CNM vs CPM

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!!

47 Comments

  1. kelli wrote:

    Oh, can’t we all just get along? And maybe embrace the fact that working in the same field doesn’t mean everyone has the same job? I know its understood in some other countries, I hope one day we figure it out here too, I would lead to such amazing improvements.

    Sunday, September 4, 2011 at 5:22 pm | Permalink
  2. kelli wrote:

    Oops, IT would lead…not *I* would…I’m not that full of myself, lol!

    Sunday, September 4, 2011 at 5:24 pm | Permalink
  3. Tiffany wrote:

    Absolutely well said….fantastic 🙂

    Sunday, September 4, 2011 at 5:29 pm | Permalink
  4. I think my immense frustration is being seen as anger. I am not angry. I am incredibly frustrated with the level of incompetence I’ve seen (I see) in some/too many homebirth non-nurse midwives.

    I totally agree with you about the educational needs being different, but that is *not* what annoys me about homebirth non-nurse midwives. It is that the education we *should* have, the education and skills we *should* have in order to attend a natural, homebirth are inadequate. When a midwife cannot diagnose a hemorrhage or an abruption… when a CPM thinks it’s perfectly fine to use garlic cloves in the vagina as a “treatment” for GBS… *these* are the things that make CPMs and lay midwives look like fools… and how dangerous we actually are to mothers and babies.

    Yes, we have disagreed over the years, but I suspect on this issue, we are far closer than much further apart.

    And the reason we can’t “all just get along” is because lives are at stake here. It isn’t just birth trauma anymore; it’s babies dying.

    Sunday, September 4, 2011 at 5:43 pm | Permalink
  5. Jenni wrote:

    “When a midwife cannot diagnose a hemorrhage or an abruption… when a CPM thinks it’s perfectly fine to use garlic cloves in the vagina as a “treatment” for GBS… *these* are the things that make CPMs and lay midwives look like fools… and how dangerous we actually are to mothers and babies.”
    I have to say I have seen MANY CNM’s choose the “garlic protocol” for GBS, and a few CNM’s be harmful by over managing births, because they have fear from being taught medical model. I mean Navelgazing Midwife, you yourself didnt know about the Hibiclens protocol, you said it couldnt be real… I have known about it for years, does that make me better than you? NO!!! Never!! no matter what letters are after our names we all have different levels of education. Thats the difference in schools, level of information retention, etc. I am NOT saying that education is a bad thing AT ALL! I think we ALL need to continue to learn and grow, but I dont think the majority of CPM’s are under-educated/dangerous. I feel that you can be any midwife and have as varied a level of education/skill as people have noses. Just because someone has a certain set of letters after their name, for me, DOES NOT prejudice me to their level of knowledge. I feel as if there is alot of prejudging in this ageless argument of CPM vs CNM. I think the whole thing is just a terrible representative of the lack of care/support for women and babies today. Hell we didnt get to 40th in infant mortality because CPMs or homebirth are the norm, if either were we might not be 40th… Just my 2 beans, not trying to be argumentative at all, but I have seen this argument go on so long that I felt like tonight was my night to speak. Thanks for reading 🙂

    Sunday, September 4, 2011 at 7:50 pm | Permalink
  6. tara wrote:

    Reading this post and the posts you have linked have pretty much guaranteed that I will never hire a CPM. I found the midwife{ology} post to be informative,but even more so that you could only find one thing to criticize and that is that she called them certified practical midwives a few times. And that she is “opinionated” I have the utmost respect for NgM and the frank way she admits to being wrong makes that grow exponentially. But you have convinced me yourself. For instance: “CNM’s deal with things that CPM’s will never deal with and they need much more education to deal with those things.” Does this mean that CPM’s will never take on cases that develop complications?Like PPH,or birth defects, prolapse, accreta or any of the other disasters that can occur? No, because they are not necessarily apparent until it’s happening. It just means that CPM’s don’t(by your own admission) have the education to deal with them. Also is one class in judgment going to be enough? Really? How about those rogue midwives that take on high risk cases, like breech and twin delivery or VBAC. Do they have the education that a CNM has with dealing with these risks? It seems to me that two factors are being forgotten here and they are the MOTHER AND BABY!!!The midwife is to serve them,not herself,not her ego. It scares me that someone would willingly choose a lesser education to deliver someone’s most precious and vulnerable little one.

    Sunday, September 4, 2011 at 9:03 pm | Permalink
  7. elfanie wrote:

