Articles of interest to Midwives

The entire text of ACNM's Issue Brief (hot linked) is provided. This statement has given rise to many comments and rumors over various e-mail lists, as well as responses to inaccurate statements contained in the document. Please take the time to read this message so you can be clear on the facts and accurate when you are discussing direct entry midwifery and the CPM credential.

Susan Hodges, Citzens for Midwifery


Subject: response to ACNM ISSUE BRIEF

Grassroots Message for 11/13/97

In response to the many e-mails and rumors concerning the September 1997ACNM Issue Brief titled "Recent Developments in Midwifery Certification in the U.S.," some members of the Grassroots Network (a private e-mail list of midwifery advocates) have compiled a list of factual errors and misleading statements regarding MANA, NARM, MEAC and the CPM credential in this document. MANA, MEAC and NARM will each be sending a formal written responseto the Issue Brief to the ACNM, as is appropriate.

This grassroots message is an effort to set the record straight regarding these inaccuracies. It is also an attempt to begin the kind of communication that is necessary for fostering respect and cooperation among midwives even when they disagree on important items. Please feel free to pass this message along, particularly to anyone who has received the ACNM Issue Brief titled "Recent Developments in Midwifery Certification in the U.S."

A list of inaccurate items, by section, with corrected information, follows, with the full text of the ACNM's Issue Brief (as received by e-mail, and believed to be a true copy of the original document) included at the end for reference.

1. The ACNM Credentialing Process

The Issue Brief states that "The ACNM Certification Council (ACC) has openedits national certification exam to graduates of midwifery education programs approved by our Division of Accreditation (DOA), which in turn is approved as an accrediting agency by the U.S. Department of Education." While it is true that the DOA is an approved accrediting agency for nurse-midwifery education programs, the above statement fails to disclose the fact that theDOA has an application pending, but has not been approved to expand its scope of recognition to include non nurse-midwifery education programs.

In other words, the DOA has not received USDE approval to accredit the one and only CM program in the U.S. Therefore the downstate CM program does not have the same accreditation standing with the DOA as other ACNM nurse-midwifery programs. The Issue Brief statement could be corrected by adding the following sentence, which is taken verbatim from the CM column of the jointly-approved CM/CPM comparison chart: "An application for expansionof the DOA's scope of recognition to include midwifery education programs is anticipated in 1998."

2. The Home Birth Option

The Issue Brief states that "Nevertheless, ACNM continues to support education and practice by CNMs and CMs in all settings and recently published a Handbook on Home Birth Practices to guide our students and members on safe home birth practices." While the ACNM may support practice by CNMs and CMs in home or out-of-hospital settings, there are no CNM or CM educational programs that require, and we are unaware of any that include, a home-birth clinical component. In fact, completion of a DOA accredited educational program by itself does not prepare graduates to attend homebirths because they have had none of the specialized training or clinical experience necessary to effectively and responsibly practice in that setting. The statement would be accurate if the words "education and" were omitted from the above sentence.

3. Standards for Practice

"We want to make sure that women have the assurance that all practitionerswho call themselves midwives meet minimum standards of academic and clinical preparation consistent with the World Health Organization definition." This statement implies that only ACNM certified midwives conform to the WHO definition of midwives. However, the WHO is not specific about minimum standards of academic and clinical preparation. Rather, as stated in your Issue Brief on page 2, "the World Health Organization (WHO) has defined a midwife as a person who has completed a prescribed course of studies in aneducation program that is fully recognized in that country, and acquired therequisite qualifications to be legally licensed to practice midwifery." By that definition, LMs and many CPMs clearly qualify. They have completed a recognized and approved course of education and training which is the basis for their licensure and/or certification.

The WHO definition of midwifery was never intended to limit recognition only to those midwives who complete a formal, prescribed course of studies resulting in a college degree. There are many midwifery credentials throughout the world and many fine, competent practitioners who are not nurse-midwives, have not received their midwifery education and training in affiliation with a degree-granting institution,and who practice primarily in out-of-hospital settings, but who fit the WHO definition. This sentence should be either omitted or followed by a second sentence explaining that ACNM-credentialed midwives are not the only ones who meet the WHO definition.

4. Other Midwifery Credentials

This entire section is completely inaccurate and should be omitted or re-written.

A) "The Midwives Alliance of North America (MANA), another association ofmidwives, has created its own credential, the certified professional midwife (CPM)." The inaccurate information in this sentence has been published by the ACNM on more than one occasion and will hopefully be clarified by thefacts stated below.

1) MANA is an umbrella midwifery organization that represents a variety of midwives, including a substantial number of CNMs. It did not create its own credential, and has no plans in the immediate future to do so.

2) NARM, a wholly separate entity, created the Certified Professional Midwife (CPM) credential. NARM is the sole certifying body for the CPM.

3) While most CPMs belong to the Midwives Alliance of North America, MANA is not, and has never claimed to be, the trade association for CPMs. In fact, MANA is not a trade association for any single category of midwife. As noted above, it was formed to embrace all midwives and support the practiceof midwifery, whether by CNMs, CMs, CPMs, direct-entry midwives, indigenous midwives, Canadian midwives, Mexican midwives, etc.

B) "MANA has also created an accrediting body, the Midwifery Education and Accreditation Council (MEAC), for midwifery education programs." Again,MANA did not create MEAC. MEAC is a wholly separate entity formed by midwives interested in establishing an accreditation process for direct-entry midwifery education programs.

