“Sorry again it won't let me post! That would be interesting, and necessary to do an extensive scientific study. I hope that MANA will one day release their 20yr study on the data that they have collected. I do want to point out again, the only DEM credential legal in CO is the CPM. So we have CNMs and CPMs only in the state. The data collected by the state via DORA includes *only* CPMs. You can contact DORA to verify. The CMA out here would never include illegal midwives in their stats, though again the CPM is the ONLY DEM credential in the state. All the best!”
“For some reason they won't let me post below. I am leaving for the weekend in a bit, but I do not view them as well educated colleagues (CNMs and CMs are different breed). I don't think MEAC has standards of education, and the PEP process, like it's students, is often abused in training certified professional midwives. I'm sorry that you think the data is insignificant. I think you would benefit from reaching out to Judith directly and reading some of the articles she has written. It's quite compelling. AGAIN, I don't think all CPMs provide substandard care, but there is a lot to be addressed. I also don't think studies where they are within a European context, or studies that only use European midwives (who are educated very differently and practice much more integrative way than CPMs) is apples to apples. I don't think we are going to agree, but I wish you well.”
“Also, I want to point out that I am pro-HB, pro-united midwifery, and see the division between credentials as due to medicine's disenfranchisement. I have gone partially through the CPM route, and now into the CNM route. I work with an OOH midwife, and actually know a thing or two about what I am talking about. It's easy to brush someone off who questions your beliefs as an Amy supporter. My basis for the stats, is I think we need US collected data, and since MANA isn't releasing theirs, what we have to go on is state stats. Those are usually who are licensed by the state, which in most cases (like CO) is CPM. It's not as flimsy as you think. I live here btw. It's not something I grabbed from a blog.”
highstreet on Aug 24, 2013 at 12:45:46
“I understand where you are coming from, and the concerns you have. But I think you would do well to look at the scientific data, or have your state commission some scientific studies of their own listing educational levels of their CPMs and DEMs, and classify the causes of death in more detail. Have a good day. I wish you the best in your practice.”
“Because the threads are so long ago a few things:
1) I am not an Amy follower, nor am I citing her research. It's insulting to think you cannot access or be privy to stat states without her blog. Believe it or not, a number of us actually feel the way we do without having to read her.
2) I understand the differences between a CPM and a DEM. State stats where I live are only for CPMs, and are still very poor. DORA does not collect data from DEMs who are not licensed, which leaves only the CPM at the moment.
3) I said the "babies die in hospitals too" comment, bc you were pointing out Ina May's campaign when I brought up some of the stats that have been concerning.
For someone who talks about being respectful and not wanting to argue, and whom I was having what I believed to be an interesting and lively conversation it is certainly interesting that with everything I pointed out, you choose to lump me in that category and dismiss everything. I am obviously pro-HB, pro-united midwifery, and believe medicine disenfranchised midwifery. Your argument doesn't even make sense. I am not some anti-midwifery, anti-HM crusader who just showed up. I actually know a thing or two.”
Wait and Be Strong on Aug 24, 2013 at 15:14:42
“Guest0609, I just would like to say that I do respect you. We agree with each other on more than we disagree. I did enjoy our conversation. I respect your passion for midwifery and your dedication to improving outcomes for birth and raising standards in OOH birth. I don't expect other people to assume my point of view; each person is different, unique and has something to offer. I wish you many blessings and success on your midwifery journey. Keep your passion!”
Wait and Be Strong on Aug 24, 2013 at 14:58:00
“1) I said, "“I believe that Guest0609 is citing information quoted by Amy Tuteur, MD". Once we started conversing, I realized you were not a follower of "Dr. Amy". Coincidence that she was just on Huff PostLive. I apologize for that assumption.
(2011)The Center for Health Statistics shall collect and report data on birth and fetal death outcomes occurring in this state, including intrapartum and neonatal transfers to hospital care from another birthing facility, hospital or other location. The center shall report the data by attendant type. The report shall distinguish outcomes between licensed direct entry midwives and direct entry midwives who are not licensed under ORS.