    Tara:
    Glad you have options…although sad that you would choose based on initials as, in my experience of 16 years, that in no way guarantees competency. As for my lack of criticism of midwife{ology} – isn’t my entire blog post a criticism of her harsh viewpoint of the differences between a CNM and CPM…? I’m certainly not going to become personal with this as she absolutely has the right to her opinion (and I said that, too).
    I take on cases that develop complications…I don’t deal with those complications beyond referring to the appropriate care provider. PPH, birth defects, prolapse, accreta….I do believe that most CPMs are educated in these areas (at least the ones that I know – I can’t speak for the entire country). But those things were part of my training!! (remember when I said that we are highly trained and I am good at my job? Those are areas I am trained in…..of course.)
    I NEVER EVER said that we don’t have the education to deal with those things and I am a little resentful of your misrepresentation of what I said (although anyone reading those words has already read my post and knows it’s not true). Please re-read my post because I’m not sure you read it fully rather than skimming it…or if you did, you didn’t read it very carefully.
    Rogue midwives taking on high risk cases….will do that regardless – but judging an entire profession on some rogue people is unproductive. There will always be people who do wrong things…your point? There are anesthesiologists who skim drugs from clients so they can get high while women undergo cesarean surgery with inadaquate anesthesia….does that mean that anesthesiologists are unethical? No…just those select few are. I refuse to accept responsibility for the choices made by anyone other than myself.
    Also…more evidence that you must have skimmed my blog….is that several times I mentioned the mother and baby and safety. If it “scares the hell” out of you that someone would willingly choose a lesser education to deliver someone’s most precious and vulnerable little ones…then please skip the CPM, skip the CNM….hell, skip the OB. Please make sure you go STRAIGHT to a perinatologist! (and I’m happy for you that you have that option)
    Good luck!

    Sunday, September 4, 2011 at 9:15 pm | Permalink
  8. Misha wrote:

    Education is one part of a much bigger picture. I personally would feel much safer in the care of a woman like Stephanie who has passion and a gift, as well as expirence and intelligence to back it up…then in the care of a highly educated person who lacks those qualities. I feel too that as a woman and mother, I have a huge responsibility to know my care provider and her qualifications. I pray I always have the freedom to make my own choice and not be bullied into someone else’s version of safe.

    Sunday, September 4, 2011 at 9:43 pm | Permalink
  9. Erika wrote:

    CPM’s and CNM’s have very different levels of education AND very different scopes of practice. CNM’s are able to induce labor with pharmacologics, collaborate with anesthesiologists to provide epidural anesthesia and then manage a mom on said epidural, prescribe narcotic pain relief, and many other skills that are clearly outside the scope of a CPM. With a greater scope of practice comes greater education; and that is as it should be.

    As a homebirth midwife, my education is commensurate with my scope of practice. This, too, is as it should be. My training includes the management of emergency birth situations such as hemorrhage, shoulder dystocia, resuscitation, retained placenta and other less likely situations. My training also includes the ability to decipher what is normal from what is not. And you know what we do when something isn’t normal? You got it, we transfer care to a CNM or OB because they have additional education AND additional tools at their disposal. I am safe because I stay within my narrower scope of practice.

    Women deserve the right to choose where and with whom they will give birth. When a woman chooses a homebirth, she knows full well that she will not have epidural, narcotic, continuous fetal monitoring or induction at her disposal. And she deserves the right to make that choice.

    Sunday, September 4, 2011 at 9:51 pm | Permalink
  10. Caitlyn wrote:

    I’m not part of the birthing profession, just a first-time mom. I want to thank you for writing this blog, because I believe it shows your commitment to MOTHER AND BABY that you wrote it. Assuming my next pregnancy is low risk, I will be choosing someone (probably a CPM — but not because of the letters) who will support that level of care. I will chose a care provider that I trust will know the limits of their knowledge and skill-set, and have the humbleness to let me know if things were to head in a direction where a different specialty is needed. As a Mother, I also feel as though there is some responsiblity needed on the mother to know, trust, and check-up on knowledge and training and limits when choosing any type of care provider. Moms need to be educated as well. Thanks again, 🙂

    Sunday, September 4, 2011 at 10:28 pm | Permalink
  11. Jen wrote:

    All I know is how I was treated by the CNM’s I’ve been to and the CPM. My 1st baby was under a CNM and after she broke my water she just sat there while the nurse helped me through the pushing phase. SO, for all her education I don’t feel it helped me all that much. With my 2nd baby I had a CNM treat me with disrepect and fearmonger me when I asked what would happen if I didn’t take the Strep-B test (I hadn’t said no, I just asked about possible outcome), yeah I transfered care to a family doctor. My 3rd baby was under the care of a CPM and she supported me through my pregnancy AND my birth, yep even while pushing. I also felt confident she wanted my baby to be as healthy as I wanter her to be, in fact I feel that my baby is a little bit her’s as well and I don’t mind sharing because she did such an amazing job and invested her time and emotions right along with me. My point: ALL that education might not make a difference in the end for a low risk pregnancy!

    Sunday, September 4, 2011 at 10:53 pm | Permalink
  12. Kolleen wrote:

    I agree with what Misha said – for me, it is not the letters that follow the care providers name that will determine whether or not they are someone I would entrust my life and that of my unborn baby with, but it is the level of care, respect and competency she shows me. A woman, like Stephanie, who has the passion for mother, baby, birth and all that goes with it doesn’t just look in a book for education and try to get that certificate to prove she can but she is always researching and growing and seeking to make herself the best she can be at what she does. Not so she can be the best – but so she can provide the most for anyone in her care. I have never used a CNM but I have had “traditional hospital births” and she by far surpasses any of the docs or nurses I dealt with in my previous deliveries in many ways. I mean no deisrespect to my previous docs, and I know that they are needed in some birthing situations – just to say that I felt more cared about, informed and respected by Stephanie.

