Sunday, June 11, 2006

DEM accreditation

This post was submitted by Ami:

"One thing I've been thinking about is the problem with standardization of training for midwives. Many DEMs seem to lobby hard against such standardization, and many stories I read about persecution from the medical establishment seem to really be about hospitals and licensing boards requiring that educational and clinical standards be met. See a typical article here.

The problem, as I see it, is that training to be a certified midwife requires schooling and time, and accreditation requires proven knowledge and a certain amount of clinical hours and labors attended before one can practice on her own. This is more expensive and takes more effort than some types of DEM apprentice style education. In other words, you can't just decide to become a midwife, attend a few births with another midwife, and then do it on your own.

Standards MUST be met, and not all DEMs want to meet them.The ones fighting against such licensing are the very ones you should not have attending your birth anywhere."

Ami is talking about midwives objecting to accreditation standards. I would add a further question. Why isn't there a uniform standard for DEMs? Many different standards suggest that some standards are not appropriately high.

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18 Old Comments:

the states that license midwives have different standards- does every doc have to belong to ACOG or AMA ? Some many states do not recognize CPM- the state I live in does not it uses the NARM exam but it has it's own process- it may become standard but right it isn't and no thank you. --saying anyting more than this is very policital-- so for some states you have to go through their entire educational program any way so that is a waste.....

By Anonymous Anonymous, at 11:08 PM  

Amy, this is somewhat of a silly question if you think about the "hostility" thread in which we discussed the fact that states have been fighting against accreditation standards for midwives because it legitimizes the profession. It is the medical lobby and state legislatures that are fighting this. NARM is trying to accomplish what you suggest with the CPM credential.

I don't think many midwives are fighting against this... most are fighting for it. The few who are fighting against it have their reasons for wanting to stay outside of the system... mainly religious and philosophical. As a libertarian, I prefer the approach Utah has taken which is to have a voluntary licensing system. That way consumers who want the "security" of standardization and accreditation can choose a CPM, and those who wish to remain outside of the system can choose someone else based on beliefs that might not be sanctioned by the "establishment".

By Blogger Mama Liberty, at 9:27 AM  

"states have been fighting against accreditation standards for midwives because it legitimizes the profession"

Ami may be referring to something different, but I was asking why different midwifery organizations have different standards. Midwifery organizations do not look to the states to set their guidelines; they write them themselves.

In contrast, there is only one standard for obstetricians. My question is: why don't midwives decide on a single standard across organizations?

By Blogger Amy Tuteur, MD, at 9:34 AM  

Which organizations are you referring to?

By Blogger Mama Liberty, at 10:26 AM  

HMMMM ...

NARM's CPM is becoming commonly accepted as the standard for DEMs for obvious reasons. Their schools (via MEAC) are accredited by the U.S. Dept. of Education. Their accreditation agency (NARM) is accredited by the NOCCA. NARM is a good standard.

NARM's CPM parallels most health professions' accreditations: must attend accredited education program, and, in the case of midwives (incl. cnms), must pass rigorous accreditation exam, must validate minimum number of births/practical experience, must maintain CEUs, etc. There are some variances in different state laws, but the CPM exhibits all the criteria of a valid professional accreditation organization ... because it is.

I don't understand why you're focusing on this. Yes, there are some DEMs who don't want to become CPMs. I would not begin to speculate about the reasons, but I think that number (dems who don't want to become cpms) is small and shrinking. While I can't speak for INDIVIDUALS, as a group, I think it's fair to say that the CPM is now accepted as the best standard for assuring DEM competency. There are rogues of any profession -- including doctors. You can't put that noose around the professional midwives who are working credibly, any more than you can do so with physicians, engineers, etc.

Personally, I'm glad the CPM is now considered the standard, b/c before the CPM is was really difficult for the average consumer to judge a midwife's skills. Now there's a relatively simple way (from the consumer's perspective, not that it's simple to become a CPM). As it gains more acceptance, it will be easier for expectant parents who want a home birth to figure out whom they might want to hire.

