CNM, CPM, DEM–can’t we all just get along?

29 April 2009 at 9:49 am 3 comments

When I read about the recent decision on the part of CNMs (certified nurse midwives–midwives with an RN) to exclude CPMs (certified practical midwives) from their definition of a midwife, I was saddened, but not entirely surprised. First of all, some researchers have pointed out that merely being a midwife (i.e., holding a CNM degree) does not necessarily mean one follows the midwifery model of care. Even if CNMs–as many, many do–follow the midwifery model rather than the medical model, some of them may be (perhaps overly) protective of their academic credentials. And there are, of course, midwives out there with a wide range of credentials and types of training–many of whom I encountered during my pregnancy last year.

When I was eight weeks pregnant, I visited my CNM (my long-time care-provider through my employer’s health insurance) for confirmation of my pregnancy. I declined an ultrasound solely for the purpose of verifying pregnancy, and instead she did prenatal blood-work and palpated my uterus. She asked if I’d considered my birthing options, and she handed me a pamphlet that talked about midwives and birth centers. “Yes,” I said, “I’ve decided to have a homebirth.” She immediately waxed rhapsodic: homebirth is the gold standard of birth, she said; she herself had homebirths for her two daughters; when she retires she would love to have a small homebirth practice; presently, due to regulatory and malpractice concerns, she can only attend–and then only unofficially–at the homebirths of family and very close friends, which she has done for her daughter, her niece, etc. She waved goodbye, promised to mail me my blood results, and urged me to come back with my baby in nine or ten months to tell her how it went.

When I was ten weeks pregnant, I started interviewing homebirth midwives. I knew that in Massachusetts I wouldn’t find a CNM to attend a homebirth, but I’d read about the CPM credential and began with the idea that it would be good to find a CPM. The alphabet soup of midwives just kept getting thicker, though, as I tried to make my decision–I read more and more about CNMs, CPMs, and now DEMs (direct-entry midwives). As I learned, some DEMs do go on to get their CPM, but some don’t, shunning all official regulations–sometimes out of principle and sometimes out of sheer busyness.

In all I met with five different homebirth midwives (and their partners/apprentices) in my first trimester: three of the midwives were CPMs, one with less than a year of post-training practice, and two with more than twenty years of practice each; two others were DEMs, who had apprenticed but never officially taken the CPM credential, although one of those was currently pursuing it in her “spare” time. I ended up going with the only midwife who had not even begun to complete her CPM, and by that point, the issue of certification became absolutely a non-issue to me. 

What was more important, honestly, was how the midwife made me and my husband feel–my midwife relaxed me completely, even at our first meeting, and I felt like I’d be in good hands. She had a great deal of practical, hands-on experience, and she answered all of our questions calmly (even my husband’s crazy questions, by the way: “Have you ever attended at a non-human birth?” he asked). Throughout my pregnancy and labor, I never second-guessed my decision. For me, she was the right fit. 

My point here is that while I think it’s important that there are credentials like the CNM and the CPM out there, for those who want and value them, and while I support all legislation to give CPMs and other midwives more legal protection, I think that we can get too caught up in these labels. What should matter more than a string of letters are the intangibles that contribute to a rich, empowering, and safe birthing experience–a midwife’s apprenticeship/experience, manner, and attitudes toward women, babies, and the midwifery model of care.



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3 Comments Add your own

  • 1. Guinever  |  1 May 2009 at 10:41 pm

    great post! I’ve often thought this same thing over the years; wishing the CNMs who have the hospital privileges would better support the DEMs and CPMs when they need to transfer. I think there needs to be a greater respect among the midwife community. It’s there in some cases, but in others, it’s just not and that’s sad.

  • 2. Michelle Wilbert  |  28 May 2009 at 1:41 pm

    Nice post; I agree. As a longtime practicing DEM who has “toyed” with the idea of the CPM for years without really finding it in keeping with my values, I appreciate that you were able to choose the Midwife you felt comfortable with. I do appreciate the ACNM’s position, however. I think that if we want Midwifery to be a unified, recognized “health care profession” available to all women in all settings, we have to agree on a standard that “works” for the majority of women in our Country, not only consumers, but young women who might be interested in becoming Midwives but who don’t have the time/money/support to become DEM’s or CPM’s ( the programs are long, often at a considerabel distance, and expensive with NO federal financial aid available which means that they are, in effect, closed to women of color, poor women etc. or who want/need to make a living. Home birth does not pay well. Most women who are home birth midwives ( as I know from long experience ) do not make enough money to support a family, or even provide half the support for a family. Without my husbands income and provision for us, I could not have practiced and my daughers/ grandaughters are not going to be living in a world where they could afford to do what I did. We have to have a standarized educational program that produces quality Midwives who can practice in any setting not only for birthing women, but for women who want to become Midwives so that we can, in time, have a truly woman-centered, Midwifery-based Maternity Care System in the U.S.

  • 3. mfomgal  |  29 May 2009 at 3:25 pm

    Great post. I, too, agree that any form of standardized credentialing is necessary in terms of getting homebirth more affordable and accessible to more women. If the CPM credential can deliver mandates for medicaid and insurance reimbursements, then so be it.

    I think women who connect with a DEM may have to continue paying out of pocket, though, in some states, but at least there will still be options for homebirth for all women.

    As for CNMs, I want so desperately for them to gain more autonomy and scope of practice in all states to improve hospital birth outcomes and increase the number of birth cneters, if they feel they need to distance themselves from MANA right now to gain more footing in their own regulatory fight, that isn’t a great thing, but may be a necessary thing.


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