3) I said, "We do agree that homebirth needs to be safer...Check out Ina May Gaskin on Maternal Mortality...Babies who die several days after an injurious birth may not be included in statistics in hospital." I was pointing out that the hospital stats may not be accurate because there is no federal reporting system that hospitals are required to adhere to and state systems are not regulated and guidelines and definitions vary from state to state. I do believe that this is a valid point to bring up concerning statistics. If a baby is resuscitated, placed on a ventilator and dies later, it is not counted as an IP death. Ina May Gaskin has a lot information concerning how statistics are reported.”
“No I am *not* citing Amy Tuteur btw. I live in CO, and know what is going on here. It is easy to assume anyone who does not agree with CPM or the state stats is an Amy follower, but believe it or not there are those that actually exist and DO understand DEM and CPM difference.”
“There is nothing apples to apples about those studies, and neither Judith nor Colorado are looking at lay midwives. Judith, an avid CPM supporter would not use them to collect birth center stats, and Colorado only has CPMs as DEMs. No lay practitioner is reporting outcomes to their state. You do midwifery and mother's and babies a disservice, but justifying the use of a subpar form of midwifery. I really have to be done with this thread now, but thank you for your comments.”
highstreet on Aug 24, 2013 at 12:38:54
“Then just use peer reviewed scientific studies. Stop trying to use raw data to impugn well educated colleagues. ”
“Since it won't let me post again after your links (arghhh!!), it appears some of these studies include Europe, Canada and UK? I am *not* in any way against HB. Those midwives are significantly different than CPMs, and all have university level education and are highly integrated in their medical system. I am not arguing against HB, I would like on myself with my OOH CNM. I just believe that the CPM credential does not a) adequately protect students and ensure they have the training they need (even MEAC standards vary from school to school) and b) side step major issue by romanticizing their credential and what it actually is. I have seen it, and known it time and again. I think that medicine divided midwifery at the turn of the center, ironically when they abolished physicians who trained directly through apprenticeship to gain consumer trust. The "diversity" we see in midwifery, and the roots of the CPM as an outgrowth of the "knock em out, drag em out" era of the mid-century, comes from this disenfranchisement. However, to truly empower midwives and heal the maternity system, I believe we need to follow an example like NZ, and form one integrated credential (like the CM) which is high educated, trained, competent in all settings, and integrated.”
highstreet on Aug 24, 2013 at 08:33:32
“Yes, and some of them specifically used CPMs from the US. Thus you can see that the peer reviewed data across all those spectrums is comparable, even to hospitals. These are quite a bit more reliable than raw data collected by a state agency without any specifics.
If you are actually interested in seeing an apples to apples comparison, then encourage your state to fund some peer reviewed studies on CPMs only. Otherwise, I think you do your fellow midwives a disservice by simply lumping them in with lay practitioners who haven't had any educational instruction.”
“Won't let me post below for some reason, but no I do understand the difference between CPMs and DEMs (which in OR could mean a lot of things, and nationwide also include the CM. Which I love.). If a CPM attends a MEAC school she/he does meet ICM standards, but the PEP process (originally developed to grandfather in midwives who had been traditionally attending births for a number of years and had valuable experience) does not meet these same standards. Part of the issue, as I see it, is that many women are choosing the CPM pathway by way of PEP over MEAC. Because birth is a normal physiological process, it is hard to see the number of emergent situations nearly enough working for a HB practice (even a busy one). Also, CO midwives are either CNM or CPM (I am from CO). DEMs, such as in OR, are not legal and would not report outcomes to DORA.”
“Also, uniting as a credential doesn't have to mean losing diversity. Look at every other country with midwives in the first world. Our shared history can deepen the level of knowledge and power within a singular credential. What do CPMs lose when they don't have access to the world of education that AMCB midwives do? What do CNMs lose without access to HB? Without a singular credential, midwifery in America will continue to be disenfranchised and disempowered. Doctor's recognized this within their own profession at the turn of the century, and eventually helped to push midwives out of birth for awhile. The division in US midwifery has it roots in medicine's disempowerment of it, it's not a symbol of diversity.”
Wait and Be Strong on Aug 23, 2013 at 23:55:22
“Midwives were always independent and local to their community.
