If berries from other countries are reading this thread and are confused, I’d like to explain the US midwifery system.
The first type of midwife is a CNM, a Certified Nurse-Midwife. This is a midwife who first earned an RN, then or concommitantly earned a bachelor’s degree in nursing, and completed a 2+ (now mostly 3) year Master’s degree in midwifery. They are very well respected health care practitioners who have close relationships with obstetricians; they have extensive in-hospital training where they see and diagnose complications both antenatally and in labor (though they typically do not manage complicated or high-risk patients); they are licensed independent providers who have prescribing privileges (can prescribe medications), admitting privileges (can admit patients to a hospital and be the provider listed as responsible for their care); they are required to pass rigorous licensure exams, meet certain criteria to be eligible (i.e. X # of deliveries, assist/watch X # c-sections/complicated births, see X # prenatal patients). They can bill insurance and are required to hold malpractice insurance. Their license is regulated by the state medical board and they are subject to formal inquiries and disciplinary hearings, including revocation of licensure and even criminal charges. In many respect they are held to the same standards as physicians [though in most US states, they are required to work under the license of a physician].
In most Western countries, including [name]Canada[/name], Australia, and all of Europe, this is the only type of midwife which exists.
In the US there is a second type of midwife, which is a “Direct Entry Midwife.” This means the midwife did not first earn a nursing degree, is not required to have a preexisting background in health care, and can train in an apprenticeship model with an existing midwife rather than in a hospital-based graduate-level accredited program. In many US states DEMs are not permitted to practice legally. They are called CPMs (Certified Professional Midwives) or LMs (Licensed Midwives, in the states where licensure is permitted). In many of the 20+ US states where licensure is permitted, it is VOLUNTARY. Unlicensed midwives are allowed to practice in these states. CPMs are NOT health care providers under the same aegis as doctors, dentists, nurse practitioners, physician assistants, etc. Their licensure is under a separate organization, not the medical board, which is called NARM, and they are NOT permitted to work in hospitals (so they attend home & birth center births exclusively; as students they do shadow in hospitals occasionally). The licensure process is very minimal compared to nurse-midwifery [note: many people will surpass these requirements, but these are the minimal standards. And they’re voluntary); Oregon, for example, requires only 25 deliveries and 100 total pregnant patients seen for licensure, as well as passing a weekend CPR course. You must also pass a 200-question multiple choice exam.[http://www.oregon.gov/OHLA/DEM/Pages/Midwifery_How_to_Get_Licensed.aspx#Application_Process]
To put this in perspective, an average obstetrics resident in an average week on Labor & Delivery would perform at least 25 deliveries as the primary birth attendant. That’s only 4/day. In a clinic day, the average patient load is between 10-20/day, given the complexity of the patients and the type of visit. So in a clinic month, they would hit that 100-patient mark in roughly 2 weeks.
Since licensure is voluntary and since many CPMs are not permitted or do not wish to carry malpractice insurance, it is a very, very difficult profession to police. “Bad apples” simply cannot be weeded out, short of facing criminal charges.
Shyshutterbug, I am very curious how people in your program are handling [name]Judith[/name] Rooks’ recent data review for the state of Oregon.
For those who don’t know, a homebirth-friendly nurse-midwife named [name]Judith[/name] Rooks was charged with rigorously examining the outcomes for planned homebirths versus hospital births in the state. Oregon is considered one of the more home-birth friendly states in the country; there is an eager clientele, the state permits CPMs to carry a few obstetric-relating lifesaving medications, and CPMs can receive Medicaid reimbursement if they are licensed. Unfortunately she found a NINE-fold (900%) increase in mortality-- not disability or complications, but death-- for the homebirth group.
