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					CPM Primer

What is a midwife?
The word “midwife” means “with woman”. Midwives have been attending women in childbirth
since the beginning of human existence and in most countries of the world still attend the
majority of normal uncomplicated births. Midwives have become professionalized in most
countries, although many traditional community midwives still practice in underdeveloped
countries; they are usually referred to as “traditional birth attendants” or TBAs.

Professional midwives typically go through a formal educational and credentialing process and
are regulated by their jurisdictions. In nearly all western European countries, for example,
midwives have always and continue to attend nearly all the normal births in their communities
under their own responsibility—they refer patients/clients to obstetricians only in the case of
complications that require a higher level of intervention. This model of maternity care where
midwives are the primary caregivers with Obstetricians as high-risk specialists is working very
well around the world. In fact, the countries that use this model have some of the lowest infant
and maternal mortality statistics in the world (see table 1 for 2006 WHO statistics).

Table 1
Country           Neonatal mortality rate 2006 (per        Maternal mortality rate 2006 (per
                  1000 live births)                        100,000 live births)

Finland                     2                                           5
Iceland                     2                                           0
Japan                       2                                          10
Sweden                      2                                           8
Germany                     3                                           9
Norway                      3                                          10
Switzerland                 3                                           7
United Kingdom              4                                          11
Canada                      4                                          5
United States               5 (ranked 34th in the world)               14 (ranked 28th)

History of Midwives in the U.S.
The history of midwifery in the U.S. differs significantly from other developed countries. In
Europe, midwives never lost their position as primary caregivers for pregnant women; instead,
as medical science advanced, the midwives were incorporated into the developing maternity
care systems and their training changed accordingly. Thus, they still stand at the center of the
maternity care systems in most European countries.

In the U.S., the colonial midwives were European trained midwives that immigrated to the
colonies, but no formal training programs were developed here until the 20th century. Midwives
in the U.S. were traditionally trained in the apprenticeship model from generation to generation
in their communities. When physicians and medical schools were established in the 19th
century, women were not admitted and the currently practicing midwives were not trained in
the emerging science of obstetrics. Midwives were eventually discredited as being ignorant
and dirty and displaced by physicians in caring for birthing women. By 1950, midwives were
nearly eliminated in the U.S. except in distinct religious and ethnic communities.
However, there was a resurgence of midwifery in the 20th century that was largely consumer-
driven and in response to the extreme medicalization of birth that peaked with twighlight sleep
and forcep use in the 1950’s and 60’s. During this resurgence, two types of midwives arose:
the Nurse Midwife and the Direct-entry midwife. Nurse midwifery was imported from the UK by
Mary Breckenridge, who founded a school in Kentucky in 1928. Later, during the women’s
movement and natural birth movement of the 1960’s and 70’s, midwives began to be trained
again in the traditional way—by apprenticing with older traditional midwives and physicians
who were supportive of midwifery. These midwives used the term “direct-entry midwives”,
borrowed from Europe to distinguish themselves from those who entered midwifery through

These two types of midwives- nurse midwives and direct-entry midwives- have continued to
develop on parallel tracts in the U.S. The nurse midwives are now well-established in the
medical community, are nationally certified as Certified Nurse Midwives (CNMs), are legal and
licensed in every state, work mostly in hospitals and currently attend approximately 10% of all
births. Direct-entry midwives did not organize as quickly but have had a national certification
(Certified Professional Midwife, CPM) since 1994, they are currently legal and licensed in 23
states, work exclusively outside the hospital, and attend 1-2% of all births in the U.S.

State of maternity care in the U.S.
Maternity care has been rapidly changing in the U.S. since the advent of Obstetricians in the
19th century. Midwives were displaced by physicians and birth moved into the hospital where
more and more technology and medication has been employed during pregnancy and birth.
There was a brief natural birth movement during the 1970’s that drastically changed the way
that birth happened in the hospitals relative to the 1940’s and 50’s when women were given
twilight sleep, strapped to their beds, forceps and episiotomies were in common use, partners
were not allowed in the birth room, newborns were separated from their mothers, and women
were encouraged to bottle feed. This natural birth movement encouraged mothers to give birth
without pain relief, partners were encouraged to take an active role in the birth, and
breastfeeding was determined to be the best food for babies.