It is time to stop arguing and go to sleep. Have a good night!”
“Saw the comment below, and no I am not mad at all. I agree that there are some fabulous traditional midwives around the world. I have been fortunate enough to encounter a few. My point is that the CPM, which fancies itself to be like these traditional midwives, leaves students woofully unprepared for the challenges they face. I am not trying to be condescending towards you, but there are a lot of points that need to be addressed. Also, the CPM was legalized in the 90's but has it's roots (philosophical and otherwise) in the 70's. We can't turn a blind eye to CPM students abused and underprepared by preceptors, and a system that does not leave them prepared to answer the maternity crisis in this country. Community discussions are important, and knowledge sharing, but it's also important not to side step the stats of what is going on here and point fingers saying "babies die in hospitals too" any time someone points out the obvious with the CPM.”
Wait and Be Strong on Aug 24, 2013 at 00:04:13
“I never said, "babies die in hospitals, too." I said, "We also have to address how unsafe hospital births can be. Statistics are often irrelevant because there is no federal guidelines for reporting."
“In response to the last comment, only CPMs benefit when the ACNM pretends that the credential is adequate. I totally believe there are CNMs and CMs out there that romanticize the CPM as it stands, which is very different from what it set out to be in the 70's. Midwifery is the oldest profession, but for it to grow in this country and be fully recognized and make the changes necessary it's about more than getting together at monthly midwifery meetings. It's about coming together as a unified credential, addressing the short comings on each end, and not denying the lack of education that needs to be addressed within the CPM. Also, you cite Judith Rooks above. Have you read her recent paper on OOH birth with CPMs in OR? She was one of the "excited" CNMs you mentioned earlier, until stats showed her there were serious issues to be addressed.”
Wait and Be Strong on Aug 23, 2013 at 22:57:32
“I have agreed that homebirth does need to be safer. However, did you not notice that the study compares less than 2,000 homebirths to almost 40,000 hospital births? You cannot have accurate results, and it is better to argue on the basic of common sense rather than "studies" in which the numbers constantly change. The first CPMs were certified in 1995, not the 70's. Informal midwifery groups are essential to bringing midwives together. If you are interested in the political aspects of midwifery, then go for it. It is your choice to be either condescending or respectful. Each midwife, including Judith Rooks, has her own story and perspective. I support her for that.”
“I have to say, I have known about 6 or 7 OOH midwives practicing on the West Coast, East Coast, Midwest, South, you name it. Practices range from 15yrs to 30yrs. I have never, not once, ever had them ask to assist a CPM. Maybe back in the 70's, or midwives in states where HB isn't as common may go to the Farm. I work with an OOH CNM, and the calls that come in from some of these ladies are flabbergasting. I agree egos need to be checked (in health care in general), and it would seem that not wanting to face a hostile nurse during an uncomfortable transfer would be a pretty egocentric reason to keep a mama home. I agree with you though, that an integrated system like Canada or UK would be ideal. It's a cultural thing on both ends, and there are few who want to meet in the middle. I *really* think, one credential (please, please check out the CM) could create some answers to these issues.”
Wait and Be Strong on Aug 23, 2013 at 21:54:33
“Waiting too long to go to hospital has more to do with fear of the unknown and possibility of separation from loved ones. "Hostility" has a different meaning when you are in the process of opening up to give birth. Also, lack of health insurance may influence some parents to wait to see if it works out rather than go the hospital "just in case". It is a difficult decision for the Parents at a highly emotional time, and a midwife has to navigate that. And yes, there are state midwifery groups which welcome ALL midwives to meet informally to share experiences. CNM's are usually quite excited to have some traditional homebirth experiences, and all midwives are glad to have the CNM's to teach and share. Midwifery is the world's oldest profession. We all benefit from supporting each other.”
