinically well-informed, while *some* CPMs have a tendency to look down on CNMs/CMs as being too interventionist and technocratic (“medwife” v. “midwife”), too quick to view pregnancy from an medical/obstetrical lens, too eager to suck up to the American Medical Association (AMA) and/or the American Nursing Association, and having lost touch with the heart and soul of midwifery. There’s really no point in arguing which point of view is right; they’re both flawed, and so long as this continues, the profession of midwifery in America will continue to struggle. The bigger picture is that right now midwives (of whatever credential!) in the US only attend 8% of all births, while in the UK midwives attend over 50% of all births!

In the UK midwifery took a much different route. Midwives in the UK were able to organise as a profession as early as 1881, and the first legislation legalising the profession was passed in 1902 through the Midwifery Act for England and Wales. Therefore in the UK, midwifery has always been its own profession, separate from nursing, and midwives have consolidated and maintained their position as the primary caretakers for pregnant women. In fact, the power of midwifery is so strong in this country that even in high risk cases, where women are very much being cared for and managed by obstetricians, they are still collaboratively managed and still have visits with midwives as well os OBs during their pregnancy in order to preserve some pregnancy normality for them. At the hospital where I am currently doing my clinical placements, midwives manage the majority of labours (doing both the US equivalent midwifery role AND the US equivalent Labor & Delivery nurse role combined) and call the OBs in for assistance when needed, but are very much autonomous practitioners. It’s true that the scope of midwifery practice is more limited here in the UK than my scope was as a CNM in New York (and as you can see from above, my experience in New York was quite specific to that state, and by no means an similar to other states). For example, I was trained in gynaecology as well as primary care and midwifery; many of the women I saw in the clinic weren’t even pregnant, but were coming for routine gynaecology appointments, such as contraception (in NY state I could prescribe all forms of contraception, as well as insert intrauterine devices/ coils), STI screening and treatment, fibroids, or abnormal uterine bleeding; I would often order initial work-ups such PCOS lab tests or basic fertility lab tests and then refer them on to my physician colleagues for further care. I occasionally saw women who were menopausal or had issues with prolapses, and of course took care of pregnant women through their pregnancy, births and postpartum period. However, in my experience midwives enjoy a much greater degree of respect, recognition and empowerment here in the UK. There are often campaigns designed to thank and recognise the midwifery role, such as the Pampers ‘Thank You, Midwife’ campaign, and I still get such a kick out of not having to explain to people what a midwife IS when I tell them that I’m in midwifery school…here in the UK, everyone knows what a midwife is, and most people I talk to have a great deal of interest and admiration for the work midwives do.

So perhaps this helps to clarify just a little bit the ways that midwifery is different in the US versus the UK? (And of course, if I’ve misrepresented anything, or gotten anything wrong, please let me know–especially with regards to CPM legislation and scope!)

 

Davis-Floyd, R. (2003) Birth as an American Rite of Passage. London: University of California Press.

Davis-Floyd, R. and Johnson, C.B. (2006) Mainstreaming Midwives: The Politics of Change. London: Routledge, Taylor and Francis Group.