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#1 of 60 Old 04-29-2013, 10:57 AM - Thread Starter
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I'm just curious, as I never thought about it.  I had a team of midwives, one who was direct entry, and one who attended the local midwifery college.  Both are licensed.

 

I have heard, mostly recently, that people aren't comfortable with the idea of direct entry midwives....

 

What is your take on it?


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#2 of 60 Old 04-29-2013, 11:25 AM
 
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I wouldn't worry so much about DEM vs. licensed, certified, and regulated midwives if the DEMs had the same educational background as the other midwives. The lack of knowledge for some DEMs is shocking. There are some who have done the science classes and have done a LOT of self study.  The problem is that without educational standards you don't know what the midwife should know, nor do you know how her knowledge or lack of knowledge will affect her decision making when problems begin to develop during pregnancy, labor, or with the newborn.
 

Safer Midwifery for Michigan is running a series of articles on their blog about US midwifery education and how this may impact the care that women think they should expect from the midwives they choose.

 

Parts 1-3 of their series. I think Part 4 will talk about MEAC accredited schools. 

 

Part 1 http://safermidwiferyformichigan.blogspot.com/2013/04/the-education-of-midwives-around-world.html

Part 2 http://safermidwiferyformichigan.blogspot.com/2013/04/the-education-of-midwives-around-world_22.html

Part 3 http://safermidwiferyformichigan.blogspot.com/2013/04/the-education-of-midwives-around-world_29.html?spref=fb

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#3 of 60 Old 04-29-2013, 11:37 AM - Thread Starter
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Yeah, I suppose that is why I never really thought about it, my DEM was in her late 50s (possibly early 60s) and has been practicing a long time, in fact she retired (mostly) about 6 weeks after my second daughter was born.  So, her experience really spoke for itself, plus she taught at the local midwifery college.  I can see how DEM would be a different animal with newer midwives.


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#4 of 60 Old 04-29-2013, 08:15 PM
 
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Well I live in a place (BC) where midwives get university degrees and are licensed and regulated, so the idea of a DEM would be hugely concerning to me.  I briefly tossed around the idea of a traditional birth attendant when I was having trouble finding a midwife (they're a hot commodity here because its covered by healthcare), but wasn't really comfortable with the idea that she didnt have any formal training. 

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#5 of 60 Old 04-30-2013, 12:39 PM - Thread Starter
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Interesting.

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#6 of 60 Old 04-30-2013, 07:46 PM
 
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From MANA definitions:

Direct-Entry Midwife (DEM) 
A direct-entry midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.

 

So in other words, a DEM is any midwife who went straight into midwifery without having to be a nurse.  In my state, we are all DEMs, but we have to have gone to an accredited midwifery school for at least 3 years, pass the national (NARM) exam upon completion of school, and had to have met the state's minimum requirements for clinical experience as a student - how many prenatal visits, postpartum visits, birth observes, birth managements, newborn exams, etc.  Once we have met all the requirements and passed the NARM, we apply for our license through our state Department of Health, so we have the designation of licensed midwife (LM) as well as the NARM designation of Certified Professional Midwife (CPM).  So just because a midwife is a DEM doesn't necessarily mean she has had no formal education.  Just kind of depends on where you are and what your state requirements are (if there are any in your state anyway).  

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#7 of 60 Old 05-01-2013, 04:44 AM
 
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Good idea for this post, Adina - and timely because we have been talking about DEMs a lot lately on the forum.  There was a thread a while back about "underground MWs" that saw a lot of active discussion a couple of years ago. It can be found here

 

Having followed along with several of the threads here at MDC on DEMs, appreciating Mothercat's participation, and having had both a CNM and CPM birth, my answer is, "I don't know".  

 

I haven't independently researched the education requirements needed for someone to label themselves a DEM but I've picked up here that perhaps the minimum requirements are too low (or perhaps not even existent in some areas?).  But, I also don't think traditional nursing school is necessary for a well-trained midwife. I can sympathize with wanting to see some of this regulated so mothers are protected from choosing a MW without adequate training. But, for me, choosing an established CPM with years of experience and training is way preferable over a new CNM. Experience and continuing ed was a bigger factor for me over whether the MW had a nursing degree. But that's different from an advocacy perspective. 

