Our state is currently reviewing whether the direct entry midwife (non-nurse midwives) who have passed the NARM exam and acquired the credential as a Certified Professional Midwife (CPM) should be licensed to practice in the state of Indiana (HB1135). Currently, practicing as a midwife without being licensed as a Certified Nurse-Midwife (CNM) is a felony in Indiana.

In considering this issue myself, I pulled up the NARM application and thoroughly read the application process. As a previous instructor within a midwifery college for direct entry midwifery and having had been invited to participate on the Midwifery Education Accreditation Council board, I have some familiarity with the direct entry process. I have observed a number of midwives in practice, both direct entry and nurse-midwifery, and have utilized the services of both direct entry midwives and certified nurse-midwives.

The education, skills and experience are mandated by the Midwives Alliance of North America (MANA) and authenticated by NARM via testing of applicants. The general requirements include having observed ten births in any capacity, including watching a friend’s birth, and demonstrate having assisted in twenty additional births under the supervision of a qualified preceptor. Finally, applicants must demonstrate having functioned “in the role of Primary Midwife Under Supervision” at a total of twenty-five births.

A total of forty-five births must be attended, with five of those in a continuity role which means that rather than simply catching-and-running, the applicant must have also provided five prenatal visits, two postpartum visits and a newborn exam. No particular curriculum must be completed. No academic degree. No certification course and no recommended reading list is offered. However, applicants are required to complete a cultural competency module.

The core competencies and test specifications, updated in May of 2012, are cause for some alarm. One would assume that the credentialing organization would utilize their best experts to create and maintain up-to-date exam questions.

However, applicants are expected to teach monthly breast self examination techniques, which even Wikipedia recognizes as out-dated and even potentially harmful (2013).

Breast self-examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling.

BSE was once promoted heavily as a means of finding cancer at a more curable stage, but large randomized controlled studies found that it was not effective in preventing death, and actually caused harm through needless biopsies and surgery. The World Health Organization, the US National Cancer Institute, the US Preventive Services Task Force, the Canadian Task Force on Preventative Health Care, and many other scientific organizations recommend against the use of breast self-examinations.[1]

In the case of shock, applicants are expected to treat by providing “fluids orally” and “refer for IV fluids.” Generally speaking, shock during the intrapartum period is a medical emergency and offering oral fluids would put the mother at risk of aspiration. IV fluids are indicated immediately. Not to worry, applicants are also tested on their ability to “activate emergency medical services.”

Competency in one’s ability to administer a limited number of pharmaceuticals is also evaluated on the NARM exam. This should not be confused with prescribing pharmaceuticals. Direct entry midwives should be familiar with administering anti-hemorrhagic drugs, antibiotics, Lidocaine and even newborn medications; however, determining when to appropriately administer such medications or choosing the appropriate candidate, considering contraindications and managing side effects, or even comprehending antibiotic classes in effort to best treat specific bacteria or avoid allergy response, and management of such pharmaceutical is NOT a core competency. If the CPM is the only attendant in a homebirth scenario and not supervised, who provides the order for the emergency medication?

Urine dip sticks are included in the test specifications as routine management in prenatal care – can anyone say archaic? A meta-analysis published in 2005 showed screening for GDM and pre-eclampsia using urine dipsticks for glycosuria is ineffective with low sensitivities. The USPSTF advises testing for proteinuria only with hypertension. ACOG advises that there are no reliable predictive test for preeclampsia. Current recommendations are to obtain a urinalysis only at the first prenatal visit in low-risk women, yet the NARM exam doesn’t include the urinalysis or urine culture within their standard laboratory tests for prenatal care.

Management of pregnancy-induced hypertension is within the core competencies for non-nurse midwives as determined by MANA, although recommended treatment includes administration of calcium/magnesium supplementation. Hypertensive disorders remain a leading source of maternal mortality in the United States. Need I remind readers that no formal education is required to sit the NARM exam, yet within their core competencies is management of one of the leading cause of maternal death?