NARM did their own study -- not funding it but collecting the data (or facilitationg the collectoin of data), if I understand correctly -- requiring all CPMs to participate in the year 2000. The date was prospective (beginning and end of pregnancy) AND was a requirement to keep your CPM (so no hidden bad results). That data collections was what resulted in the BMJ study. I'm guessing there might be plans for another study (you'd have to check with NARM).

By Anonymous Anonymous, at 12:31 PM  

MANA is not an accreditation agency. It is a professional support group. and even some CNMs belong to MANA. MANA's function is not the same as NARM.

Other than that, I can't think of any major DEM groups. Sure, there are various smaller groups (like, for example, black midwives group), just like there are various doctors groups, etc., but as far as setting standards of education, most midwives agree NARM is "the" standard.

Now, you might have read about midwives not wanting requirements allowing only cnms in a given state (they way some judicial rulings are coming down in absence of DEM licensure in some states), but there is no large scale movement toward refusing any standardization. Midwives want to standardize their own education and certification -- like other professions. That mean NARM, and the CPM.

I hope this helps clears up some of the misunderstanding for you!

>> In other words, you can't just decide to become a midwife, attend a few births with another midwife, and then do it on your own.<<

On this we TOTALLY AGREE!!!!!!!!

By Anonymous Anonymous, at 12:40 PM  

>>Anonymous said...
the states that license midwives have different standards- does every doc have to belong to ACOG or AMA ? Some many states do not recognize CPM- the state I live in does not it uses the NARM exam but it has it's own process- it may become standard but right it isn't and no thank you. --saying anyting more than this is very policital-- so for some states you have to go through their entire educational program any way so that is a waste.....<<

I'm a home birth supporter, and I don't understand what you're point is. Every doc does have to graduate from an accredited education program. ACOG and AMA are essentially trade unions (more or less, no matter what they say, that's how they function) but ACOG and AMA are NOT accreditation agencies, so your question doesn't make any sense.

Doctors have been legally recognized long enough that they are entrenched in the system and have generally autonomous state medical boards. While you are technically correct that requirements to practice as a doctor are not standardized exactly accross the nation, the standards from state to state are roughly the same. However, there are other professions that have national accreditation groups with the same (or very similar) function of NARM. The ACNM might be the best example. Most states require anyone who wants to practice as a nurse-midwife to be accredited by the ACNM, sometimes with additional requirements.

One reason the CPM is likely to be the standard (eventually) in all the states is because in this day and age (govt's trying to save money) AND with such a small group, it simply isn't feasible for indivdual states to create and administer their own standards, tests, etc. I believe this is a trend with almost all professions that are currently working toward legality in varios states -- not just midwives.

By Anonymous Anonymous, at 12:50 PM  

no because of the "history of midwifery in America" many states write the practice guidelines- not midwives necessarily - they write what is allowed practice- disallowed practice --- as well as allowed meds- I have said this before- some states where it is legal to practice midwifery you cannot carry oxygen to resuscitate a compromised baby- or pitocin to stop a hemorrhage- this is part of why you are going to get spotty results all the way around-
and you think you have it bad with an HMO-- try ignorant folks in the legislature-

By Anonymous Anonymous, at 1:29 PM  

for one I don't really want to discuss this on line- on amy's group.
look up your states and see which ones have what requirements? yes they may be similar to the CPM but as long as there is no resciproscity then for some midwives who do not practice anywhere outside of the state they become licensed in it is just an added cost and burden. in addition to dealing with politics or an organization!!!!!!!
Just as Amy has stated she does not belong to ACOG... some midwives do not want to belong to NARM/CPM --- it will not be spelled out here by me but suffice it to say if you are a midwife and belong to this organization you know very well the politics ..

By Anonymous Anonymous, at 1:43 PM  

>>Anonymous said...
for one I don't really want to discuss this on line- on amy's group.
look up your states and see which ones have what requirements? yes they may be similar to the CPM but as long as there is no resciproscity then for some midwives who do not practice anywhere outside of the state they become licensed in it is just an added cost and burden. in addition to dealing with politics or an organization!!!!!!!
Just as Amy has stated she does not belong to ACOG... some midwives do not want to belong to NARM/CPM --- it will not be spelled out here by me but suffice it to say if you are a midwife and belong to this organization you know very well the politics ..