“I am well aware of Ina May Gaskin, and her beliefs/videos/movies/writings/etc. Believe me. I do think that the whole "babies die in hospitals too", is quite a disservice to the women whose babies die at home or in hospital. It doesn't excuse an inadequate credential (the CPM) and their poor outcomes. When we are talking about utilizing midwives to improve outcomes in this country, and people are taking notice of the huge discrepancies between AMCB midwives and CPMs, while pointing out poor CPM outcomes, you can't just say "well babies die in hospital too". We all know that OB care isn't the answer to safer outcomes (or to address the issues with cost)! No one is saying that OB care is the answer (least of all me), but let's not get away from the issue when discussing midwifery in the US.
Bottom line: low risk, full term, health pregnancies should not be having the outcomes with CPMs at home that they do. And why is that? There is little educational and clinical standards in their training. Even if you do license them, it often does not ensure safety or that they will carry med mal in the even that they do injure someone.
I don't think the standard of care should be the obstetrical model either, but I do think we need ONE credential of midwife with university education, making midwives competent to practice in every setting, and integrating them into the system as a whole.”
Wait and Be Strong on Aug 23, 2013 at 23:12:37
“I know this will make you mad, but there are manyf "traditional midwives" in the world who have a tremendous amount of information to teach and share. The requirement of "university education" will indeed make midwives a homogenous group, but we will lose so much when we lose our diversity. We were not made to be alike. Not even midwives. But I do agree that within the community of birth, we all have to raise our standards.”
“You have to understand that because birth is often times a normal physiological process, you aren't going to see irregularities at home as often in say the hospital or even a birth center. A busy HB practice may serve 20-30 women a year. An apprentice seeing on 20 births a year, by the time she finished and sits for NARM will have far less experience with life threatening emergencies than midwives in Canada, the UK, or AMCB midwives. She will know what her preceptor prepared her for. While I can understand people's hesitancy to work in the hospital culture, there are many valuable things that you learn in an environment with populations of varying risk in the presence of other care providers. It creates a kind of safe guard to fill in gaps that other's may leave in your education. Without this knowledge base, and far lower standard for didactics and credentialing, you are literally thrown into a "sink or swim" situation. Although, this time it's the mom and baby who must sink or swim if the midwife is unprepared, doesn't know what she is looking at, or doesn't know how to handle the situation. This is often times why transfers are emergent.”
Wait and Be Strong on Aug 23, 2013 at 21:20:35
“I truly agree with most of what you said. Every practitioner in and out of hospital needs to seek help when faced by the unknown. One reason that some midwives wait longer than they should to transport is that the reception at the hospital can be hostile, and in a difficult situation, the midwife should not be separated from the mother she is serving because the mom needs her for emotional support. If hospitals would welcome the birthing woman and midwife, there wouldn't be such a hesitation to go to hospital in the first place. No matter how difficult the situation, keeping the mother feeling "safe" is essential to mom & baby's welfare.
I agree that midwives would benefit from hospital instruction. I also believe that OB's and hospital birth practitioners would greatly benefit from observing midwife attended homebirth. Though there may be unmedicated births in the hospital, they are not "natural" as birth is in the home setting. Often, CNM's will ask traditional midwives to let them assist at births, and the CNM's are almost always amazed and pleased because they have only been exposed to an obstetrical model of midwifery. All birth attendents need to work together, support and teach other and check egos at the door in order to benefit the women and babies who depend on them.”
“I understand what you are saying about the CPM looking to legitimize their profession, and I agree with medicine disenfranchising midwifery as a profession (at the turn of the century, and currently with AMCB midwives). As you stated above, there have been numerous issues to removing barriers to practice for the CNM/CM credentials. However, I do not believe that the medical profession currently views CPMs as a threat to their business (their med mal maybe when they bring in some of the disasters that they tend to). As you also stated, with less that 1% of the population choosing OOH birth, the real competition lies not with the CPM but with the CNM/CM credentials. If you want to improve birth in this country, bringing in more AMCB midwives and removing barriers to practice is where to start.
Statisticians actually do account for the discrepancies you sight above as well. They of course realize that CPM serve smaller populations, but when you account for that (as the DORA stats do), the outcomes are still unacceptable for any care provider. Judith Rooks (epidemiologist), a once adamant CPM supporter in OR , also addressed this in her findings. You are also assuming 3 babies died of anomalies that would have otherwise not been able to survive in the hospital. I know first hand that one of those anomalies would have easily been picked up upon with correct fundal height assessment.”