For the past 25 years, the pendulum has been swinging the other way as the rates of
epidurals, vacuum extraction, inductions, IVs, antibiotic prophylaxis and particularly C-sections
have escalated. (See Table 3 below)

Table 3: U.S. C-Section Rates 1970-2007
1970        5.5%                                       1996      20.7
1975        10.4                                       2000      22.0
1980        16.6                                       2002      26.1
1990        23.5                                       2006      31.1
1993        22.8
Statistics from the Center for Disease Control, NCHS

Despite the intention to improve the health of mothers and babies through the increased
medicalization of pregnancy and birth, the evidence does not support this intent. According to
the 2006 Report from the World Health Organization, the U.S. ranks 34th in the world for
Neonatal Mortality. 33 countries have better birth outcomes than the U.S. including virtually all
western European countries, the Republic of Korea, Singapore, Slovenia, Greece, Iceland,
Israel, Japan, Australia, Canada, Cyprus, Czech Republic, and Cuba.

At the same time, the U.S. spends more per capita on healthcare than any country in the world
(see Table 4 below), so what is the difference? Marsden Wagner, neonatologist and former
head of Maternity Care at the World Health Organization, believes the difference lies in the
position of midwives in the maternity care systems of these countries. In nearly every other
country with better outcomes, midwives are the norm for birthing mothers and only high-risk or
complicated pregnancies are referred to physicians for medical management and intervention.

Table 4: Per Capita Total Expenditure on Healthcare
United States            $5,711
Canada                   2,669
Germany                  3,204
Japan                    2,662
France                   2,981
Sweden                   3,149
United Kingdom           2,428
Switzerland              5,035
World Health Statistics, WHO, 2006

Types of Midwives currently practicing
There are three different midwifery credentials available in the U.S. today:

•Certified Nurse Midwives (CNMs) are nationally credentialed and the vast majority of CNMs
work in the hospital setting. A CNMs training consists of first becoming an RN followed by a
two-year advanced practice training in midwifery leading to a masters degree in midwifery.
Their clinical experience is largely conducted in hospitals. They often work in practices with
Physicians, although in Maine, they sometimes work in private practices. There are
approximately 11,000 practicing CNMs in the U.S. today and they attend approximately 11%
of the births. In Maine, there are approximately 50 CNMs in 29 hospital-based practices. No
CNMs currently attend births outside the hospital setting.

The CNM credential is accredited by the National Organization of Competency Assurance

Certified Professional Midwives (CPMs) are midwives who are trained specifically to attend
births at home or in freestanding birth centers. The CPM credential is competency-based and
thus allows midwives to enter the profession through a variety of educational routes, including
3-year accredited programs and structured apprenticeships. There are currently approximately
1300 CPMs in the U.S. who attend just over 1% of births. There are approximately 30 CPMs
currently in Maine practicing in homes or free-standing birth centers.

The CPM credential is accredited by the National Organization of Credentialing Agencies

Certified Midwives (CMs) receive the same midwifery training as CNMs without the Nursing
degree. The vast majority of CMs work in hospitals. This is a new credential (available for
about 8 years), was created by the American College of Nurse Midwives, and there is only one
educational program for CMs, located at SUNY Downstate. Only 3 states currently license
CMs. There are no CMs in Maine.

Uncredentialed Midwives are home birth midwives who choose not to become credentialed
for philosophical, religious, or cultural reasons. In Maine there are a few uncredentialed
midwives who have small practices in distinct religious, ethnic or cultural communities. These
are often communities who traditionally give birth outside the hospital and they train their own
midwives to serve their communities (Amish, Mennonite, Native American…..).

Who are CPMs?
Certified Professional Midwives are nationally certified, direct-entry midwives who attend births
in homes and freestanding birth centers. CPMs must either graduate from an accredited
program or go through a portfolio evaluation process to verify their education and skills,
whether it be training in another country or a community-based apprenticeship. All CPM
candidates must pass an 8 hour written exam and a skills exam, and must recertify every 3
years. They must participate in regular peer review, continuing education, and are certified in
adult and neonatal resuscitation.