1:43 PM<<

I don't know what state you're in, but I am relatively familiar with a few state midwifery licensure laws, and I know most of them are not just "like" the CPM. Most of them require it. All the most recent states require CPM itself. (Texas I think does not but they have an uninterrupted history of state or county documented midwives -- with good outcomes -- unlike most states that have had a few decades of no midwife regulation whatsoever.)

I don't know why you even brought this up on this forum if you didn't want it discussed. Your cloak and dagger approach "I know, but can't tell you" is a disservice to the whole discussion and reflects poorly on home birth midwives and the women that hire them.

You seem to be arguing against becoming a CPM because the red tape would be bothersome and maybe you object to some of the results of standardization. Please correct me if I am not summing up your stated argument, but that's how I'm reading your post. That is shameful. That gives the home birth community at large a bad name.

As far as reciprocity goes ... you can't even start to have reciprocity until you have legal status in more states. Heck, attorneys don't even have automatic reciprocity and look how "in the system" they are. Do doctors? I doubt it. Nurses often don't. This is a silly argument against becomming a CPM.

If you don't like NARM's polices, then join them and campaign to reform their politics.

It's time the reticent in the home birth community get its heads out of the sand and realize this is a make or break deal and instead support the best option there is.

Insisting on remaining disenfranchised is a disservice to the women you serve. It ensures you will be more likely to have a break in the continuity of care in transports (and even if you have a good system now, that can disappear in a new york minutes so stop fooling yourself!) And by "break in continuity of care" I don't mean enabling midwife to remain in charge of care, I mean keeping care going continuously, like midwife's report is believed and patient is smoothly transitioned into the hospital when necessary (instead of hospital staff starting over in assessing patient and baby).

There is really no downside to becoming and promoting the CPM. I've heard this line of thinking before, but I cannot support it in the least.

I think it is so irresponsible -- both to midwifery and to pregnant women in your area -- to be a midwife and not become a CPM based on some lame political lament.

By Anonymous Anonymous, at 4:51 PM  

>>no because of the "history of midwifery in America" many states write the practice guidelines- not midwives necessarily<<

That is not because of the "history of midwifery", it is the "history of all health care laws". Sheesh.

Oh, and I'm a home birth mom -- non-nurse midwives all three times, lest you think I'm from "the other side".

By Anonymous Anonymous, at 4:54 PM  

This is Ami, BTW.

I actually live in Utah. Part of me likes the libertarian approach. But when a DEM is practicing medicine, I don't think it is appropriate. The problem is that they are representing medical authority when it comes to birth and recieving money in exchange for their services. This authority by alleged knowledge and experience makes the exchange not completely equal and consensual. The relatively less educated patient is trusting the midwife to know what she is doing. That is why she hired the midwife.

This is why I would prefer more controls in Utah than there are. Your patients trust you. Unfortunately, we find that the trust is not always justified. That is why those kinds of laws are important, to protect people.

I wondered what options were out there for me in Utah. When I was doing my research, I found it difficult to find a midwife here. Basically, it seemed like they were accredited and worked only out of hospitals and a single birth center in the area, or they were independent DEMs. I remember reading a lot of persecution type literature regarding regulation with "They are taking our rights away!" being the clarion call.

Homebirth shouldn't be made illegal, but the lack of regulation of midwives in my state is not exemplary, IMO.

By Anonymous Amka, at 7:02 PM  

"But when a DEM is practicing medicine,"

I meant an unregulated DEM.

By Anonymous Amka, at 7:03 PM  

This is why I would prefer more controls in Utah than there are.

I assume you know that it is only in the last year (two at the most) since DEMs in Utah were legalized. They have only just begun to set the "controls" in motion.