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#8 of 60 Old 05-01-2013, 05:09 AM
 
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I'm in the same boat as sunnymuffin; midwifery is closely regulated here in Ontario as well. If I lived elsewhere, I'd have to be very careful about DEMs. I agree that experience is paramount but if certification isn't regulated in a particular area, what is there to stop an unscrupulous person from lying about her experience? I have no issues with self taught midwives if they complete an exam to ensure their studies meet the same standards as the formally trained MWs. I don't believe all MWs need to come from a nursing background, just that their training is on par with accredited MW programs.
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#9 of 60 Old 05-01-2013, 05:40 AM
 
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I'd say experience is more important to me than title. That being said, if I have a choice between a DEM, CPM and CNM with equal experience I'd be more likely to choose the CNM.


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#10 of 60 Old 05-01-2013, 05:45 AM
 
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I think one of the problems with classifying midwives as DEMs is that we don't know if we're talking about direct-entry midwives like those from Canada or the UK (meaning formally-educated, registered, and legal - only without a nursing degree ) or a self-determined midwife who maybe went to a couple midwifery conferences and has now hung out a shingle (or these days, a web site) and is advertising services as a 'direct-entry' midwife.

 

There is a huge difference. At least in educational pathways for direct-entry midwives.

There are some direct-entry midwives in the US who have been trained similarly to CPMs - and perhaps have more experience than some CPMs - but who very deliberately choose to not become certified. This usually reveals a philosophical deviation from other credentialed and certified midwives. If I were considering hiring this type of DEM, I would take a good, hard look at why this qualified midwife would eschew certification and licensure - and be certain that her philosophies were also my own.

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#11 of 60 Old 05-01-2013, 05:47 AM
 
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The newly passed and signed Indiana midwifery bill specifies that a Certified Direct Entry Midwife (CDEM) must posses ans RN license or at minimum an Associates degree in Health Sciences. I checked on the courses required for the health science degree. These are courses usually taken by pre-nursing students, EMTs, etc. While not nursing courses they would give the necessary science background that midwives need. Couple that with a good midwifery university based program and midwifery as a profession has taken a big step forward (IMHO).

 

 

When we are talking about DEMs, it is their education that we need to be discussing, not the fact that they aren't nurses.  I understand Navelgazing Midwife's point about the skills learned in nursing and how they apply. http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2013/4/28/nursing-school-worries.html  However, it also needs to be a lifelong process. I have become a big proponent of pulse ox screening for Critical Congenital Heart Defects (CCHD). This has just been in the last year that I became aware of this. I am dismayed by the number of CPMs and DEMs who are in complete opposition to using the simple technology at the 24 hr. visit. They feel it will diminish their midwifery skills. If a cardiologist can't tell which babies have CCHD just by looking at them, then how would a midwife know? It is the attitude of not needing to keep learning that most concerns me. I am sure it exists in CMs and CNMs also, but when we talk about it, the CM and CNM attitude seems to be, "Well, of course we need to be doing this."

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#12 of 60 Old 05-01-2013, 07:19 AM
 
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I think certification, formal training, and licensing are important, but I feel like requiring all midwives to get a whole nursing degree is a little overkill. 

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#13 of 60 Old 05-01-2013, 07:30 AM
 
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I think certification, formal training, and licensing are important, but I feel like requiring all midwives to get a whole nursing degree is a little overkill. 

And I don't feel its overkill at all. I love midwives but I've known three mamas to have very poor outcomes with DEM's. We used a CNM.
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#14 of 60 Old 05-01-2013, 02:42 PM
 
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Certified Midwives (CMs) are educated in the same programs as CNMs, sitting side by side and doing clinicals together. They are then certified through the same organization, AMCB.

They would be considered DEMs because they didn't earn a nursing degree before becoming a midwife. But, that is not usually what we think of in the US when we talk about DEMs.


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#15 of 60 Old 05-02-2013, 12:02 AM
 
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I am comfortable with direct-entry midwives and have used them myself.

 

With any midwife, I would ask about her education and experience. Education varies and experience can vary widely, whether we're talking about DEMs, CPMs, LMs, or CNMs. Most CNM programs don't require any out of hospital experience. If I'm having a homebirth, I want someone who was trained in out of hospital birth. I also think that we shouldn't be afraid to require more education for CPMs and LMs.

 

When hiring a midwife, I'd ask:

 

How many births have you attended? In what settings?

How were you educated?

What emergencies are you trained to handle?

