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.
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?