Attending vaginal births after a previous cesarean within a limited resource setting is included as a core competency for the direct entry midwife on the NARM exam and applicants are expected to be knowledgeable in “recognizing signs, symptoms of uterine rupture and knowing emergency management,” yet we learned earlier this includes oral fluids for shock and calling for an ambulance.

Direct entry midwives are expected to know that consuming an alcoholic beverage is among the best treatment regimes of preterm labor (see page 42 of the Candidate Information Bulletin, May 2012, for verification of this shocking point). Did I mention my concern?

The NARM competency exam tests for the applicant’s ability to obtain fetal heart tones during the intrapartum period, but not their ability to assess fetal well-being. The important difference here is that a CPM can identify a baby currently alive, but is not expected to identify one in distress and in need of medical management.

Applicants are tested on their ability to “instruct the mother to stop pushing after delivery of the head” and “clear the airway with suction of mouth and nose” in the presence of meconium (2012, p 45). A large study conducted in Argentina and the USA, demonstrated in 2004, that such procedure is not only unnecessary, but potentially harmful. Apnea and cardiac arrhythmias triggered by pharyngeal stimulation may result, as well as worsening hypoxia and damage to the upper airway (Vain et al, 2004). Core competency creators for the NARM exam may not be familiar with the American Academy of Pediatrics (AAP), developers of the Neonatal Resuscitation Course (NRP). They too discourage the above procedure and offer an extensive course on the best neonatal resuscitation procedures including intubation when appropriate and administration of emergency medications (deemed outside the scope of a direct entry midwife, yet necessary as soon as 90 seconds from birth). Applicants should be familiar with mouth-to-mouth resuscitation however, as part of the NARM exam test specifications.

Ironically, the NARM exam does test the applicants ability to apply principles of client confidentiality, yet as part of a random audit to ensure application integrity, applicants may be required to submit client charts to verify their participation in care. Is a medical release obtained from every client as part of this process? Is this an ethical use of private medical records?

I appreciate that not all midwives want to be nurses first, while I can’t imagine why one would choose to attend births in a limited resource setting without being quite confident in their clinical skills. The Certified Midwife is an alternative route still requiring academic education and testing from a certifying body that remains up-to-date with evidence based care practices.

I am not opposed to women birthing wherever and with whomever they choose. I am not opposed to reducing the penalty for practicing midwifery without a license in effort to decrease abandonment rates. I am concerned that licensing direct entry midwives at the above standards (and with the current proposed bill requiring only a high school diploma) that consumers will be lead to believe this standard is sufficient for primary care. My greatest issue with this bill, is that legislative leaders would best serve consumers by removing barriers to nurse-midwifery practice so that more CNMs will be available to homebirth families.

Written collaboration requirements for prescription privileges should be abolished, restrictions to malpractice insurance should be addressed, hospitals should be mandated to extend CNMs privileges where maternity services already exist, insurance companies should be required to cover services by our profession and Medicaid recipients should be allowed to choose CNMs as a primary provider while pregnant. If CNMs are prevented from practicing to the full extent of their training, which is currently moving towards the doctorate level, what rationale do we have for supporting similar practice by a high school graduate?

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17 responses to “HB1135”

  1. michelle

    I wholeheartedly agree with everything in this post. I also enjoy it because you have clearly articulated every reason I am uncomfortable with CPMs/DEMs/Lay midwives. The facts you presented and your explanation of the ways that LMs differ from CNMs just reinforces my view of the lay midwifery bill here in Indiana.

    I think your example of the way that NARM suggests LMs deal with shock is particularly telling… oral fluids are not enough. I also found it shocking that NARM/MANA requires so few pre-natals, postpartums and newborn exams.

    Thank you for writing! This is very informative especially for anyone who is confused about what lay midwifery means in general.