    Now, I do have a question – and it may be stupid, but I am curious…*could* a CPM also be a CNM or do the two different training focuses compete with or confuse (not sure of the right term here??) the care giver in certain situations? Meaning does it have to be one or the other for any given individual or can the two training/certifications compliment each other within the same individual?? Just curious…

    Sunday, September 4, 2011 at 11:38 pm | Permalink
  13. elfanie wrote:

    Yes, Kolleen…you can be both if you desire and complete the requirements for both….no conflict of interest.

    Sunday, September 4, 2011 at 11:51 pm | Permalink
  14. Elizabeth wrote:

    Midwife-ology is very biased and inaccurate in my opinion. She has a history of misinformation. I think she has good intentions but bites off more than she can chew.

    Sunday, September 4, 2011 at 11:56 pm | Permalink
  15. Diana wrote:

    Hi, Stephanie!

    I’m glad you have chimed in on this situation – I had hoped that you would jump in. I have been following Mrs. Herrera’s blog with great interest for several years, especially lately as she has taken more of a critic’s role within the midwifery community (that’s not a bad thing – critics help us to see our own weaknesses). Her contention seems to be that the level of education for CPMs should be higher to avoid unsafe midwifery. So, do you believe that there are any weaknesses in the current standards for CPMs, even allowing for the fact (as you so ably defended above) that their education level does not need to be that of a CNM? Do you believe that there is/are any skills or knowledge that should be covered by the NARM and aren’t? (Besides the one you listed on risk assessment.) And can you comment upon cases (like the Liz Papparella case) in which it did seem that a midwife (CPM) was practicing really bad midwifery, resulting in the death of a baby? Would stricter exams and/or training prevent this, or are these just (in your opinion) the rare bad apples in the bunch? Is there anything that the CPM community should be doing and isn’t that could prevent bad situations like that one?

    As always, your blog is awesome! Keep it coming!

    Monday, September 5, 2011 at 12:12 am | Permalink
  16. Sara wrote:

    My issue is that a midwife can become a CPM with very few births observed, 25 or 50. BUT there are several complications that happen 1 in 100 or 1 in 200 births. How can a CPM be trained in recognizing these complications if they haven’t seen enough births to see them? Yes, maybe the CPM has read about these complications–but so have I. I hire the midwife because I trust that she has experienced these and automatically and reflexively knows how to react, not because she might have read about it sometime.

    Most of the time birth works well, and in those circumstances anyone or no one can help. But 10 to 15% of the time some kind of complication happens–and that’s when you need someone well trained. 50 births doesn’t cut it if you have some emergency that goes south fast. 50 births is just enough experience to be dangerously over-confident. A midwife need to see more births before you respect (and not necessarily “trust”) birth.

    Homebirth advocates dismiss many complications as “rare.” That’s fine if you are lucky, and not so nice if you are not. Those of us who get unlucky have our birth stories picked apart by natural birth advocates, trying to find how we didn’t “trust birth” enough.

    Monday, September 5, 2011 at 12:30 am | Permalink
  17. elfanie wrote:

    Diana:
    I don’t believe that the level of education for CPM makes them unsafe…although I always think that more education/information/experience can help anyone. Do I think there is a weakness? I think that if you view your CPM designation as a destination, an endpoint, then yes! If you see it as a minimum (which it is supposed to be), then no….as it is, IMO, the minimum skill set and experience someone should have in order to assist birthing families.
    I have opinions on specific cases (like the Papparella case….and others) but I hesitate to express my opinion as I don’t want to pour salt into anyone’s wounds – nor do I feel like my opinion should be shared because I don’t have all of the information. I have read Liz’s birth story of Aquila – but don’t feel ti’s my place to second guess her feelings or experience nor the midwives who were present. I, too, have dealt with a placenta abruption which we transported IMMEDIATELY and resulted in a healthy mom and baby…but could something like that happen to me?
    Sure. Could also happen during labor of someone who is planning a hospital birth. I’m not beyond the reach of bad things, neither can I save every baby – nobody can make that guarantee.
    I do not believe, from reading her blog, that stricter exams or trainings would have necessarily prevented this outcome. (they were, after all, on their way to the hospital) The closest times I’ve come to losing mothers (two of them) was in the days AFTER risking them out and transferring to a hospital (sepsis in one mother after a cesarean, and HELLP syndrome that was left WAY WAY too long – platelets in the 20’s with an active nosebleed at the time she was being prepped for surgery). am I saying that to impune the hospitals? NO I AM NOT! I’m using it as an example that we all do the best we can and even if something happens we might have responded differently to when we are looking back on it…it doesn’t mean we’re incompetent or undereducated or reckless. Sometimes it just means we’re human.

    I would say that the only thing I wish CPM’s were offered easier was more CEU opportunities…and more focus on continuing the learning (maybe if someone needs an incentive they should offer an “CPM-ADV” degree that’s more of the “doctorate” of midwifery….it’s an idea.

    Monday, September 5, 2011 at 12:34 am | Permalink
  18. elfanie wrote:

    Sara: I have been attending births for 16 years and there are still many emergencies that I have never seen or dealt with. I also promise that there are physicians who see things in the course of their practice they have never dealt with before then. You can’t possibly require someone to have experienced EVERYTHING POSSIBLE before they are finished with their training…sometimes didactic knowledge and simulation is all you can possibly do to prepare. Anything else is unrealistic and unfeasible.

    However, you do make me realize that I don’t know this………how many births is a CNM required to have in order to get her degree/designation?

