What’s Wrong with Certified Professional Midwives? Pt. I: A CPM’s Education is not Comparable to a CNM’s
Originally posted February 24, 2012
I’m a glutton for punishment and I am invariably self-analytical. So a few months ago, when I first realized there were women out there who really believe that CPMs are a danger to mothers and babies, I wanted to understand why. Why are so many people down on CPMs? What problems do they have with the profession and are these problems valid? Are they fixable? How do I personally feel about these criticisms and can I reconcile my desire to skillfully serve women and babies with the objections some have against my calling?
I started searching around for cogent conversations- not snarky, groupthink parties where everyone just tells one another what everyone else is already thinking- but somewhere that included both CPM supporters and detractors and where people seem interested in having conversations… I found The Navelgazing Midwife’s Facebook page and website and started reading. I followed lots of rabbit trails and came to respect Barb’s (the page & siteowner’s) experiences and viewpoints. Even if I don’t ultimately agree with their take, Barb and the women who frequent her page have something to say that I think CPMs need to hear.
A few weeks ago, I took the plunge and asked on Barb’s Facebook page: Why specifically do you feel that CPMs/DEMs are unqualified to practice? And boy did I get answers. I was so appreciative of everyone’s willingness to discuss, to share their perspectives. After reading the many answers and side conversations that arose, I distilled the objections down into five major points. This blog series is my attempt to process those points. I am not an expert on anything I’m writing about, this is simply how I see these issues atthis time. I look forward to listening to and learning from all women as they share their homebirth experiences- both positive and negative.
So the first major objection against CPMs? A CPM’s education is not comparable to a CNM’s education.
Ah- funny how the first objection should center on an issue that is near and dear to my heart. This may be the only objection that was raised against CPMs that I feelis wholly without merit…
Let me explain: I am a homeschooling mother. For the past 10 years, I have researched, questioned and finally embraced the legitimacy of alternative forms of education. I’ve spent the last 5 years deeply investigating the various ways people learn, what educational success really means and the superiority of self-education. I believe that that part of the prejudice against DEMs/CPMs is actually a difficulty accepting the credibility of alternate educational modalities. Some people just can’t believe that quality outcomes are possible without traditional education experience. As a matter of fact, one criticism about CPMs that I’ve seen levied against the profession again and again is that you don’t even need a high school diploma to become one(gasp!).
Sample list of educators & scientists who
failed to complete formal high school
· Catharine Beecher – co-founder of the Hartford Female Seminary
· Jill Ker Conway – first woman president of Smith College
· Timothy Dwight – President of Yale University
· William Samuel Johnson – President of Columbia College
· Fred Terman – President of Stanford University
· Booker T. Washington – Founder of Tuskegee Institute
· John Witherspoon – President of Princeton University
· George Washington Carver
· Pierre Curie
· Albert Einstein
· Michael Faraday – electrochemist
· Oliver Heaviside – physicist and electromagnetism researcher
· Alexander Graham Bell – invented the telephone
· Thomas Edison – perfected the electric light bulb
· Benjamin Franklin – invented the lightning rod
· Orville and Wilbur Wright – built the first successful airplane
Educational methods are changing as fast as technology. No longer does anyone expect that the only real education is one garnered at a brick and mortar school, in a desk as a lecturer speaks at the front of the class. While this is certainly one way to be educated- if that kind of education is right for you- many people are entering on-line, distance and apprenticeship educations (and not just in midwifery).
State Departments of Education know that alternative education modalities work- that’s why many states now offer online public charter schools.
And let’s be honest, there are many, MANY reasons someone might leave primary/high school and most of these reasons may have NOTHING to do with intelligence or ability. Not having graduated from a state approved educational institution does not mean one is stupid or incapable of doing skilled work. But is this criticism about CPMs being uneducated even valid? To criticize CPM education & training, we have to know how these practitioners are actually being trained.
The third NARM Job Analysis [where NARM surveyed their CPMs to be sure the knowledge and skills they require of new CPMs actually allows them to DO midwifery effectively] was begun with focus groups in 2008, sent as a web-based survey to all CPMs in 2009, and issued as an analysis report in 2010. NARM’s Testing Company, Personnel Research Center, guides all of the psychometric aspects of the CPM process, including the Job Analysis. The survey was sent to 1099 certificants (those with current certification as of 2008 and whose contact information was current) and responded to by 471, a response rate of 42%. Respondents represented 44 states. 45% were trained through apprenticeship, 33% through a MEAC-accredited program,12% through a non-accredited program, and 7% were self-taught. 2.4% were nurse-midwives. 36% had attended some college, 37% were college graduates, 8%were nurses, 7% had master’s degrees, and 1.5% had PhDs. The survey did result in an updated task list, but no major changes were identified in the overall job of the Certified Professional Midwife.
This means that 81.5% of a representative sample of CPMs in 2010 had at least SOME college. Additionally, 45% of this representative sample were trained via some sort of formal midwifery training program- most of those were MEAC schools (MEAC- the Midwifery Education Accreditation Council- is accredited by the same group that accredits Nurse-Midwifery training programs).What this tells us in big, fat letters is that most CPMs have not only graduated from high school, but are pursuing formal higher education along with their specific midwifery training. Whatever anyone says, this doesn’t sound like a group of women who are uneducated, distainful of academic work, and incapable of understanding how to be a midwife.