  2. Kristi

    Thank you for writing this post. The information is well researched and thoughtful. While I advocate for women being able to birth where they want and with a provider they are comfortable with, I am uncomfortable with practitioners who do not have enough education to care properly for pregnant women and neonates. Emergent situations can happen so quickly that without a skilled provider able to intervene appropriately or timely, death or permanent disability can be the result.

    When a family is looking for a health care provider and they are told that their provider is licensed, they will probably not be looking further to understand that their provider may not have the proper education or experience to care for them appropriately, or to manage their care in an appropriate manner. Your stated examples of NARM’s standard of care makes me very uncomfortable having their practice legalized in Indiana.

  3. Emily

    What an excellent article. I had no idea that direct entry midwifery meant no required academic courses. I think you really addressed the issue at the end. The problem is not just weak direct entry requirements, but difficulty in practicing midwifery even as a CNM. Once again legislation is addressing an issue in the wrong manner. Thank you for writing.

  4. Cindi Denbow CNM

    This is certainly a hot topic. I feel your frustration as a practicing CNM in the State of Florida where CPMs/DEMs/Lay midwives have the legal right to practice. While I have had the honor of working with some fabulous Florida Licensed Midwives, they are not all equally experienced, educated or carry the same level of professionalism while practicing midwifery. In my area, I have been bullied to the point of being threatened with physical harm by these so called “professional” midwives. Recently a local Licensed Midwife publicly threatened to burn the birth center down on her business facebook page.
    I operate a Birth Center in Florida and am forced to follow the same rules for Licensed Midwives because the Birth Center Rules were written from the Licensed Midwife Rules & Regulations. They are beyond outdated and not evidence-based. For example, dipping urine on all clients every visit, yearly pap smears, etc… You listed some great examples of the lacking of evidence based practice on the Narm exam as well.
    Thank you Penny for posting this. You are a well respected CNM in our field because you have work hard and continue to fight for what is right and just. If we are to preserve the Art of Midwifery, we must practice evidence based Midwifery and carry ourselves with dignity and professionalism.

  5. Elizabeth

    I agree this is such a well written article, it clearly explains so many of misconceptions about the level of training required. I understand that women rightfully trust their bodies and trust birth but emergencies do occur and it is very important to have a practitioner skilled in recognizing and appropriately managing emergent situations at a birth.
    It is important for the public to be aware of the differences between non-academically trained CPMs and Graduate level educated Nurse Midwives (CNMs) and not simply believe that licensed and regulated means safe.

  6. Kim

    While I appreciate your thoughts on the topic, all of my homebirths were attended by direct-entry midwives who did the NARM exam, and I had excellent care with all of them. I’m afraid that you are looking at this through the medical eye, which is the same reason that OB doctors look down on you, a CNM. Lack of formal education does not equal inadequate care. In my experience, I would say that it has enhanced my care as my midwives have listened to me, but they also require that I take charge of my own well being. Instead of feeding me answers, they encourage me to find those answers so I can be confident in my findings, not just taking them at their word.

  7. Angie

    I had my first child 8 years ago with a lay midwife, 2nd child was a transfer, and third with a CPM (all outside of IN). The third child was not breathing at birth and was transferred to the NICU. The last thing I would have ever wanted was a CNM (being all “hands off, let me do it myself”), but my viewpoint has changed. Penny’s post confirms what I observed – when intervention is truly warranted, they did not have adequate training. I wrongly assumed a CPM could intubate. I rested in that certification process. That said, my 2nd child was not treated properly according to current standards of care in the hospital either… Yikes. I don’t see the existence of CPMs as a problem, but I do see the requirements are lacking. I also did not like that my midwives were not able to work with local medical staff, due to hostility from the hospitals. I truly feel that is something that puts women and children at grave risk. Not to mention it was terrifying. I have not met Penny, but the kind of care she describes sure sounds good to me on the other side of three births…