C) "With MANA's support, the North American Registry of Midwives (NARM) has been established as a certifying body to administer an exam for persons wishing to be certified by NARM as midwives." Not true. Here are the actual history and facts:

1) At one time NARM administered a written exam and midwives who passed that exam were listed on a registry. However, NARM never issued certifications based on this exam.

2) In 1995 NARM hired a professional testing company which designed andconducted a thorough Job Analysis, revised NARM's written exam, added askills assessment component, and created an extensive application and documentation process. Candidates who complete and pass all aspects of theprocess are awarded the Certified Professional Midwife (CPM) credential by NARM.

3) Finally, NARM certifies CPMs, NOT midwives.

D) "NARM permits experienced midwives who have not completed a MEAC accredited education program to take its exam." This is entirely misguided on several counts.

1) While NARM works closely with MEAC, and all graduates of MEAC accredited programs are prepared to sit the NARM exam, NARM was not created tocredential only graduates from MEAC accredited programs. While the ACNM maintains and is familiar with the one-to-one model that characterizes degree-based education (graduates from DOA approved programs sit the ACCexam in order to receive the CNM credential), it is not the only model andis not applicable to NARM's competency-based, many-to-one model (graduates from many educational routes, who meet NARM requirements, sit the NARM exam in order to receive the CPM credential).

2) NARM's mission is to validate the knowledge, skills and experience ofmidwives who have received their education and clinical experience in avariety of settings. The term for this type of education is competency-based education. It has an underlying philosophy which is fundamentally different from that of university-based education. However, it is not considered second-class or inferior by professional educators, although the ACNM is guilty of implying this in its references to NARM andthe CPM credential.

A copy of Dr. Catri's excellent summary of competency-based education is available from NARM, as well as her review of the NARM's CPM process. Dr. Mahlman's review of NARM's exam process is also available from NARM.

4) A summary of certification and education requirements as stated in the CM/CPM comparison chart, which was approved by both NARM and ACNM in July, 1997, is listed here:


Certification and Education Requirements for the CPM Seven categories that require various combinations of the NARM writtenexam (W), skills exam (S), and documentation (D). Entry Level--W,S,D; MEACAccredited Schools--W,S; CNMs--D of 10 out-of-hospital birth; State Licensedor Certified Midwives--varies from state-to-state, but all areaspre-approved must be professionally equated with NARM exams; GrandMidwife--W,D; Internationally Educated--W,S,D; Special--W,S,D. Education content must incorporate: MANA Core Competencies, NARM Task List, NARM Skills List, NARM Examination Bibliography.* Accept MEAC accredited programs, apprenticeship, self-study, classroom learning or any combination of the above that prepare the student formastery and validation of midwifery knowledge, skills, and experience.


This approved language, which the ACNM was certainly aware of when preparing this Issue Brief, was apparently ignored for the above section. Note that NARM "accepts MEAC accredited programs" as well as other educational programs, including ACC certification. Note further that the experienced midwife category, a temporary, start-up category, was already past when the comparison chart was prepared, and had no relation to MEAC accredited education programs.

E) "Potentially then, there could be many categories of midwives practicing in a particular state: CNMs, CMs, CPMs, midwives with a state credential,and lay midwives without formal credentials." The above sentence is correctexcept in reference to states which have their own licensure procedure.These states confer licenses, not credentials, and these midwives are often referred to as Licensed Midwives. The licenses are generally recognizedonly by the state issuing the license.

F) "Clearly, this may cause confusion for consumers, health care institutions and state regulators alike." This sentence is particularly offensive to women and consumers because it implies that the average consumer is not capable of evaluating a variety of practitioners. The only confusion for consumers, policy makers, and health care institutions occurs when they must sort out inaccuracies and mis-information, such as those presented in this Issue Brief. 1) CNMs, CMs, LMs, and CPMs have different acronyms, and represent practitioners with different educational backgrounds, underlying philosophies, qualifications, skills, and practice settings. 2) Any person of average intelligence is capable of discerning the difference between these practitioners and making a decision based on his/her needs.

3) A general public that is capable of discerning the difference and appropriateness of health care providers as diverse as Medical Doctor (MD), Physicians Assistant (PA), Registered Nurse (RN), Licensed Nurse (LN), Certified Nurse Practitioner (C.P.), Doctor of Osteopathy (DO), Psychiatrist, Psychologist, Masters of Social Work (M.S.W.), and the list goes on, is certainly capable of evaluating the strengths and weaknesses of each of the current midwifery credentials—CNM, CPM, and CM. 4) As for health care institutions and state regulators, they are in the business of evaluating these credentials and making health policy decisions regarding practice by each. While these decision makers may favor one practitioner over another, it is doubtful that they are confused once presented with factual information concerning each credential. Moreover, itis their job to learn the differences between each of these practitioners, much the same as they must distinguish among all the other health care professionals such as those listed above.

This section (Other Midwifery Credentials) should either be omitted or completely re-written to provide correct information. Furthermore, any re-write should be submitted to the identified entities to confirm accuracy.

The intent of this e-mail message in its entirety is to encourage better communication between midwifery organizations to insure that consumers, midwives, policy makers, and health care institutions do get accurate information and facts regarding midwifery. Women and families benefit most when they can freely choose from a variety of birth settings and maternal care practitioners trained to practice in those settings. There is no one setting or practitioner that is best for every woman.