As more and more direct-entry midwifery schools develop and become nationally accredited, a
larger portion of the CPM applicants are graduates of accredited programs. In 2006, over 50%
of new CPMs were educated in formal accredited programs and the trend towards formal
training continues.

CPMs accept only low-risk clients and attend only low-risk births. In the event of a significant
complication in pregnancy, during the birth, or post partum, CPMs consult with or transfer care
to a physician. CPMs are trained in prenatal, intrapartum, post partum and newborn care,
including management of the variations from normal that can occur during the childbearing
year. They are trained in prenatal risk assessment, phlebotomy, nutritional counseling, normal
prenatal care, fetal monitoring, labor assessment and support, birth care, administration of a
limited number of drugs to control hemorrhage, IV administration, suturing in case of perineal
lacerations, newborn resuscitation, adult CPR, newborn assessment, and post partum care.
CPMs offer all the current pregnancy screens such as the Quad screen, Ultrasound,
Gestational diabetes screen, and GBS cultures. They also offer eye prophylaxis, vit K and
perform the Newborn Metabolic Screen and file birth certificates with the state.

What is Care from a CPM like?
CPM care varies somewhat from provider to provider but all adhere to the “Midwives Model of
Care”. This model recognizes birth as a normal, natural physiological process that usually
does not need to be interfered with. Other components of this model are:
       •Concern with the physical, psychological, and social wellbeing of the client—a holistic
       •Individualized care, personal attention, time to build relationships
       •Continuity of care; the same person who provided prenatal care is present throughout
               the birth and post partum period
       •Frugal but appropriate use of technology
       •Empowering women through informed choice in all aspects of care
       •Referral to medical providers when outside our scope of practice
The schedule of care with a CPM is the same as with other maternity care providers and the
procedures done at clinic visits are similar. CPMs generally spend 1 hour per prenatal visit and
are present throughout a woman’s labor and 2-4 hours after the birth. Both the pregnant
woman and her partner are considered partners in their care and all information and
assessments are shared with them.

Is birth outside a hospital setting safe?
Many rigorous studies have been done to investigate the safety of birth outside the hospital
and the evidence is overwhelming. Planned home birth with a trained attendant is as safe or
safer than birth in the hospital.

The most recent and relevant study was conducted by Canadian researchers Kenneth
Johnson and Betty-Anne Daviss and was published in the British Medical Journal in June,
2005. "Outcomes of Planned Home Births with Certified Professional Midwives: Large
Prospective Study in North America." Can be accessed online at

This largest prospective study of planned home birth with a direct-entry midwife (5400 births in
year 2000) shows that birth at home or in birth centers is as safe as hospital birth for low risk
women, yet carries a much lower rate of medical interventions, including Cesarean section.
The researchers analyzed outcomes and medical interventions for planned home births,
including transports to hospital care, and compared these results to the outcomes of 3,360,868
low risk hospital births. According to the British Medical Journal press release, they found:
• 88% of the women birthed at home, with 12% transferring to hospital.
• Planned home birth carried a rate of 1.7 infant deaths per 1,000 births, a rate "consistent
   with most North American studies of intended births out of hospital and low risk hospital
• There were no maternal deaths.
• Medical intervention rates of planned home births were dramatically lower than of planned
   hospital births, including: episiotomy rate of 2.1% (33.0% in hospital), cesarean section rate
   of 3.7% (19.0% in hospital), forceps rate of 1.0% (2.2% in hospital), induction rate of 9.6%
   (21% in hospital), and electronic fetal monitoring rate of 9.6% (84.3% in hospital).
• 97% of over 500 participants who were randomly contacted to validate birth outcomes
   reported that they were extremely or very satisfied with the care they received.

This study provides irrefutable evidence in support of the American Public Health Association's
resolution (2001) to increase access to out-of-hospital births attended by direct-entry
midwives. This study supports the World Health Organization's 1996 position: "Midwives are
the most appropriate primary healthcare provider to be assigned to the care of normal birth

Do CPMs carry malpractice insurance?
Currently there is no product available to a CPM in Maine that would provide professional
liability insurance for her practice. Insurance companies are not eager to insure a small pool of
unlicensed practitioners and do not offer malpractice insurance to CPMs. A license would be
helpful in pursuing insurance in the future.
There are a few states that provide an affordable malpractice insurance policy to licensed
midwives in their state; New Hampshire is one that does this.