    Monday, September 5, 2011 at 12:55 am | Permalink
  19. The minimum requirement for CPMs is 40 births, 20 as primary attendant and 20 as an “active participant.” Additionally, 10 of those births need to take place outside the hospital and at least 3 must have continuity of care–initial prenatal visit, pregnancy care, and birth (source: NARM CPM Candidate Information Bulletin, Revised March 2011 http://www.narm.org/pdffiles/cib.pdf).

    The minimum requirement for CNMs is 20 births as the primary attendant. There is no specified requirement for additional births attended as an assistant or for out-of-hospital births or continuity of care (source: ACME Criteria for Programmatic Accreditation of Midwifery Education Programs with
    Instructions for Elaboration and Documentation, Revised June 2010.
    http://www.midwife.org/acmedocs/ACME.Programmatic.Criteria.12.09.%206.10.pdf).

    Monday, September 5, 2011 at 2:16 am | Permalink
  20. Reese wrote:

    “It is the midwife who thinks she knows everything and can deal with everything that is dangerous.”

    This post was very timely for me, I’ve been thinking a lot about this lately and I’ve come to the conclusion that there is one huge piece that medicine disregards, and it is it’s major downfall – in my opinion. That is faith. How many times does a doctor tell someone who has suffered from a disease that they will NEVER XYZ? Just today a man shared his story with me about how after surgery where a tumor was removed from his brain, he was left with a totally paralyzed right hand. The doctor told him it would NEVER EVER be restored to use. The man didn’t listen, and kept searching until he found a doctor who would and could work with him. He moved here to AZ and found one who did. The treatment was successful and he now can use his hand. Thank goodness he didn’t listen to the doc who was trying to toss his faith in the can for him. There are just too many things we do not know… we are not just treating physical bodies, but spirits as well. Spirits are powerful to heal, and surprise us in many ways. Talk to anyone practicing medicine – especially around the time of birth or death, and if they’re paying attention they will tell you there is something to spirit.

    You may have less training but the needs for your position are met, and it leaves room for bigger and better tools. You have room to be moved by Spirit. To be inspired to know how to deal with things, to prevent and solve problems… to love your clients, and to cry with them as they bring forth their children, giving them eternal gifts of love and respect that will impact their families forever. I applaud you Stephanie, for I believe you are a true champion in this respect. You preach it, you live it. Many lives are blessed because of it.
    Thank you from the bottom of my heart.

    Thank you for your human honesty, reality, and your heart Stephanie.

    Monday, September 5, 2011 at 2:28 am | Permalink
  21. Tiffany wrote:

    At my school we were required to have 40 births. That’s it. Then you hope your first job has a good orientation for a new grad :p. It’s impossible to come out of school having experienced every emergency but what is drilled into us is how to handle those emergencies should they arise. I experienced pph x 2 as a student. Never had a shoulder dystocia until I was on my own. I handled it, because those steps had been drilled into my head all throughtout my time as a student plus my previous experience as a labor nurse. The downside to all my experience and education? I had to spen d the first 18 months unlearning fear based practice from how I was taught as a labor nurse. And it takes a good 2 years or so before I felt comfortable in my roll.

    Monday, September 5, 2011 at 3:26 am | Permalink
  22. Erika wrote:

    For the record, I am submitting to NARM under their Experience Midwife Portfolio Evaluation Process and am required to document 75 births – not 40. This is also JUST to allow me to take the test. It is only after the portfolio review is done, permission is granted to take the test and the test is passed that the CPM credential is given. There is also a hands on skills component to the test.

    Monday, September 5, 2011 at 7:49 am | Permalink
  23. Sara wrote:

    I’m not expecting CPMs to have seen everything, but I do expect a basic level of competence, and 40 births isn’t it, not when there are emergencies that threaten the lives of your clients that you cannot see with that low level of experience. And only 20 of those that you are the primary on, right? Compared with how many births for a CNM? Hundreds, right, since they are training for more years and in the hospital, where you can handle more than a handful of births per month.

    And if experience makes one “fear-based,” then that makes me want to run faster away from CPMs towards someone who DOES respect what DOES rarely go wrong! Don’t you see how this attitude is disrespectful towards the women and babies who do have complications! It’s like we don’t matter. It’s that lack of experience and respect that directly leads to the home birth tragedies we’ve read so much about lately.

    My perfect faith in how my birth would progress did NOT help me when I had a non-progressing home labor ending in hospital transfer and c-section for true CPD. I’m thankful that my experienced (750 births) CPM insisted on the transfer. I’m deeply deeply thankful that my “rare” condition did not put our lives in immediate danger or require that we get to the hospital fast. Our transfer was very slow. But other low-risk people have rare emergent conditions come up during labor, and if midwives can be certified without having seen and acted appropriately during those emergencies, you are cavalierly putting the lives of those moms and babies at risk.

    You can’t have it both ways. You can’t both “trust birth” and also be looking for complications and appropriately react to them. Many CPMs that advocate not testing for GD, GBS, using non-tested protocol to deal with GBS, etc. How is that looking for complications? In my case, Gloria LeMay says that CPD is a myth. (Poof, magic, I go away!)
    It’s disrespectful and dangerous to the “rare” women and babies who get these complications.

