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Warning flags from the Carnegie meetings.

Like many direct-entry midwives, I was very excited to hear about direct-entry and nurse-midwives sitting down together at a series of meetings funded by the Carnegie Foundation. In my joy to see that the American College of Nurse-Midwives (ACNM) had finally recognized that nursing need not be a requirement for midwifery training, lost sight for a while of what seems to be really going on: the ACNM is accepting input into formulating core competencies and curriculum for the training and/or certification of direct-entry professional midwives which i will govern. The ACNM position paper adopted 3/90 makes this quite clear:

"One result of that [first Carnegie Foundation] meeting was near unanimous agreement that we should have one standard of professional midwifery in the United States, and that the ACNM has set that standard. However, an important part of that agreement was recognition that there are several ways to meet the standard of professional midwifery."

In other words, in the newly developing ACNM programs, a woman won't have to become a nurse first, and she may get some credit for apprenticeship, or there may be challenge mechanisms so she can meet some requirements through life experience. However, at present a foreign-trained nurse-midwife who wants ACNM certification must pay $8000 and spend six months completing a full-time "precertification program" before she is allowed to sit the ACNM exam. If that's the way they treat a midwife trained in Great Britain or the Netherlands, are we whose training they suspect likely to come off any better?

And is the ACNM really likely to change its position of discouragement and even hostility toward homebirth? It obviously can't be totally unaware of the exemplary record of Dutch midwives and the statistical work of Marjorie Tew showing no causal relationship between improved infant mortality statistics and the move to hospital birth in Britain. The health of the mother and the skill of the attendant, not the place of birth, are determinants of outcome. But is the ACNM likely to temper its drive to make nurse-midwifery acceptable to the American medical establishment and start supporting midwives'and birthing women's rights to determine where birth takes place? I commend the ACNM for recognizing that there need to be more midwives in America and for reversing its stand that nursing is a prerequisite for midwifery training. Once it has been recognized that midwives are the solution to the current crisis in prenatal care, it is politically expedient to want to be in charge of these new midwives. However, are those who run the ACNM aware that as their ranks swell with new midwives who have a background in or affinity for home birth, they are going to have to come around still further? Or won't they?

And if ACNM-recognized direct-entry professional midwives" will be working in hospitals and clinics to meet the burgeoning demands for cost-effective maternity care and will be granted reimbursement by insurance companies, where will this leave the direct-entry midwives who don't want to or cannot spend the time and money required to take this training? They (we) will be left even further down the ladder, even further away from any kind of legal recognition or third-party reimbursement.

Like the grannies of the last generation of midwives, any midwife who doesn't want to leave her home and pay thousands of dollars to do what she is already doing very well, may find herself further cut off from clients and recognition, forced into retirement or back into the underground (isn't this what the ACNM has wanted all along?). And all this despite the fact that she may have certification from her state midwifery association and recognition through MANA and the International Confederation of Midwives.

Is there really "near unanimous agreement" that the ACNM should set the one standard of professional midwifery in the future? MANA is not in agreement with that! Maybe the time has come for us (through MANA) to stop debating the pros and cons of national certification and say, "If the ACNM is going to establish certification over us, then we must establish our own certification procedure, too, (and quickly!) and become a powerful political force comparable to the ACNM." As a group, I find us pretty naive and "powerless" politically, and pretty busy catching babies. But perhaps with help from consumer groups such as the Midwifery Communication and Accountability Project, we can find the strength to resist midwifery coming totally under the jurisdiction of the ACNM. Could we set up our own national certification program (MANA is already poised to do it after years of consideration and debate) and accept ACNM input into core-competencies and curriculum, just as it is allowing us to do? Then if there really is to be only one certifying organization in America, let it be something entirely new, or something which MANA and ACNM establish as equal partners. The International Confederation of Midwives feels that direct-entry midwives in America have something unique to bring to midwifery in the world; let's not discount it or give it away.

In order for me to feel comfortable having all legally recognized direct-entry professional midwifery governed by the ACNM, I would need to see some "good faith" changes from the ACNM, such as: discussion about what skilled, practicing direct-entry ("lay") midwives can realistically expect in terms of cost and training to become certified in such new programs; simplification of the challenge mechanism for foreign-trained midwives to show a true interest in having more midwives practice; and taking a stand in support of the rights of midwives to practice in all settings, including birth at home (without the requirement of physician backup or malpractice insurance in ways that are impossible to obtain). Okay, ACNM, how about a strong position paper supporting home birth if we're going to support your being in charge?

In the meantime, I urge all of us to support MANA and make our views known. Why are we letting the future of direct-entry midwifery in America come under the jurisdiction of the ACNM? I would also urge midwives in states such as California to act now with every ounce of strength they can muster to achieve favorable legislation. Because once ACNM direct-entry midwifery is established, the legislatures are going to tell lay midwives to forget it, that there's already a mechanism in place to be a legally recognized midwife. Let's get busy and not stand by and watch as we sell ourselves down the river.
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Title Annotation:Carnegie Foundation meetings on midwifery certification
Author:Baldwin, Rahima
Publication:Special Delivery
Article Type:editorial
Date:Mar 22, 1991
Previous Article:What is the definition of a midwife?
Next Article:New treatment for neonatal jaundice.

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