How do you handle emergency transports?


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#16 of 60 Old 05-02-2013, 10:26 AM
 
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With any midwife, I would ask about her education and experience. Education varies and experience can vary widely, whether we're talking about DEMs, CPMs, LMs, or CNMs. Most CNM programs don't require any out of hospital experience. If I'm having a homebirth, I want someone who was trained in out of hospital birth. I also think that we shouldn't be afraid to require more education for CPMs and LMs.

 

I think that both educational routes are lacking when it comes to clinical sites. CNMs/CMs should need to spend some of their clinical working in OOH birth settings and CPMs/DEMs should spend some time doing clinicals in hospital. After all, both will, at some point,  have contact  with the other setting and should be familiar with both.

 

In the European model for midwifery education (DEM and CNM) the clinical time is spent  caring for low and high risk pregnancies in the hospital, with little to no time OOH. Except for the Netherlands the home birth rate is 0-2%, so for all those well-educated midwives, they are doing birth in hospital, and have numbers that we are envious of.  It isn't where the birth takes place as much as it is a well rounded and comprehensive midwifery education that makes the European midwives so good.


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#17 of 60 Old 05-02-2013, 02:01 PM
 
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I feel like anyone can test and "be" a midwife but not everyone can be a great midwife. It takes something truly special which I find lacks in most CNM's in my area. They are medical and cold and hospital is the only experience they have. I like the CPM's or DEM's as you called them, because the bulk of the clinical training came from hands on experience in homes or birth centers and they are use to different variations of normal. I prefer a CPM or DEM to anything else. I want a midwife who doesn't use epidurals on a routine basis and one who isn't afrain to climb under my in a crazy position while I am pushing! LOL! The compassion and love they exude means a lot more to me than education! Of course, experience is important but where I live, midiwves come by referral rather than being easily accessible, so that eliminated inexperienced midwives a bunch.

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#18 of 60 Old 05-02-2013, 08:52 PM
 
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I have used a CNM and a CPM.  I would agree that the CPM was more willing to educate me and I also felt more open to throwing out the craziest baby/pregnancy questions I had. Of course my CNM was in a hospital setting which may have added to the colder medical approach.  I have interviewed a CNM that did homebirths and she was as great as any CPM I have had but we moved before I could actually use her.  I shy away from DEM's just because I think it is important to have emergency supplies like oxygen, pitocin, etc. present at the birth for the off chance something happens.  Where I am located DEM's are not able to carry these materials because of a lack of licensing.  I also tear every single time I deliver and I like having someone with some experience in suturing and have the supplies to do such.  The DEM's I have interviewed have been unable to provide that service for me due to a lack of licensing.  Because of this, after delivery I would have to go to the hospital to get stitched up which kind of defeats the purpose of giving birth at home just to hop in the car and go to the hospital to get stitched up.  I have also noticed that the DEM's in our area do not provide the additional support that takes stress off (once again do to a lack of licensing) like being able to order blood work, ultrasounds, glucose tests, strep B tests, file for birth certificates,vitamin K administration, hearing screens, PKU's, etc.  To some people they don't mind this and don't want it.  I am one who likes to have these other tests done and don't want to be running around trying to line it up by myself.  I guess I like the convenience of having one person completely aware and able to assist me with these tests. Overall, I love CPM's and think it is great to have them in the list of options for a woman and her child.

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#19 of 60 Old 05-05-2013, 05:17 AM
 
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This is a good story about the changes to improve the education and training of birth attendants in Bangladesh. It applies here because it illustrates that maternal and infant mortality decrease with trained attendants, specifically an educated midwife. Bangladesh instituted a 3 year university based midwifery education program. The education model is based on international standards. These are DEMs in the sense that nursing is not a prerequisite to entering the midwifery program.

 

If all CPMs/DEMs in the US attended this same program they would meet the international standards for midwifery. Does anyone know what percentage of US CPMs and DEMs have a university based education specific to midwifery?

 

What we do today, will pay off tomorrow: the case for midwives

 

85% of women will never need the skills a midwife has learned as that woman will probably have an uncomplicated pregnancy and birth. However, if the woman or her baby develop complications, knowing the midwife has the necessary education, skills, and competency will mean a great deal to the mother and baby.