    Monday, September 5, 2011 at 8:38 am | Permalink
  24. Sara wrote:

    Thanks so much for allowing my voice to be heard. Other natural birth websites just delete any contradictory points of view–which also shows a great lack of respect towards the women and babies who circumstance shunts into the “rare” category.

    Monday, September 5, 2011 at 8:40 am | Permalink
  25. Kolleen wrote:

    Sara – I have read your comments and as a complete outsider I have to say I am a little confused? I am not a midwife, nurse or in the medical profession at all so I am coming at this as a total bystander…

    From the comments you made it sounds as though you had a CPM who was wise enough to transfer you when a situation arose that was beyond her scope of care…and it sounds like that transfer (while not the desired path) had a positive outcome…but it also sounds as though you are now not in favor of women having the right to choose a homebirth with a CPM should that be who they desire to have attending their birth? I don’t understand why you would want to take that choice away from other women? I truly mean no disrespect to you at all and I am sure that your unexpected transfer was a traumatising event for you and not how you had hoped things would go – but you were in capable hands that knew when to move you to the next level of care. I don’t think that in this post (or any for that matter) Stephanie is saying it is ALWAYS better to “trust birth” no matter the cost or potential negative outcomes – the only thing I could hear or imagine hearing from Stephanie is to trust that your body does know what to do and she will be there to help you recognize symptoms, concerns or any irregularities that need to be handled differently.

    Again, Sara, I men no disrespect – just trying to understand where you are coming from…

    Monday, September 5, 2011 at 9:49 am | Permalink
  26. Sara wrote:

    Yes, I had a good outcome with a CPM–well, except that she was snotty and treated me like I was unworthy of natural birth, but that’s another story. And it was a huge waste of money since I had to pay her and the hospital. But otherwise we turned out fine, and I’m grateful. 🙂

    My CPM was one of the experienced ones. Recently there was a case in the news about a woman who was in labor for 8 days, resulting in a dead baby. That could have been me with a different, less experienced midwife. I think that the standards for a midwife, with whom we entrust the lives of ourselves and our children, should be higher than they are.

    My outcome turned out to be fine, but I gained respect the “rare.” 40 births is not enough for a CPM to gain the same respect for the rare.

    It’s not a matter of women having the choice. They do have the choice to have anyone or no one attend their births. It’s a matter of midwives representing themselves as safe and able to spot complications when their training does not give them enough experience in real-world complications. It’s that there is no way for a woman to check out the records of a midwife she is hiring, other than to ask and trust the midwife to tell the truth. I think minimum education standards for CPMs should be raised and that women should be able to check the midwife’s records with an independent licensing agency.

    Monday, September 5, 2011 at 10:13 am | Permalink
  27. elfanie wrote:

    Sara:
    But, like Tiffany pointed out below…..a CPM’s birth requirements are the same as a CNM’s birth requirements? (mine were slightly higher since I went for my LM before I went for CPM….but not appreciably so)
    So you think that both CPM’s and CNM’s are both unprepared and unsafe to spot complications? (or OB’s for that matter, since they are trained the same way to diagnose complications as we are….)

    Monday, September 5, 2011 at 11:35 am | Permalink
  28. Sara wrote:

    CNMs and CPMs have the same # of birth required? Really? Did Tiffany say that?

    Monday, September 5, 2011 at 12:12 pm | Permalink
  29. elfanie wrote:

    Tiffany said: “At my school we were required to have 40 births.”
    Amy said: “The minimum requirement for CNMs is 20 births as the primary attendant. There is no specified requirement for additional births attended as an assistant or for out-of-hospital births or continuity of care (source: ACME Criteria for Programmatic Accreditation of Midwifery Education Programs with
    Instructions for Elaboration and Documentation, Revised June 2010.
    http://www.midwife.org/acmedocs/ACME.Programmatic.Criteria.12.09.%206.10.pdf).”

    In my state the minimum number of births required is 50 (although most everyone gets much more than that because 25 of those have to be primary under supervision which are harder to get than you think). CPM’s minimum requirement is 40 – with 20 of those as primary attendant.

    Monday, September 5, 2011 at 12:50 pm | Permalink
  30. Jenny wrote:

    I think we’re also missing a point here.. CNM’s are trained more in PHARMACOLOGY… not birth per se. They are trained in INTERVENTIONS and handling those interventions since they may affect how a birth progresses. Birth, when it veers away from natural and into managed waters does carry more risk, and different management. CNM’s had better be more trained in those processes than a CPM. As I understand it, CPM’s are trained to handle low risk, natural birth. Yes, emergencies happen. Yes problems come up. They can also come up in the hosital. But moms and babies can die in either situation… that is a risk of pregnancy and birth. Period. A hospital is not necessarily safer because there is more training. More training in what can go wrong due to interventions is very different than more training (and experience) in actual births. Personally, I would prefer a CPM who makes it her business to read, learn, and share with other midwives and their experiences than the CNM who is learning about more drugs, more surgeries and more managed labor care. You can’t experience everything. So surround yourself with others and learn from everyone.

    Monday, September 5, 2011 at 12:53 pm | Permalink
  31. Kolleen wrote:

    Sara,
    Thak you for the clarification. I think it sucks that you were treated poorly by your midwife – that. to me, is the worst feeling in the world.