Do CPMs get third party reimbursement?
In states that do not require CPMs to be licensed, most clients pay out of pocket for CPM
services, although some insurance companies do reimburse for part of the fee.

How do CPMs differ from CNMs?
The most significant differences between CNMs and CPMs are in their site and scope of
practice (see Table 5).

CPMs work primarily in the home setting with a growing minority working in freestanding birth
centers. CPMs provide the out-of-hospital choice to families who desire it.
CPMs care for healthy low-risk women during the childbearing years only and cannot
prescribe any medications.

CPMs offer a specialized type of maternity care to those women and families who are used to
taking responsibility for their healthcare, desire a non-medicalized birth, appreciate the
individualized and personal care CPMs are able to provide, whose spiritual and cultural beliefs
lead them to birth outside the hospital, who live in rural, underserved areas, or who appreciate
the affordability of CPM care. CPMs provide a completely unique service that is not being
offered by any other type of provider currently in the state of Maine.

CNMs are trained to work in hospitals and with a few exceptions, that is where they practice.
They provide an excellent choice for women seeking a hospital birth experience.
CNMs are also trained to provide care to women from puberty to menopause and beyond.
They have limited prescription privileges. Besides maternity services, CNMs offer well-woman
care, family planning, and routine gynecological care for women of all ages. Because they
have hospital-based practices, they can manage a broader range of pregnant clients.

Table 5: Differences in Scope of Practice
Type of Provider               Scope of Practice
Certified Professional Midwife Prenatal, intrapartum, and post partum care for normal healthy pregnant
         CPM                   women. Well baby care until 6 weeks post partum. Some routine well
                                    woman care (annual exams). Cannot prescribe medications. Work in out of
                                    hospital settings only.
Certified Nurse Midwife             Primary care to women throughout the lifespan. Prenatal, intrapartum and
         CNM                        post-partum care for essentially normal, healthy pregnant women. Well
                                    woman care, family planning, some gynecological services. Can prescribe
                                    medications. Work mostly in hospitals, few do home births or work in birth

What is the position of CNMs on the licensing of CPMs?
The Maine Association of Certified Nurse Midwives (MeACNM) wrote a letter of support for the
licensure of CPMs in 2007 when the first bill to license CPMs was introduced by the Maine
Association of Certified Professional Midwives (MACPM).

How do CPMs interface with physicians and hospitals?
It is critical that good collaborative relationships are established between CPMs and
physicians and hospitals in order to maximize the safety of home birth. In approximately 10%
of all cases, consultation with or referral to a medical provider is required either prenatally,
during the birth, or post partum. This can vary from a simple question about an unusual
finding, a request for testing such as an ultrasound, access to a medical laboratory for
bloodwork, or a transport to the hospital during labor. The vast majority of interactions between
CPMs and physicians and hospitals are for access to the technology and medications that are
available in those settings, not urgent or life-threatening situations.

Currently these relationships vary greatly depending on geographic location. CPMs practicing
in Maine have some very open, helpful and supportive relationships with Doctors and
hospitals, but in general they struggle with these collaborative relationships with the medical
community. This lack of willingness to collaborate with CPMs is based in a strong cultural bias
against CPMs and birth outside the hospital setting. We find there is a lack of information and
a plethora of misinformation circulating about our practices and resistance to becoming more
informed and building relationships with CPMs.

Part of this resistance may stem from fear of liability, although it is clear that physicians are not
held liable for care that was given before they were their patient. This immunity is parallel to
any transfer of care from one provider to another within the healthcare system such as from a
family physician to a specialist, or a CNM to an OB/GYN.

Education comparison
CPMs attend a 3-year accredited program or complete a 4-5 year apprenticeship. In order to
gain the credential, applicants must document a minimum of 1350 hours of clinical experience
including attendance at a minimum of 40 births (20 at which the student was the primary
caregiver), 75 prenatal visits, 40 post partum exams, and 20 newborn exams. Applicants must
also document mastery of all entry level skills (signed by the preceptor), document where/how
didactic learning occurred, and pass a skills exam and an 8-hour written exam.

