CNM vs CPM – is one better?

I’ve been reading a lot of blog posts and Facebook messages and such lately being critical of non-nurse midwifery – and when I see the same topic over and over again it usually means I’m meant to write a blog post about it.

First lets start with some background – here is  blog post from Midwife{ology} that explains the difference between a CNM (Certified Nurse Midwife) and a CPM (Certified Professional Midwife – although the author incorrectly says “certified practicing midwife” a few times)…
Notice not only that she explains the difference, but then in her last paragraph becomes opinionated as to how woefully inadequate the training and requirements for CPM are compared to CNM’s.

Lets move to a very popular midwifery blog, Navelgazing Midwife. I have known Barbara for at least 14 years and respect her in many ways (despite our differences). Barbara has shared her journey from birthing mother to midwife…to her current frustrations (bordering on anger) focused on the “NBC” (natural childbirth community).
Barbara has come to a place in her life where she says that non-nurse midwives are dangerous, those in the NBC are judgmental and blindly follow an ideal that is both WRONG and putting mothers and babies at risk. She, too, laments to the inadequacy of non-nurse midwifery training.  Her latest post “Suddenly” expresses her current position quite well.

Now we have arrived at the far end of the spectrum – the well-known “Dr Amy” (Amy Tuter, former OB whose built a career on lambasting homebirth and homebirthers.) She thinks that anything outside of a hospital is reckless abandon and insanely stupid (almost beyond words, although Dr Amy never seems to be at a loss for words).

I’ve been in the birthing community for 16 years…and doggonit, if they have a right to their opinion, then I think I have a right to mine. (for the record, I think that each and every one of these ladies has a right to their opinion and I will give them a standing applause for them speaking up and shouting their opinions! Yay for strong women who stand up and speak out! I hope they continue!)

So my opinion is this: There is no comparing most CNMs and CPMs. They don’t have the same job and therefore, the preparation to do that job isn’t (and doesn’t need to be) the same. CNM’s deal with things that CPM’s will never deal with and they need much more education to deal with those things.

It sounds like I’m dangerously close to saying that most CNM’s are more educated than CPM’s, so let me make it clear. I am. I am saying most CNM’s have more education than CPM’s.

YES, I AM A CPM! (I’m also an LM – a midwife licensed in my state to legally practice homebirth midwifery) As a CPM I will say that I believe that CNM’s have more education than most CPM’s. Way more.

I don’t think that’s a bad thing. What I mean is, more education is always a good thing and every single day I’m looking things up, I’m learning more than I knew the day before, I’m constantly learning – and more knowledge is always good! But for what a CPM is going to deal with in her job as opposed to a CNM – a CNM’s job NEEDS more training!

Lets take pharmacology…I can’t prescribe medications, so why should I be required to have the same knowledge base as a CNM who prescribes? I will never induce someone, so why should I be required to know how to manage an induced labor, when to do Cervadil, how often, dosage of Pitocin, etc? Someone under my care will never have an epidural or an analgesic, so why should I need to know how to manage those births?

Does a CNM need to know as much as an OB? Is she practicing more dangerously because she doesn’t have the same level of education and skills? Do her patients suffer because she can’t do a vacuum extraction or cesarean? Of course not…an OB needs to know how to deal with much more than the CNM needs to know how to deal with. A CNM needs to be able to identify when this mother’s pregnancy or birth is falling outside of what she is able to manage and when to call in backup assistance – ie. The OB. She must determine what and when she is still dealing with things she is trained to deal with, and when things are going wrong in a way that the mother/baby need more aggressive attention/intervention than she is able to provide.

Guess what….that’s my job, too!! And I am DAMN good at it! I don’t have to know all of the protocols for dealing with preterm labor or preeclampsia…I have to know how to IDENTIFY those things and when they are at a level that require a hospital. I don’t have to know every response to things that can go wrong…I just have to know what “wrong” IS and when it’s easily fixed by me or if we need to get additional assistance. Oftentimes when I identify something as, “Wrong enough that we can no longer continue with our plans for a homebirth”….it’s a CNM that I call! And they do many things safely that I am unable to do (and, frankly, don’t have the knowledgebase or skills to do).

That in no way makes me less competent at my job than she is at hers. If I identify a problem and transfer someone to the hospital, then I did my job just as much as the CNM that identifies a problem that requires an OB’s care! She doesn’t have to know the OB’s job, and I don’t have to know the CNM’s job.

Now, I have seen some pretty flakey midwives out there…but almost always they are “lay midwives” (ie. No credentials at all). Without any certification or licensure, then anyone can call themselves whatever they want and it doesn’t mean a thing. I actually heard a “midwife” recommending homeopathy for placenta previa…?!? I find that embarrassing to me and my profession. (then again, I wonder if OB’s feel the same way when they look at things like, “My OB Said What??” ) I guess there are flakes in every profession, right?

I can hear it coming so let me see if I can stop the flood of responses defending lay midwifery – of course you can be a good midwife if you aren’t credentialed. If I gave up my license, I would still be a good midwife. BUT – while many lay midwives may be awesome, if there is a flake to be found out there then yes, it is often a lay midwife. Doesn’t mean most lay midwives are flakes, but it does mean that most flakes are lay midwives.

My point is that to compare and contrast CNM’s with CPM’s in an attempt to discredit CPM’s is like comparing CNM’s to OB’s to show how inadequate the CNM education is. It’s ridiculous, because it’s a different job with a different set of requirements.

Do those critical of CPM standards really think that upping the standard is going to improve the midwife’s skill set?? Honestly, if THAT is your critisism then I have a solution that might stop your headache from that brick wall you’re banging your head on…

Rather than slamming CPM’s for their education requirements being less than a CNM and thinking that making their educational requirements comparable is going to make moms and babies safer…..let me tell you what you COULD be focused on that is realistic and can actually make a difference….

Make it a requirement that all CPM’s take one class in risk assessment and judgment calls….and make all the hospitals receptive to welcoming those cases that are appropriately transferred in with a clear plan and protocol in place for welcoming these homebirth transports (especially non-critical ones) and thereby making the CPM better equipped to make that call, and parents less afraid of it. Let’s work on the communication and respect FOR TRANSPORTS so that it’s not something to be feared, working on both sides to improve decisions from the CPM as well as improve birthing experiences from the hospital.

I do not see how it would benefit me, my practice, or (most importantly) the outcomes for my mothers/babies for me to learn about interventions such as management of preterm labor, magnesium sulfate, inductions of labor, chorioamnionitis, etc. Those moms don’t need me…they need a hospital.

I think that rather than defending their incredible knowledge and skill base…CPM’s should understand and acknowledge that we don’t have to know how to deal with everything! Our knowledge IS limited…and if you don’t embrace that then you are who makes ‘them’ nervous. It is the midwife who thinks she knows everything and can deal with everything that is dangerous.

I admit I have areas that go well beyond my knowledge and expertise…and I’m thrilled to be surrounded by CNM’s and OB’s that I can call when I reach those boundaries. So rather than sitting here telling you that my education is as good as a CNM, I will only say that my education makes me as safe to do homebirths as a CNM’s education makes her safe at doing hospital births….and I’m proud of both of us and embrace our differences!!