    Personally, I think that whomever you choose as your doctor or midwife – CNM or CPM is a very personal thing and it would bother me more to be treated poorly by someone I had chosen and trusted than whatever letters followed their name.

    I agree that anyone offering to care for another individual – especially 2 in a birthing situation – should be highly educated. I think that this blog did a great job in showing the different types of education there are to serve different purposes and that’s what it seemed meant to do. As was stated in the blog (or possibly the comments after?) it was not a comparison of which was better necessarily – CNM or CPM just clarifying the differences. For me, I know that a CNM has a different set of tools taught to them and that they should be well educated – but those letters after their name would not be a deciding factor for me. In choosing any care provider for any medical needs I have I want to find someone who is passionate about what they do, that looks at my needs not as a job but as a joy. Somone that loves every joyous aspect of what they do and is continually seeking to further their knowledge on that subject – not because they have to but because they want to…that is the difference (to me) and I think that shines through a person whether they want it to or not. Can’t be faked or made up – passion is a driving force and it stands out.

    Again, thank you for your clarification and I am sorry your midwife was unkind to you.

    Monday, September 5, 2011 at 1:02 pm | Permalink
  32. liz p wrote:

    the midwife responsible for my daughter’s death was licensed and was a CPM . so no, “most” bad midwives are not lay midwives- actually of all the homebirth loss parents i have met (around 20 so far) most had NARM accredited CPMs at the wheel of their baby’s deaths.

    Monday, September 5, 2011 at 2:29 pm | Permalink
  33. elfanie wrote:

    And if I pull out 1000 babies’ names who have died in hospital births….would that prove the incompetence of hospitals or OB’s? of course not!!! It would prove a couple of possibilities…
    1. they had an incompetent care provider (no matter what the initials after their name or years of experience)
    2. they had a care provider who made human errors in judgment despite being competent
    3. their baby died despite competent care and there being no clear choice that could have been made differently.

    I am sorry for your loss…and I’m not in a position to judge which of the 3 options occurred in your specific case. However, your unfortunate experience, no matter how tragic, doesn’t illustrate or prove any point. The plural of anecdote is not data which is why quality research is so very important – a great many things that we might THINK often turn out to not be true (wouldn’t you think that continuously monitoring of the baby would help save babies? Yet every single solitary study has shown that not to be the case.)
    I also think it’s a shame we have to speak of groups as a whole – rather than the individual. Just because that doctor is disrespectful and dangerous doesn’t make all doctors that way…same with midwives – all midwives, regardless of credentials.

    Monday, September 5, 2011 at 3:10 pm | Permalink
  34. Tiffany wrote:

    Jenny – As A CNM, I can assure you that we aren’t learning primarily about surgeries, drugs, etc. We dont learn about surgeries since we don’t do them. We have extensive training in normal, low-risk birth. Because thats our scope of practice. We also learn about complications and the other medical stuff but we are taught first and foremost that birth is normal and doesn’t need a bunch if interventions. I’m not a mini-doctor and that is kinda how your response came across. I am a midwife.

    Sara – yes, 20 births for minimum competency for accreditited schools. My school required 40. I don’t think it’s the number of births that truly matters. I tell patients my 11-year-old can catch a baby when things are going well. It’s when red flags or complications arise that you need me. So I definitely believe it’s important that training be provided to handle emergencies until a higher level of provider can take over. I can’t speak for CPMs because I don’t know what training occurs, but I was very well trained in what to do and the red flags to watch for. As a new CNM, I was competent and safe. I asked a lot of questions, checked out concerns sooner rather than later with other providers. As I gained experience, my level of comfort expanded. And that would hold true for any provider. Experience teaches.

    I’m a fan of licensing, certifications, etc. for appropriate education and training. I’m a fan of homebirth and LMs, CPMs. Do CPMs have core competencies and are requirements standardized across the country (as we CNMs are). Who does NARM oversee?

    Monday, September 5, 2011 at 5:48 pm | Permalink
  35. elfanie wrote:

    Yes, Tiffany…CPMs have core competencies as set forth by MANA: http://mana.org/manacore.html
    The NARM CPM certification *IS* what standardizes midwives across the country…..before CPMs there was no standardizations across the country for non-nurse midwives.

    Monday, September 5, 2011 at 10:25 pm | Permalink
  36. Margaret CNM wrote:

    This is a coherent and well-reasoned approach to the CNM/CPM debate and I am so glad a friend linked me to it on Facebook. You can expect quite a bit of traffic to your site as this gets out in the blogosphere – precisely because it goes directly to the education question and you don’t pull your punches on saying the two educational paths are not equivalent.

    I believe that what midwifery advocates have been trying to avoid is the division into two tiers of our one profession. In other countries indigenous women who attend births without having the equivalent of a university level education are referred to as traditional birth attendants. Internationally, the title of Midwife denotes a common standard of training. That is not the case here in the US, where the title MIDWIFE is used quite broadly. The letters that would help clarify which “type” pf midiwfe – CPM, LM, CNM and CM – are like those confusing coding modifiers we try to deal with in billing :-). They require considerable research or inside knowledge to interpret and are confusing for the average family just looking for a competent care provider.