CNMs are RNs and then extend that with 2 years of training in midwifery and women’s
healthcare. A CNMs scope of practice is broader than a CPM’s, so a portion of a CNM’s
education is devoted to those topics (i.e. family planning, basic gynecological care,
menopause, primary healthcare for women).

See table 6 to compare the curriculum of a CNM program (the one many CNMs in Maine have
graduated from), a CPM program (Birthwise Midwifery School in Maine), a family practice
physician program (UNE), and the apprenticeship route of CPM training.
Table 6: Educational Comparison of Maternity Care Providers

                                                                        Maternity Care

                                                          Anatomy and
                                                                                                        Clinical Requirements

                                           Total Credit

                                                          Credits in

                                                                        Credits in

                                                                                         Credtis in

                                Years of


 University of     MD-          4 yrs                                                                   Years 3 & 4 are clinical training.
 New England       Family       post                       9 cr           7 cr             2 cr         There is one required OB rotation
 Medical           Practice     Bacc                                                                    (6-8 wks). Further OB training in
                                                                                                        residency programs (generally 4
                                                                                                        months if OB practice is desired).

 Frontier          MSN                     66 cr                                                        4-10 months of clinical training
 School of         CNM          2-3 yrs    (51              2 cr          21 cr            3 cr         with a CNM preceptor
 Midwifery and                  post       didactic,      in
                                BSN        15             addition
                                           clinical)      to RN
 Nursing                                                  reqs

 Birthwise         Certifi-                                                                 2 sixty hour rotations and 18
 Midwifery         cate of      3 yrs       93 cr         4.0 cr     38 cr       1.2 cr     month preceptorship
 School            Midwifery               (48
                   CPM                     didactic,
 in Bridgton
 Maine                                     clinical)
 Apprentice        National     3-5        An apprentice-trained midwife uses the Core Competency document published by
 Trained CPMs      certifica-   years      the Midwives Alliance of North America (MANA) as a guide for her didactic
                   tion                    learning and the NARM skills list for organizing her clinical training. She works
                   CPM                     on-going with a mentor midwife who meets NARM criteria, performs self-study,
                                           has tutorials with mentor midwives, and may attend classes and workshops in
                                           order to meet those learning goals. She must provide legal documentation of all
                                           required supervised clinical experiences as required by the credentialing body
                                           (NARM), and pass the credentialing written and skills exam in order to receive her
                                           national CPM credential.

Information gathered from school websites and

Why do some families choose CPMs for their caregivers in pregnancy?
A small but growing number of women and their families are choosing to give birth in a less
medicalized setting under the care of a CPM. They make this choice based on their own
personal, philosophical, spiritual, or cultural perspectives that inform their desire to birth
outside the hospital. Their reasons vary greatly but all approach their pregnancies and births
as normal, natural processes, want to minimize the level of technological intervention and are
seeking a more individualized model of care. CPM clients tend to be well informed and are
accustomed to taking responsibility for their own healthcare. Some clients are fully insured
and choose to pay out-of-pocket for this care and others have no insurance and find CPM care
much more affordable than a hospital birth.

How do CPMs contribute to rural access to care?
CPMs serve many communities that do not have a local hospital. Some of our clients would have to
travel nearly an hour to receive hospital care and even further if they wanted to work with a midwife in
the hospital. This is a hardship for rural mothers who have to travel long distances for prenatal and post
partum appointments as well as travel while in labor, particularly if they have a history of very fast births.
If they have other children this becomes even more difficult. CPMs are ideally suited to work in these
rural areas where prenatal and post partum visits often occur in the home as well as the births.

Legal status of CPMs
Currently 23 states license the practice of CPMs, including our neighbors New Hampshire and
Vermont. There are 8 states that outlaw the practice of CPMs and the other 19, including
Maine, neither outlaw nor regulate their practice (

In the 19 states where the legal status is unclear, midwives continue to practice at the risk of
being taken to civil court in the case of a complaint, poor outcome, or accusation of practicing
medicine without a license. Such cases have happened and continue to happen in many
states, including Maine in 19___ when a midwife was accused of ________ by the attorney
general, taken to court, and acquitted after spending thousands of dollars on legal fees.