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#20 of 60 Old 05-05-2013, 06:21 AM
 
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I have been a home birth CNM for 14 years and I was an L&D nurse for 10 years  before that.  I used to agree that there is a place for non-nurse trained midwives here in the US, but I have since found that CPM training is woefully lacking.  I precepted a CPM student last year who stopped her training when she found out she couldn't complete her training in only one year (in November 2011 NARM changed some rules).  I was shocked to find that up until that time, if you completed your number of clinical experiences and passed the exam you could  be a CPM in one year.  Also, up until that time you could be a high school drop out and be a CPM.  Now, those things have changed.  What has not changed is that a formal educational component is not needed. As long as a midwife (who need not be licensed) has signed off that you've completed your clinical experiences, you can sit for the exam.  An acceptable midwife would be one that has attended at least 50 births on her own.  I'm an experienced midwife and didn't know to ask these kinds of questions about the training of a midwife.  How can the average "consumer" really know what kind of training her midwife has?  THAT is why we need licensing boards to do this work for us.  Would anyone really go to an unlicensed doctor, chiropractor, dentist?  Why would you use an unlicensed midwife? Ask your midwife why she isn't licensed.  Most will say they only license CNM's in this state.  Then ask, "Why aren't you a CNM."  They will likely say CNM's don't learn about home birth in their training, only hospital birth."  My question is, "Isn't birth the same whether it's in a hospital, a home, a taxi cab, a Walmart bathroom..." 

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#21 of 60 Old 05-05-2013, 07:09 AM
 
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  Then ask, "Why aren't you a CNM."  They will likely say CNM's don't learn about home birth in their training, only hospital birth."  My question is, "Isn't birth the same whether it's in a hospital, a home, a taxi cab, a Walmart bathroom..." 

 

This was the question also asked earlier. What specifically do CPMs/DEMs learn about birth at home that would not be something that was learned in midwifery in general?

IMHO, CPMs and DEMs are limited in what they know, as are CMs/CNMs who have only worked in hospital. Neither is working to the full scope of what they could be doing to assist women.

 

I think that the best midwife is the one who has the education, knowledge, experience, and skills to proficiency, as well as the flexibility to use all those things no matter the setting where she attends birth.  The knowledge base of the CNMs and CMs would seem to give them the edge.

 

If my choice for a medical procedure or surgery came down to a physician who was really likeable (warm and fuzzy), but not as skilled or competent, or a physician who was brusk, but extremely competent, I would take brusk over warm and fuzzy everytime.

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#22 of 60 Old 05-05-2013, 08:53 AM
 
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Does anyone know what percentage of US CPMs and DEMs have a university based education specific to midwifery?

 

No, not really, but this is a slide from a presentation given by NARM at the 2011 home birth summit

 

 

The problem with this chart is that it doesn't answer the question about the level of education specific to midwifery.

 

There is no way to know from this chart if the CPM's education is in art or classical music or nursing or horticulture or anthropology or what.

 

We do know that the minimum level of formal education required for CPMs is a high school diploma. It really doesn't matter what additional degrees *some* midwives may have - if they are not required for practice, licensure or certification. The lowest minimum is what sets the standard for the profession.

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#23 of 60 Old 05-05-2013, 05:30 PM
 
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The chart also doesn't specify whether the college work is in health sciences or other degrees. It's fine to have college level courses, but  neither economic nor engineering degrees have little to do midwifery.

 

Were there any other charts during the presentation that were more specific to coursework related to health sciences or midwifery?


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#24 of 60 Old 05-06-2013, 04:50 AM
 
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Were there any other charts during the presentation that were more specific to coursework related to health sciences or midwifery?

 

Here's a link to the entire presentation. I need to make a correction - this presentation was from the "CPM Symposium" not the Home Birth summit.

 

I have never seen any information regarding education specific to midwifery. It's even difficult to suss out how many CPMs have graduated from an accredited program. But I suppose that information is somewhere.

 

We're getting off topic from direct-entry midwifery... unless we're including CPMs as direct-entry midwives. Though I believe the original question was referring to DE midwives as distinct from CPMs.

 

Edit: [answering my own question] According to another presentation from the CPM Symposium, approximately half of the new CPMs attended a MEAC accredited program.

 

 

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#25 of 60 Old 05-06-2013, 09:54 AM
 
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I thought I has seen it claimed on this board that the MEAC programs were the equivalent of the Canadian program of study?  Having taken a look at some of the websites for MEAC accredited schools (such as Birthingway) and comparing it to the information provided on the Safer Midwifery for Michigan website re: Canadian midwifery education, it seems like there is a bit of a disconnect there.  Not sure which more accurate?