    Tuesday, September 6, 2011 at 12:28 am | Permalink
  37. Jenny wrote:

    Tiffany: I’m sorry, in re-reading my comment, the caps emphasized poorly what I was trying to express in what is different between the levels of experience beyond low-risk natural birth. Both CNM and CPM should have beyond adequate training for low risk natural birth. What I was trying to convey was that a CNM, when working within hospital protocols, is going to receive more experience (and hopefully training) to handle the interventions and pharmacological aspects that would not have any place in a home birth with the CPM. (Additionally, being a part of the hospital staff, experience dealing with the surgical conditions when c-sections occur is what I was referring to with surgery, I did not mean to imply that CNM’s were doing them) :-p

    Tuesday, September 6, 2011 at 1:55 am | Permalink
  38. Bridget LM, CPM wrote:

    I do free consultations with my potential clients. I do not charge them to sit down and talk to me for an hour about homebirth/midwives.

    Up front I tell them that this is an interview process on both sides, I do not take moms that I feel are poor candidates for homebirth. I’m also not out to “sell” anyone on homebirth (which I make clear) and after going over various info we go step-by-step through my informed consent. It is clear about my education, years of experience, situations I’ve experienced, what I feel is low/high risk, cases that other midwives may take and I won’t, risks of out of hospital birth vs. in (and links to studies comparing them), and so on. It is the Big Ugly paper that talks about all of the Big Uglies.

    I also encourage them to ask the hard questions and don’t be afraid that I’ll be offended. At the 36 week visit I do the same, they invite anyone they want to that one and they’re welcome (encouraged!) to ask lots of questions.

    I think transparency is important. The people who choose homebirth tend to be different from even those who choose to go with a birth center. I’ve had a few Dads who seemed committed to NOT hiring me after we went through the informed consent and then a few days later I get a call and we have another conversation. I’ve had a few moms who seem uncomfortable when I talk about things like shoulder dystocia or NRP stats because they’re afraid their partner will back out.. but these things are important and imho part of good midwifery care.

    I feel confident about my abilities to be a good midwife. I will never been a rootin-tootin cowboy midwife (nor do I want to be – though would LOVE to volunteer in third world countries later). I’m conservative compared to some others out there and while I trust that most low risk women can have an uneventful birth at home, I know that it can turn on a dime and being prepared is important.

    I also trust people to make decisions for themselves. So whether it’s someone going unassisted or another scheduling a c-section. It’s not my birth and it’s not my right to tell them how they “should” be doing it. As a midwife though, it is my right to define the moms I will (and will NOT) care for and practice accordingly. If you have a McD’s diet, only walk to the mailbox, and are so anti-hospital that I worry you wouldn’t transport if I wanted you to.. I’ll help you find the right care provider, it’s not me.

    Also, if you doubt whether a CPM is skilled/etc enough to be your midwife.. then perhaps a CNM *is* your best option? Listen to those little voices in you and trust them!

    For many women my style of care is exactly what they want and we manage to find each other. I provide in-home care so my clients don’t have to find babysitters and the dogs get used to the midwife. I don’t keep an office because my goal is to keep my costs low enough that I don’t have to turn people away because of $$. I also keep my client load low enough that I’m not a stressed out crazy person. 🙂

    People will always have lots and lots of opinions about everything.. as long as we respect others to make their educated decisions, then it all goes well. All of the midwives I have practiced with have an informed consent so parents know exactly what they’re getting with a CPM.

    Tuesday, September 6, 2011 at 9:16 am | Permalink
  39. Bridget LM, CPM wrote:

    P.S. On the subject of # of births.. I had WAY more (WAAAAAY more!!) than 40 by the time I applied to sit for NARM. I think most other applications do as well. I had lots of hospital experience as a doula, lots of observes before being hands on and then lots more manages than I truly needed. I’d be surprised to find many CPMs that had *just* that number specified by NARM. In my experience most had been to/assisted/etc easily 100+

    Tuesday, September 6, 2011 at 9:24 am | Permalink
  40. Tiffany wrote:

    Jenny – thanks for the clarifications 🙂

    Steph – thanks for the info. Was looking around a bit but wasn’t sure where to look for information on the training process. The core competencies seem pretty comprehensive!

    Tuesday, September 6, 2011 at 10:54 am | Permalink
  41. Angela Ruiz wrote:

    I just wanted to say that this is an awesome post, but the conversation following was was even better! I, being one of Stephanie’s high risk transfers and also being cared for by a CNM with a prior pregnancy makes me “have” to chime in!
    I won’t go into the specifics on my daughter’s birth which was cared for with a CNM but I will just say that it was a perfectly healthy pregnancy and birth. I was left laboring on my back and someone I had met only one time before delivered me. It was horribly painful and I was left feeling like “this was a midwife?”
    My pregnancy with my last seemed to be great! I
    Was so excited to be having a home birth with Stephanie. And that statement alone should show you the respect I hold for her. I had borderline placenta pre via but after many ultrasounds and when I say many I mean 6! By the 36th week I had my last one and my placenta had moved up and we were all clear for a home birth. Well about 6 weeks later(my babies like it inside and dont want to come out) I went into labor. This labor was different I started bleeding! It had been 7 years since my last birth and didn’t know if this was normal. Called Stephanie and this was on a Saturday morning and she answered not a damn machine. We went over what’s normal bleeding and what’s not for a mother with three previous births and so on. I hung up went about my day then an hour later my bleeding picked up, I called Stephanie at that time she wanted to know if I wanted her to come over to evaluate. I still wasn’t sure but she said she was on her way.