These cases are not malpractice suits being filed by dissatisfied clients, these are charges
being filed by hospitals and other medical providers who are unsupportive of CPMs and out-of-
hospital birth. In states where CPMs are licensed, there is a complaint and disciplinary process
available to deal with grievances that does not involve the civil courts and that has the
authority to limit or prohibit the midwives practice as the case requires.

Why have the CPMs in 23 states submitted and passed legislation to license
their practice?
It is customary for emerging health-related professions to eventually become regulated--
particularly those who use restricted medications and supplies, who are responsible for the
physical safety of their clients, and who must be part of a larger system of healthcare providers
to perform their job safely. All of these are true for CPMs.

Following are the specific ways that licensing CPMs will benefit the public and CPMs:
1. Licensure will provide parents with assurance that their midwife has met state and
        national standards and is being held accountable in her practice.
2. The public will have a state licensing board to contact with complaints.
3. Licensure will provide a disciplinary mechanism with which to respond to cases of
        negligence or misconduct on the part of the midwife.
4. Licensure will provide a defined scope of practice for CPMs to work within.
5. Legal recognition of CPMs will encourage better collaboration between midwives and other
        maternity care providers and hospitals when such collaboration is indicated. This will
        ultimately result in better care for pregnant women under the care of midwives.
6. Licensure will allow CPMs access to a limited number of restricted supplies and
        medications necessary for safe and responsible midwifery practice, particularly anti-
        hemorrhagic drugs in the case of heavy bleeding post partum.
7. State regulation clearly defines the legal status of CPMs.

Why professions are licensed by their states.
According to the Office of Professional and Financial Regulation, Maine licenses professions
only if its members pose a potential threat to public safety. Although the commissioner
determined that CPMs did not meet that criteria through the Sunrise process conducted in
2007, it seems obvious to many that CPMs, by the nature of their work, pose a potential threat
to the public. If Nurse Midwives, EMTs, massage therapists, acupuncturists, interior designers
and hairdressers all are licensed in Maine, it seems counter-intuitive that CPMs would be
denied licensure based on that criteria.

A license gives the public some assurance that their providers have met a certain standard
and are being held accountable to it. A license also gives the state a way to prohibit a
providers from practicing if there is evidence of negligence or misconduct.

A license provides an accountability mechanism that protects the public as well as the
profession. Licensing also can give access to the tools and services needed by the
professional if these are not available to the lay person.

Summary of what happened with LD2253 in 2007-8

This is the second attempt to pass a bill to license CPMs in Maine. In December of 2006
the Maine Association of Certified Professional Midwives (MACPM) submitted a bill under the
sponsorship of Rep. Nancy Smith that would license CPMs in Maine. The bill was heard by the
Business, Regulation, and Economic Development Committee (BRED) in April of 2007. Since
this is a new proposed licensing program, a Sunrise Review was required by the
Department of Business and Financial Regulation. This process took place during the summer
of 2007, with interested parties answering a series of questions provided by the Department
that would help them decide whether licensing CPMs in Maine was necessary. A public
meeting was held in Augusta in August where Ann Head, commissioner of DBFR asked
questions of the people present and recorded answers. More evidence for and against
licensing was collected into the fall and Ms. Head released her report in February 2008. Her
decision was in opposition to the licensing of CPM due to her belief that licensing CPMs would
not offer any significant protection to the public in regards to health and safety.

A second public hearing was held in March of 2008 and following that, a vote was taken in the
BRED committee and the majority vote (7-6) decided to continue supporting the licensing bill.
At the same time the minority vote submitted a minority report to give CPMs the ability to buy
and administer 5 restricted medications (pitocin, lidocaine, oxygen, eye ointment and Vit. K)
without a license. These two bills were taken to the House for a vote with the majority bill
succeeding (8 -5 ). The bills then went to the Senate for a vote and failed (12-23), but with
the minority report succeeding ( ).

There was significant public criticism of the bill that passed due to the lack of precedent for
allowing non-licensed providers access to restricted medications. This is the first bill of it’s kind
in the nation and presents some significant hurdles in it’s administration. At this writing
(August, 2008), the policies and procedures for this statute have not been finalized, so no
experience has been had regarding it’s implementation.