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#26 of 60 Old 05-06-2013, 12:26 PM
 
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I thought I has seen it claimed on this board that the MEAC programs were the equivalent of the Canadian program of study?  Having taken a look at some of the websites for MEAC accredited schools (such as Birthingway) and comparing it to the information provided on the Safer Midwifery for Michigan website re: Canadian midwifery education, it seems like there is a bit of a disconnect there.  Not sure which more accurate?

 

I think that schools like Birthingway and MCU would be comparable, as they're degree programs.

 

I checked out the Michigan website and got two things out of it:

 

- At this point, if you're not a CNM, you're not good enough to be an American midwife.

 

- Complaining about the current options without offering other solutions.


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#27 of 60 Old 05-07-2013, 12:27 AM
 
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I think that schools like Birthingway and MCU would be comparable, as they're degree programs.

 

I checked out the Michigan website and got two things out of it:

 

- At this point, if you're not a CNM, you're not good enough to be an American midwife.

 

- Complaining about the current options without offering other solutions.


I am pretty sure that is not what Sara Snyder at Safer Midwifery is saying. If you read her story, she was cared for by 2 CNMs, who did not have enough experience or education for doing breech OOH. The result was several minutes of head entrapment. He died 13 days later.

 

If she feels that a 3 year university based European model education is the minimum qualification for competent care for mom and baby, how is that a bad thing? No one is saying that DEMs can't be good midwives. The question is what is their level of education and competency. Currently, it's very low compared to the rest of the developed world. There may be very competent DEMs who do a lot of self study, but in some states there are no minimum entry requirements for a DEM to practice. How can a lack of education be a good thing for women and their babies?

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#28 of 60 Old 05-07-2013, 12:40 AM
 
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In my opinion they should not be legal.  Story after story shows amazingly low levels of education and ability to deal with emergencies among DEMs.

 

To me, CM or CNM is real midwife.

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#29 of 60 Old 05-07-2013, 08:37 AM
 
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There are solutions, but no one really likes them yet. There are master's degrees in midwifery for non-nurses. Even Bastyr is officially a master's degree now. There's still resistance to working within the mainstream medical and educational system. 

 

The hard fact is that the standard for independent health providers in the US is becoming a postgraduate qualification. NPs have it, pharmacists have it, SLPs and PTs have it. It's no use complaining that Canada and the UK have BSc midwives. 

 

I have heard that newly minted CNMs do not come out prepared to work independently, especially in OOH settings, but it seems to me that this defect could be fixed within the context of CNM programs if there were a desire to do so and preceptors could be found (I realize there is a vicious circle element to this, but keep in mind the growth of midwifery in Canada has also been slowed by this problem--there aren't enough existing midwives to train the new ones). Part of the original DNP proposal involved the equivalent of residency for midlevels, but I believe ACNM is not on board with requiring the DNP. 

 

I should add that while I do not feel a midwife needs to be an RN, I do not agree that the homebirth only model is sufficient. The model argues that the midwife doesn't need to know everything they do in the hospital because she's not going to be there. What this does, in practice, is limit exposure and familiarity with complications. "Good enough" is not good enough. 

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#30 of 60 Old 05-07-2013, 08:47 AM
 
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Education is great, and I don't have a strong feeling about what education should be required, but there's no trumping experience.  I don't care what letters you have after your name or how many books you've read.  I want someone who's seen and done it all.  At least twice.

 

Isn't the example of Ina May Gaskin and the outcomes on the Farm an excellent example?  There are so many competing interests in hospital births and birthing education.  Keeping up on the most recent science is great, but when I was researching my birth I was shocked by the woefully inadequate studies out there. 

 

What I want in birth is a skilled and experienced caregiver, and most importantly, one who's hands aren't tied by licensing or mind limited by "education."  Birth is hands on and messy.  Position means so much.  I want a MW who will assess me at a glance, and will move where I move, not the other way around.  And I just don't believe I could get that with CNMs.  Not where I live anyway.

 

I love the DEM who attended my birth.  The more barriers we put up, the more we tie MWs' hands.  What that means of course is asking good questions, taking responsibility for our own care, and being very public about bad service.  But those are things we should be doing anyway.


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