    Well the bleeding got worse and when Stephanie arrived it was immediate transport. No ambulance but we had to Roll! I was scared at this point and very upset and worried that we wouldn’t get there in time. She stayed with me and I mean stayed with me not as a doula, and more than a midwife she was my CAREGIVER. She explained through every step of the process what “they” were doing to me because well, “they” weren’t. I was given three IV’s and was being prepped for surgery, an emergency c-section. I have never had surgery before, of any kind and only been in the hospital three times prior, yep for my previous births. STephanie was the owne who was there calming me down and assuring everything was fine.

    Well the girl who drew my blood, took it from a site below one of my many IV’s. Thus screwing up my blood count….yeah, bad they gave me three units of unnecessary blood, the whole while Stephanie was telling them to re-draw they were wrong about the count. Well the surgery went fine and I had a healthy, thriving 9.1 pound baby boy!
    Stephanie was there during the surgery in the waiting room and until I was awake in recovery and called me afterwards several times. Even with this beyond traumatic birth I have to say if you wouldn’t want a CPM at your birth that’s your choice but my choice was awesome. Any of this could’ve happened at a hospital but I learned that just because you’re an OB or a CNM doesn’t make you qualified to be a CAREGiVER. That’s what’s missing from a lot of birth providers! I wouldnt trade my experience for anything I now will look for a CAREPROVIDER like STephanie for every aspect of my medical care. It’s not going to be easy. But I know will expect to be treated like she treated us, you don’t know what you’re missing. She had the medical knowledge to know when it was an emergency, treated it with the utmost respect and acted accordingly, all along providing care and comfort. I was taken care of and treated medically by her, and what’s funny is though even my birth with my CNM was uncomplicated I was never “cared for.”
    I had to speak up for a woman who showed me respect I should have been given with every other birth!

    Sorry for any errors my iPad won’t let me scroll up.

    Sunday, September 11, 2011 at 2:03 pm | Permalink
  42. Lorrie wrote:

    Well I am in school heading to nurse midwifery and had originally done about half of the PEP requirements for a CPM. My reason for changing had to do with my personal experience of preterm labor and having to beg a CNM (whom I now work for :-D!) to help me with meds to stop the infection and contractions because my CPM could not. I did not want a preterm hospital birth again and were it not for the CNMs willingness to help I would have. I decided that I wanted to have the maximum number of skills/tools to help my own clients achieve their out of hospital birth desires. Then I saw my own CPM (whom I love dearly) get a pair of silver bracelets and a lot of heartache and I knew I had made the right choice for me even though it will mean four more years of delay to reach my goal.

    Saturday, September 17, 2011 at 11:34 am | Permalink
  43. Nancy CNM wrote:

    I just want to say thanks for a great post and thanks to everyone who has commented as well.

    Wednesday, October 19, 2011 at 3:02 am | Permalink
  44. L&D RN wrote:

    I have no problems with CPMs and CNMs having different scopes of practice and different educational backgrounds, but I do wish there was a standardized form of education for CPMs, much like RNs (it could be a degree program similar to RNs, less/different than CNMs). I know that if that was a respected, viable option I would have gone that route. It is quite possible through the PEP process and even some of the CPM training programs to have an inadequate background. One thing that I find CPMs are often lacking in is communication with other HCPs in the event of a transfer of care, and also charting. These are important bits to be considered a knowledgeable professional and be respected in the community.

    Wednesday, October 19, 2011 at 5:49 pm | Permalink
  45. Annie wrote:

    Thank you for this post. So far, the most level-headed discussion regarding the reasons for the difference between the CPM and CNM credentials.

    Like Lorrie, I was more than halfway through my PEP application for NARM and have now chosen to work towards my CNM. I chose this route to have both the highest skill set possible and the ability to work anywhere in the world among other things. I like that I will have experience from each path under my belt.

    Wednesday, October 19, 2011 at 8:21 pm | Permalink
  46. Lorrie wrote:

    To the comment above, most every parent who has lost a baby in the hospital has lost one at the hands of an OB. That does not mean that all OBs are bad or that they all cause too much infant death. Babies die. My own died in a hospital, but I don’t blame anyone. I am so grateful that when I did my CPM training time, I was with the Amish community. I learned a lot about accepting God’s will and understanding that not all babies will survive no matter what setting or provider you use. I don’t think going now for my CNM will make me immune to the possibility of tragedy when I practice. It just means that I have great diagnostic tools and meds at my disposal to minimize certain types of risk. Some types of risk can never be eliminated by provider, setting or training. I like what the one person said about how we didn’t get to be 40th in the world because of CPMs and/or homebirth. 1% of all births are home births. Clearly “we” are not the real problem…

    Thursday, February 9, 2012 at 3:13 pm | Permalink
  47. CNM student wrote:

    I know this is an old post….but I just had to comment on the required number of births required by CPMs vs. CNMs. In order to enter my CNM program I had to have a minimum of 2years experience in L&D. TWO YEARS on an labor unit is equivalent to a lot of birth experience prior to even entering the program..in my case it equals out to be about 306 births… Quite a bit more than “40”

    Saturday, February 27, 2016 at 5:26 pm | Permalink

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