Why a new licensing bill is being drafted for submission in 2009.
Although grateful for the ability to legally obtain and administer a few of the drugs necessary
for safe midwifery practice, there are many limitations to the current statute. MACPM originally
sought licensure for CPMs because of the accountability mechanisms it provides and the clear
definition of our practice as defined in the bill as legal. As more and more CPMs begin practice
in the state (Birthwise Midwifery School graduates 10 midwives each year, some of whom stay
in Maine), the CPMs feel a real need for regulation of the profession as a matter of public

There are several more medications that are not included in the statute that are important for
CPMs to have access to, such as RhoGam, IV supplies, ultrasounds and methergine.

A clearly defined scope of practice, as provided in licensing regulations, will bring some
common standard to the practice of out-of-hospital birth that will facilitate better collaboration
and cooperation between CPMs and the medical community as well as between CPMs
themselves. This will only benefit the mothers and babies being served.

Licensing CPMs will offer Maine citizens a safe and affordable option for their maternity care
that could, if supported, be a significant asset to the state.

How this new bill addresses some concerns voiced by legislators during the
2008 legislative session.
MACPM has rewritten the current licensing bill in important ways in order to address some
concerns we heard from legislators last time around. Following are the concerns and how this
new bill addresses them.

•“Not all midwives are required to be licensed with this bill”.
        LD 2253 was a title licensing bill— only licensed midwives could use the title “Licensed
        Midwife”, however CPMs could practice unlicensed if they desired. MACPM wrote the
        bill this way in order to be respectful of the existing and potential traditional midwives
        that practice in distinct religious, cultural, and ethnic communities in Maine (Amish,
        Mennonite, Native…). This new bill will require all CPMs to become licensed in Maine,
        but includes an exemption for the traditional midwives described above. This is a
        common exemption found in other state’s midwifery laws.

•“We are not comfortable with the apprenticeship route to the certification”
       Currently, midwives can go through a Portfolio Evaluation Process when they apply for
       certification and prove their competency through documentation of training and testing.
       The national credentialing agency makes a provision for the apprentice trained
       midwife, because that is how most CPMs were trained prior to the development and
       accreditation of schools for CPMs in the past 15-20 years. Although MACPM believes
       apprenticeship is a viable training model for midwives, this has been a real stumbling
       block for the legislators.

       This new bill requires that all licensed midwives in Maine attend a MEAC accredited
       program or pass a rigorous challenge process administered by Birthwise Midwifery
       School beginning in 2012. Prior to that date, all currently certified CPMs will be eligible
       for a license.

•“If CPMs are using medications, we should require pharmacology as part of their
       This is addressed in the new bill by the revised education requirements. MEAC
       accredited schools must include pharmacology as part of their core curriculum.

•“Even people without a high school education could become midwives”.
       The new bill requires that all licensed CPMs be high school graduates.

•“The state should collect data from CPM practices in order to monitor how the program
       is working”.
       The new bill requires that all licensed midwives file prospective statistics for all their
       clients through MANAstats or other data collection mechanism.

There are currently 9 states where CPMs are licensed whose Medicaid program reimburses
clients for care by a CPM.

Why does the American Medical Association say they oppose every bill to
license CPMs?
•They claim CPMs are inadequately trained
       See education section.

•They claim CPMs have inadequate training in pharmacology
       The Bill to License CPMs requires training in pharmacology.

•They believe home birth is unsafe- public health and safety in jeopardy
       The scientific evidence does not support this view.

•They say a state license would sanction the practice of CPMs
       If CPM practice is safe, needed, and cost-effective as the evidence shows, wouldn’t
       this be considered a benefit to the state?

•They fear licensing CPMs would encourage more home births
       Again, since home births have been determined to be a safe option for healthy women,
       why is this a problem?

•They state CPMs lack of collaboration with medical resources
       This seems like an illogical argument. CPMs believe part of the difficulty with
       collaborating with the medical community is based in our unclear legal status and lack
       of regulation. We believe a licensing program will improve cooperation between all
       maternity care providers.