Wait and Be Strong on Aug 23, 2013 at 20:47:50
“I don't believe that OB's find CPM's a threat to their practice, but I do feel that they find OOH births a threat, when women who have health insurance are choosing to stay OOH. Most women who birth OOH are usually much happier with their birth experience and won't return to hospital for subsequent pregnancies and they tell friends. Denying state licensing keeps OB's as the definition of "safe practice"...making the assumption that birth in the hospital is almost always a "safe" experience for mom & baby.
We do agree that homebirth needs to be safer. But we also have to address how unsafe hospital births can be. Statistics are often irrelevant because there is no federal guidelines for reporting and statistics can be hidden in a hospital setting. Check out Ina May Gaskin on maternal mortality. Babies who die several days after an injurious birth may not be included in statistics in hospital. If you go into a NICU, you will find that there are quite a high number of babies who sustained birth injuries with supposedly the "best quality of medical care".
My personal opinion is that the "standard of care" should not be determined solely by obstetrical model. Midwives, of all certifications or none, need to be equally respected in the process of determining "standard of care" for the benefit of both mother and child.”
If you could point me to where they have their morbidity and mortality stats in your links, I would *love* to see them. They DO have data, but you have to go through a very stringent vetting process to access it. They actually have been collecting data on this for 20yrs, but have never released it for review. What data are you speaking to that has been medically reviewed? By whom? I am honestly just not seeing it in the links above.
I recognize that the ICM has done work with MANA, but PEP processed CPMs (which are the majority), do not meet their standards. They have spoken of how in very underserved areas of the world, their education may be adequate.
To be honest, I am not saying all CPMs are poor midwives. I personally would like to see one credential (like the CM) legal in all fifty states. I have explored both pathways, and seen the work of midwives (and the midwifery politics) of each group. I must be frank in saying that I don't feel the CPM credential in it's current incarnation offers the standards and education that should be required for the services they are providing.”
"Birth center care results in a perinatal mortality rate (1.3 per 1,000 births overall; 0.7 per 1,000 births excluding congenital anomalies) significantly lower than national outcomes reported for the same time period (Rooks, 1992b)."
"A meta-analysis of six controlled observational studies was conducted...This study examined the safety of planned home birth backed up by a modern hospital system compared with planned hospital birth in the Western world.
"The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician"
"The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America."”
highstreet on Aug 23, 2013 at 23:29:19
“Thanks for being honest. I think part of the issue here is that you are conflating DEMs with CPMs.
There are plenty of actual DEMs practicing that didn't go thru any educational component to their training, and if included in your data will throw off the actual numbers for CPMs. CPMs on the other hand, do have to meet or exceed the ICM Global Standards for Midwifery Education in order to be accepted by NARM for certification.
Your link from OR is from the Judith Rooks you spoke of. And although her paper doesn't provide sources, it does do just what I spoke about above. It speaks of only DEMs, and doesn't differentiate from CPMs. Thus the mortality rates are inflated by non-professionals.
Your link from CO is a better source. However, again they are called DEMs, and so we cannot determine their certification or level of education. Their rates are higher, but we also don't have cause of death or any other details to shed light on their situations.”
“Again, I believe you are misinformed. I comparing the CPM outcomes (low-risk, full term, otherwise healthy pregnancies) to the same groups care for by CNMs (OOH and in hosp) as well as physicians. There outcomes speak for themselves. MANA has never released their perinatal outcomes or maternal mortality/morbidity outcomes, and are not present in the links you provided. They actually do make it quite easy for CPMs to participate in this project and to record their outcomes. I work with an OOH practice, and fully recognize the need for collaboration and better integration, in addition to the safety of homebirth. What I think *you* are failing to recognize, is that you are discussing a credential not applicable to practice in another first world nation with significant bridge programs, that does not meet ICM standards, and has far too wide a variance in education and training. Also, the ACNM may have some political ties with MANA, but no they do not work with CPMs as a trade organizaiton.”
highstreet on Aug 22, 2013 at 22:01:34
“Like I said, you are going to have to post links to the info you are referring to support your claim. All the credible research I have seen shows that CPM's have outcomes on par with hospitals, and lower intervention rates. All the data I posted supports that. I'm sorry you think that MANA doesn't post their internal data. They don't have any data to post. It's an association of independent providers. Their data has been collected and studied by many medical and scientific organizations and posted in the links I provided.