By Anonymous clever ID, at 10:55 PM  

The Utah law is new.. very new.

to who ever thinks that CPM = midwifery in many states or that resciprocity is meaningless- try going from one state where you are licensed to another where you aren't granted to just take the test like doctors or lawyers but to start over with maybe an entire apprenticeship to re-do or 2 more years of school... or no possible way for you to become licensed because of the testing "red tape" .. not to mention illegal stuff. I think that many have no clue what laws are out there and how the are used to limit midwifery-- CNM , CPM, LM, DEM--- by the way according to ACOG all of the rest of us other than CNM are lay midwives....
and what has been done to midwifery in America is part of our history-- you trimmed my post it was "History of Midwifery In America" Had to do first with health department registries -- then licenses then forced retirement .... in many states.
keeping in tact the licensing laws in the state you live in if you have a license law and that process along with accepting the CPM could help- but not relying on a single process or organization to last into the future. the CPM relies on MEAC and the NARM exam as well ---

By Anonymous Anonymous, at 11:21 PM  

>>to who ever thinks that CPM = midwifery in many states or that resciprocity is meaningless- try going from one state where you are licensed to another where you aren't granted to just take the test like doctors or lawyers but to start over with maybe an entire apprenticeship to re-do or 2 more years of school...<<

That proves your point. Get CPM more accepted, and then you'll have smoother transitions from state to state.

And, yes, CPM does, essentially, equal miwifery in many states, esp. those with newer laws. It's the trend, and it's a good trend. Yes, CPM does depend, in part, on MEAC, again, ~standardized~ educations by midwivs, for midwives, that is recognized on the federal level.

If you wanted to discuss the progression of midwifery regulation over the past four decades, you should have stated your point clearly. What you wrote in your original post about the history of miwifery did not clearly describe any history. You wrote:

"many states write the practice guidelines- not midwives necessarily - they write what is allowed practice- disallowed practice --- as well as allowed meds- "

That is vague and is written as if you were discussing current regulation practices.

I acknowledge the scenario you describe (non-midwives regulating midwifery) exists in a couple of states (maybe a few). And, yes, historically, midwives' licensing laws were either allowed to expire, written out of existence, or licensing agencies (usually dept. of health) stopped issuing new DEM licenses. But that is not the way things have been trending in the past 10 years.

Working to get the CPM as the standard, and a midwifery board run by midwives is important, and it will help with future reciprocity. If you don't advocate for that, then, if you can even get licensure all 50 states, you will end up with different states having varied requirements that are not easily interchanged. You can't expect states with hodge-podge (read - different) standards to offer easy reciprocity. Unless there's some sort of easily understood standard, you are not working toward acheiving reciprocity.

Many of the professions that have enjoyed continuous legal recognition have easier reciprocity due to the fact that state legistlatures understand and accept the standardization of education, testing, etc. And those professions have practiced openly in a continuous fashion.

Unfortunately, DEMs have not seemed to have practiced continuously. Note I said "has not SEEMED to", meaning that's the perception of the aveage person and average legislator. It doesn't matter to the average person and average legislator if you or I think midwives have always practiced, and that midwives provide good care. We have to communicate clearly that there is a national standard of midwifery (which there is -- CPM) that states can rely on to ensure comptency in DEM to license them. We have to communicate that to people who can vote to make licensure a reality.

If you don't advocate using CPM for the standard requirement for DEM state regulation, then you are making reciprocity less likely in the future. The trend licensure laws is NOT for the state to administer it's own exam; states are turning more and more to professional accreditation organizations and/or schools accredited by a national professional organization.

Stop shooting yourself in the foot by denying the need of standardization.

By Anonymous Anonymous, at 1:17 AM  

I guess I am saying I want both- in the states where they have developed a way to be licensed- don't drop that add to it CPM process as another way to be licensed- but not the only way.
I just don't like all the eggs in one basket--

By Anonymous Anonymous, at 1:00 AM  

" Anonymous said...

I guess I am saying I want both- in the states where they have developed a way to be licensed- don't drop that add to it CPM process as another way to be licensed- but not the only way.
I just don't like all the eggs in one basket-- "

The probem is that a licensure process means "we think this is the minimum of what you need to be safe." E.g. you complete the requirements, you can be licensed.

You won't get an alternate path, because by setting up licensure, you then have to address the question of why something what they ALREADY said was required is all of a sudden not required.

What you might be able to do is set up an alternate training. E.g. "you must attend 40 births supervised by a CNM and take a 40 hour class, or attend 350 births in the care of a DEM and take a 10 hour class."

This runs into a lot of flak, and rightly so.

By Blogger sailorman, at 2:36 PM