‘The key to success is to risk thinking unconventional thoughts. Convention is the enemy of progress. If you go down just one corridor of thought you never get to see what’s in the rooms leading off it. ‘ — Trevor Baylis
Working midwives are consistently giving feedback to NARM concerning the skills and knowledge necessary for the job. The requirements and testing of student CPMs are formally reviewed by an independent company every 5 or so years. This means the quality of entry-level CPMs is constantly increasing as their predecessors learn more about best practices in the real world. This is an amazingly responsive way to create new professionals in any field!
The NARM CIB (Candidate Information Bulletin which details the pathways to midwifery and the knowledge and skills necessary for entry-level CPM status) reads:
NARM recognizes that the education of a Certified Professional Midwife (CPM) is composed of didactic and clinical experience. The clinical component of the educational process must be at least one year in duration and equivalent to 1350 clinical contact hours under the supervision of one or more preceptors. The average apprenticeship which includes didactic and clinical training typically lasts three to five years. [Bold mine]. (90% of CPMs qualify this way- either by completing didactic education through formal schooling- MEAC or otherwise- or through self-study during apprenticeship.) ALL candidates must demonstrate mastery of didactic information through the 8 hour NARM written exam prior to certification…
The clinical experience includes prenatal ,intrapartal, postpartal, and newborn care by a student midwife under supervision.
From the above NARM Job Analysis, we know that 45% of practicing CPMs were trained through formal midwifery school, and that most of those were MEAC schools (some of which offer accredited degrees in Midwifery and government based financial aid). Most CPMs are completing formal, didactic education necessary to grasp the information needed to be a midwife and then the candidate is tested to see whether she has mastery of the knowledge. This is a concrete way to assure that the applicant knows what she needs to know to serve women and their babies.
Note, MEAC students have their clinical component- including minimum number of birth assists, primary births under supervision, prenatal visits, postpartum visits, newborn exams and continuity of care cases- of their training incorporated into their education program, this is the same way nurse-midwives receive their training.
‘If everyone is thinking alike,then somebody isn’t thinking.’
— George S. Patton
But, what about those pesky PEP (Portfolio Evaluation Process) candidates? There’s no guarantee that they’ve ever cracked a credible book or that they know the first thing about the hands-on skills needed to be a midwife… Or is there?
According to NARM’s CIB, a PEP candidate must obtain an approved preceptor (this will be a suitably experienced CPM, CNM or LM), have the preceptor verify both midwifery knowledge (the things all midwives must know to practice as defined by NARM) and skills (the things all midwives must know how to do as defined by NARM). Then the PEP candidate has these skills verified by a second CPM who is also an approved skills evaluator, she meets the minimum clinical requirements NARM demands and she takes the NARM written exam to verify her knowledge of midwifery related information. Many PEP candidates are evaluated by several CPMs prior to taking the written exam.
It seems to me, that the type of education offered in MEAC schools is equivalent to the education midwives get in the UK; accredited, quality didactic and clinical education. And if MEAC is equivalent to European university-based midwifery education, then PEP trained candidates are those who CLEP the courses. PEP candidates have real life educational experience, knowledge and abilities and they prove their abilities via extensive testing and skills demonstrations. This is education, folks, REAL education. People taking information and applying it to the real life situations they encounter.
So this brings us back to educational modalities. If both MEAC candidates and PEP candidates are able to verify the knowledge and skills necessary to be a midwife, why does it matter HOW they came by the information/skills? Was Beethoven less capable because he came by his genius naturally instead of being formally taught in composer school? Was Joan of Arc less a military leader because she didn’t go to West Point? Was Jesus less a spiritual leader because He didn’t go to seminary?
“See, the sad thing about a guy like you is in 50 years you’re gonna staht doin some thinkin on your own and you’re gonna come up with the fact that there are two certaintees in life. One, don’t do that. And Two, you dropped a hundred and fifty grand on a *%@# education you coulda got for a dollah fifty in late chahges at the public library”
–Will, from Good Will Hunting
There’s a part of this equation that I haven’t yet explored, forgive me for prattling on even further. This has to do with the way we think about the educational standard for midwives in this country and I myself have fallen into this trap in this post. By arguing that CPM training is ‘just as good as’ CNM training, we make CNM training the standard to be achieved. As skilled and as dedicated as many nurse-midwives are, I fail to see how their training is superior to other midwifery pathways. A nursing degree that accompanies midwifery training is the deviation from the global norm in midwifery, yet I haven’t seen one study that suggests that a midwifery practitioner with a nursing degree has better client outcomes. Globally, midwives are NOT also nurses- these are two separate disciplines. In the U.S., the lines between midwifery and nursing have been blurred because of the medical field’s determined efforts to stamp out community midwifery in the early 20th century. Nurses were acceptable medical practitioners- being under the authority of physicians who controlled (and do still control) how nurse-midwifery was practiced. Certainly, nurse-midwives have better access to the U.S. maternity system, to medical supports and adjacent equipment and prescriptive powers, but that has to do with professional nepotism, not proven professional superiority.
So my conclusion about CPM education?: It’s good. It adequately trains women to be midwives, verifies both their knowledge and their practical skills and adapts as better practices are discovered. I have no problem with various routes into the CPM credential- some rivers flow straight, some meander more freely, but they all end at the sea.
‘Even a thought, even a possibility can shatter us and transform us.’
— Friedrich Nietzsche
While I’ve disagreed wholly with the CPM critics on the point of education, I find the other objections they shared on the Navelgazing Midwife’s Facebook page more valid and thought provoking. To some of these issues, there are no easy solutions, but I want to explore the problems as best I can to understand and, hopefully, to help make the CPM profession that much better in the future.