“Did you take the time to read what I posted below before writing this? Apparently not. Many states are collecting outcomes from CPMs in an effort to better understand their outcomes (whereas MANA has never reported theirs. Imagine if ACNM or ACOG refused to release their outcomes.) You can look at the DORA site for DEMs in CO or at Judith Rook's paper which she presented to legislatures on OOH in OR (she was once a very vocal CPM supporter). I can see from your thoughts on licensing above though, that we are *not* going to agree on what providing safe care is.”
highstreet on Aug 22, 2013 at 12:25:58
“You are comparing large hospital based policies of outcome reporting to a loose association of independent practitioners. These are large, moneyed groups with the resources to hire people specifically to track and document everything and accumulate it in one place. CPM's all do that in their own practices, but don't have the resources to pass it on to MANA or NARM. There are plenty of scientific studies that do track their outcomes, and the evidence is widely available.
Safe care can be provided in hospital or out of hospital by highly certified and educated care providers. What doesn't help midwives, doctors, mothers, or children is to continue to drive a wedge between them and their ability to coordinate care. Europe's model of working together is better for everyone involved.”
“Please also understand, that I am very much a midwifery advocate and soon to be student in midwifery. I work with midwives as well, but the US has to very different credentials, which provide very different levels of care. Also, the above statement that the CPM is a "nationwide credential" is incorrect. It is only legal in 29 states, with varying degrees of how they can practice and what they can legally carry-including life saving meds.”
“You can google the DEM stats in Colorado which are available to the public, and view Judith Rooks recent report in OR for starters. There is also the fact that MANA has not released their stats in over twenty years (at least not to the public). This is not to say that all AMCB midwives are wonderful, or that all CPMs are incompetent (I do stand behind my statement that they are not eligible to practice by either ICMs standards or those of other first world nations as well). However, the credential as it stands in insufficient in providing quality educated midwives across the board.”
“Licensing ensures you meet the minimum standard to practice, being licensed by the medical board does not mean that education, experiences, or qualifications are on the same level. It speaks nothing of carrying med mal to protect patients in the event of injury, or legally carrying potentially life saving prescriptions or tools. CPMs do not meet the standard to practice in any other first world country, and in the states where they are legally licensed to practice we are seeing more and more state statistics being collected suggesting a perinatal mortality rate at minimum 5x higher than that of the highest risk pregnancies in hospital. Midwives are skilled in carrying for women in low-risk birth, but please do not equate low-risk with normal. Every care provider attending a birth, must be equally skilled and able to provide care (even more so OOH), when things suddenly become not normal. This includes having access to consultation and referral with OBGYNs and Perinatal groups.”
Wait and Be Strong on Aug 23, 2013 at 14:13:19
“For many years, independent midwives tried to obtain licensing within their individual states. Most states did have laws to license independent midwives, but would refuse to provide an exam when midwives applied. At the same time, CNM's were finding almost complete resistance to their profession within hospitals and with insurance companies. CPM certification was created by MANA after many years of trying to establish a legal avenue for midwives to work with medical professionals and to provide women who choose homebirth safer options in the case of difficulties in pregnancy and birth. MANA's first choice was to obtain state licensing. CPM was established because the medical profession did not want competition as they defined midwifery "as the practice of medicine". Therefore, midwives could be prosecuted for practicing medicine without a license.
Homebirth rate in U.S. is less than 1%. If you compare the statistics to 99% of the population you will have skewed results. If 3 babies die due to anomalies incompatible with life in a homebirth population, it is going to look like a tremendous percentage.
MANA does not want to publish because we all know that the statistics will be used to target midwives for prosecution. The medical profession would be unlikely to do that to one of their own.
Please watch Ina May Gaskin CPM: Birth Matters: A Midwife's Manifesta