•The current system, recognized by ACOG, is working well.
       By international standards, a strong argument can be made that the U.S. maternity
       care system is not working as well as it could. We rank 34th in neonatal mortality rate
       and 28th in maternal mortality rate (2006 World Health Statistics, WHO). Our cesarean
       rate is quickly approaching 1/3 of all births, and we spend significantly more per capita
       on healthcare than any other country in the world.
       It may be time for all types of maternity care providers to come together and look at the
       reasons for our outcomes in this area, including the role of midwives in our system as
       compared to other countries with better outcomes.

Why CPMs believe the AMA/MMA opposes a bill to license CPMs:

       •There is a federal mandate from ACOG to oppose all CPM licensing bills
       The national ACOG has instructed and developed materials for states to oppose all
       CPM bills. ACOG issued a Statement on Home Births in February, 2008 that reiterated
       their long-standing opposition to home births based on their “belief that the safest
       setting for labor, delivery and the immediate postpartum period is in the hospital, or a
       birthing center within a hospital complex… or a freestanding birthing center that meets
       the standards of the Accreditation Association for Ambulatory Health Care…” This
       belief, however is not supported by any evidence and is overwhelmingly disputed by
       the existing evidence as well as the American College of Nurse Midwives (ACNM), the
       American Public Health Association (APHA), the Royal College of Midwives and the
       Royal College of Obstetricians and Gynaecologists in Great Britain (Joint statement
       No.2, April 2007).

       •Physicians view this as a turf battle
       The growing interest in non-medicalized birth and birth outside the hospital is seen as a
       threat to physician scope of practice (particularly OB/GYN practices). The AMA has
       historically opposed nearly every profession that has tried to secure its place through
       legislation (i.e. Nurse Practitioners, Nurse Midwives, Chiropractors, Acupuncturists,
       Naturpaths). Physicians believe they should have a monopoly on the services they
       provide and that any other professional that offers related services is infringing on their
       scope of practice.

       MACPM believes that maternity care choices are essential for pregnant women.
       Women have and will continue to choose to give birth outside the hospital so we
       believe licensed professionals should be available to serve them.

       •A powerful cultural taboo exists in the U.S. around birth in any other setting
       than a hospital
       Because home birth was virtually eliminated and most people have never experienced
       or witnessed a home birth, people hold an uninformed view that it is dangerous.
       Physicians are trained to view birth as a potential complication and rarely see a normal,
       unmedicated birth from start to finish. Therefore, it is difficult for them to understand
       why anyone would want to give birth at home.

       The answer to these concerns is to look at the studies that have been done that
       overwhelmingly demonstrate the safety (and benefits) of birth outside the hospital.

What are the financial considerations of licensing CPMs?

The financial benefits of CPM care are extensive. Complete pregnancy, birth, and post-
partum care by a CPM costs between $2000-$3500 in Maine. An uncomplicated birth in a
hospital costs between $5000-$10,000. If the birth is by c-section with no complications it
costs around $12,000. Let me illustrate the savings to the total cost of healthcare in Maine in
2006 using Maine Vital Statistics data.

Number of home births in 2006:        136
Cost of home birth, figure used:      $2750
Cost of hospital birth, figure used:        $7500
Cost of c-section, figure used:             $12,000
Savings per vaginal birth when CPM used:    $4750
Savings per c-section avoided by CPM care:  $9250
Number c-sections avoided by CPMs):         35
        (4% rather than 30%)

Maine Healthcare dollars saved in 2006 by using CPMs
35 C-sections avoided:                 $323,750
Savings of 101 normal births at home:         $479,750
                              Total savings: $803,500

In a state where 1 in 8 (12.5%) of non-elderly residents (136,000) lack health insurance
coverage of an kind, CPM care may be an important option to preserve and support. (“Health
Insurance Coverage Among Maine Residents: The Results of a Household Survey”, 2002. Muskie
School of Public Service, Institute for Health Policy.)

For those concerned about the cost of a new licensing program to the state, an economic
analysis of the cost benefits of the licensed midwife program in Washington state indicates
that “The cost savings to the health care system (public and private) is estimated to be ten
times the cost of the program.” (Midwifery Licensure and Discipline Program in Washington State:
Economic Costs and Benefits, A report to the Washington Department of Health, Health Management
Associates, October, 2007)

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