I am glad this conversation is taking place. I think transparency in all practices (medical and midwifery) is important.
I am also a CPM, and about to be an RN, and very interested personally in ensuring that 1) midwives are competent and 2) midwifery grows as a viable option (in and out of hospital). Liz, I've read your story... and it is truly heart breaking. In this post I am going to try to keep on topic of your original question and not speak to what I know about your story.
1) I think that when it comes to changing and improving the way that transfers happen in the US we need to approach it from both ends. I do think it would be best if midwives were more integrated into the system to allow for smoother transfers, but the OB system in this country doesn't follow it's own best evidence and research. Yes, the hospital is absolutely the best place to be for emergency management... but I have seen too many moms who were outside of my scope get way too many interventions that didn't support healthy birthing. It is very hard position to be in when, as the midwife, you know that a mother would benefit from IV fluids or epidural rest but she doesn't need a c-section.... but the options on the other end are so limited at so many hospitals. I think that we would have the best outcomes if we do the fewest interventions possible, while also doing necessary interventions when needed- and that is a difficult balance to find.
2) I do have a college degree (from an accredited college) in Midwifery. I know that those degrees are uncommon among my peers so perhaps my perspective is influenced by my own experience. When I was a student I went to school for 4 years, and apprenticed and took on primary care under supervision during that time. I had been to births in the triple digits before I started my solo practice. At the same time I had a friend who got her CNM and went to about a third as many births as I did, and many of those she only had an observer role. Just among the midwives I know in person there is a wide range of experiences, and it isn't cut and dry where the most experienced or educated midwives always have the best outcomes.... I have thought long and hard about this and the best I can come to is that we should have a high standard for the education and experience required for all birth providers. However, it would not serve midwifery in any way for that education to be administered or created by ACOG because midwife and physicians are different so midwives need to learn midwifery and physicians need to learn medicine. If I had to say in general, CPM's have more experience than CNM's at the start of practice. CPM's, because of the nature of OOH birth, have also spend a lot more time with laboring women, and with un-interventive birth than CNM's. One of tthe strengths of that kind of experience is that CPM's can (generally & should) be able to know normal from abnormal, and know when that abnormal needs to move to another setting. I don't think that this is something that CNM's (or MD's) can say about their training. I have been criticized in my own community for being "too medical", even when my statistics were better then "traditional" midwives. It is an ongoing issue within midwifery that really needs resolution... we need to stop judging one another on things that aren't the heart of the issue. To me, it should be able the ability to provide quality care as evidenced by the statistics (which should also include measurements of client satisfaction as well as harder data).
3) I think that all providers should be required to track and submit all of their statistics. I also think that this information should be made available to the public in a meaningful way. I have worked with many great midwives and doctors over the years. I have also, sadly, been lied to by both about their protocols and outcomes. This makes me incredibly sad as I have a very high personal standard for integrity, but it does happen. Requiring this kind of data gathering would be beneficial for so many reasons.
The MANA stats project, as far as I know, is not keeping any information from anyone. What I do know is that there is a team of people still working with that data and working on improving the collection methods so that it can continue to be useful. In the CPM 2000 study (published in the BMJ), they used different filters for sorting the data than other studies.... this is not wrong, or unethical, (and it is common practice in medical research), but to be able to accurately compare data and sets the information needs to be sorted so that we can compare apples to apples and not apples to oranges.
4) Medical and malpractice insurance only complicate this issue further. In this thread I have read differing points of view, all of which have some validity to them. Neither of these issues are going to be solved simply or easily, unless we move to single payer health care in this country (and I really don't think that is what this post is about). I think that creating consistency in the education and credentialing will help a lot on their own.
For me, it is important to remember that midwives have always played a vital role in caring for mothers and babies, all over the world as long as we have been giving birth. That is not to say we cannot work to grow and change and improve (I believe we should). It would a huge loss to women everywhere for midwifery to become medicine.
Very interested in hearing the thoughts of others.
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