  8. Freiya

    I’d like to share some thoughts as to why someone might choose the CPM route to midwifery rather than the CNM route. At age 17 I was accepted to a pre-med program, but I got pregnant and changed plans. I would never consider nursing because their primary job is to carry out doctors orders. In most states, including Indiana, a CNM has no more authority to write prescriptions than a CPM (a NP is the only “nurse” deemed qualified to write a script in Indiana).
    I may not agree with everything I learn at my MEAC accredited school or with everything any preceptors I have may do, but I would agree with almost nothing I would see done by doctors and CNMs in a hospital setting. Correct me if I’m wrong, but I’m pretty sure the CNM credential does not require any homebirth experience or even any experience with entirely physiologic childbirth (no meds, no IV, no physical restriction of any kind). I’m not entirely sure what CNMs are taught about comfort measures, but I guarantee medication use is a greater part of the curriculum. I would also take bets that I could find outdated/non-evidence based protocols in almost any nursing text currently in use. Just like a CPM, a CNM must be educationally self directed in order to truly provide the best care for out of hospital births.
    I will admit my bias. I suffered and could have died due to a “medwife” giving cytotec without anything resembling informed consent. Not all CNMs practice this way, but those in hospitals are seriously restricted by hospital protocol. The only reasonable explanation I could come up with for the way I was treated was that job loss is a real possibility if a CNM doesn’t follow rules.
    I would love to see more CNMs attending homebirths, but I don’t see that happening. If you want to improve the education for CPMs, then maybe CNMs should be encouraged to become preceptors for midwifery students. I would love to see birth centers with both CNMs and CPMs (it happens in some states). We can all learn from each other.

  9. Carla King CNM


    Thanks so much for your very informative post, as well as your responses and sharing the rationale for your own path to midwifery. I admit, I was under the assumption that CPMs had significant midwifery training and extensive preceptorships. That the CM and CPM credential were used interchangeably, not realizing that they sit for different exams. That requiring a national exam and having a national alliance meant there were stringent requirements to practice midwifery. I assumed that there are good and bad CPMs the same as there are good and bad CNMs and MDs, not BECAUSE there is a lack of standardized, intensive education. While I do believe there are some very safe CPM practitioners just as there are some very medical minded CNMs, I think the most important part for women, is truly knowing the difference, knowing their practitioner, and understanding their skill set.

  10. Negative Commentary | Believe Midwifery Services | Central and Northern Indiana Homebirth Midwife

    […] outside the law for so long. I don’t report. I don’t speak ill. However, two years ago, I did testify against the direct entry bill. Why? Because when I testified in front of the House, the bill only required a high school diploma. […]

  11. Jamie

    I hope this comment gets a response, since the post is already so old. I want to become a CPM, because I don’t have the time or money to spend 6+ years learning to be a nurse (which I have no desire to be) then a midwife.

    I agree that it isn’t safe to attend some births and pass a test, but I’ve found a few programs that actually teach at a college level. They offer a 2 year associates degree and classes include biology, chemistry, etc. You then spend extensive time training with a local midwife before taking the certification test.

    Am I correct in thinking that this route of education is not what you were referring to when you thought the standards for certification were too low?

    I’d love to be a midwife, and learn what I need to knowledgeably work in a homebirth environment. But I don’t want a bachelor’s degree where I have to take art 101 and sociology and freshman English and tons of other things that have nothing to do with being a competent midwife. I feel like the associates degree is a good way to cut out all of the unnecessary stuff, while gaining the knowledge I need.

    I know as a CNM you’re very much an advocate for that route, but I would love to hear your thoughts on this. Here’s a link to one of the school’s I was looking at attending. https://www.swtc.edu/academics/programs/health-occupations/midwife

  12. Honest Midwife | Believe Midwifery Services | Central and Northern Indiana Homebirth Midwife

    […] I blogged about the NARM exam here, and shared the not-so-popular position that the minimum requirements for the CPM credential is grossly inadequate for safe care of the birthing mother and child. Hire a childbirth educator and a doula. Don’t be fooled into believing you have a clinician who can provide clinical discernment and emergency management when you pay your direct entry midwife. Or hire her, enjoy her company, her encouragement, her presence but know her limitations. […]

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