The May  issue of OBG Management online features an article that caught my eye:  Lay Midwives and the OB-GYN: Is collaboration risky? I decided to read further and see if any new light could be shed on this tired subject, which has been discussed in multiple venues.

First, I wondered what how the author defines “lay midwife”.  I discovered that she uses the term to include any midwife who is not a nurse as well, even if they are certified and licensed by their state.

Next, I decided to find out how other entities define a “lay person”.  I  liked Wikepedia’s definition:  ”A layman or a layperson is a person who is a non-expert in a given field of knowledge”.   That sounds to me like a perfect description of a medical doctor, who most certainly is a non-expert in midwifery!

The author goes on to argue that CNMs (certified nurse-midwives) are recognized by the American Midwifery Certification Board (AMCB), while certified professional midwives (CPMs), those who are non-nurses, are not recognized by the AMCB.  This is true, and some of us CNMs can recall when the AMCB was formed, requiring us to pay yearly dues for the privilege of having the AMCB keep track of our continuing education, and requiring us to complete modules obtained from the board for required continuing education.

Does the simple fact that the AMCB does not recognize CPMs mean they are inferior?  Absolutely not!  The AMCB was created by nurse-midwives for nurse-midwives, and never intended to recognize non-nurse midwives except for the handful of non-nurse midwives who have graduated from their university-based graduate program and are recognized in only three states.  The AMCB and ACNM have maintained that graduate level training is necessary for safe midwifery practice, and often worked against licensing of CPMs, rather than working together with their sister midwives.  Does having a graduate degree, with a heavy focus on academics such as health policy, statistics, nursing informatics, and similar courses, make me a safer midwife?  I doubt it.

Physicians have continually fought against reimbursement for “lesser trained” providers.  I take issue with the “lesser trained” title.  I am differently trained, and my sister CPMs are differently trained.  That does not make us lesser providers.  The author of this article argues that a normal pregnancy can become life-threatening with little or no warning.  This is true, as evidenced by some of the complications the author indicates may occur without notice:

• cord prolapse
• life-threatening maternal hemorrhage
• maternal seizures
• uterine inversion (she fails to mention that this is nearly always caused by the provider pulling on the umbilical cord after birth to hasten delivery of the placenta)

If this truly emergent conditions are taken so seriously by physicians, why do they not remain present in the hospital during a woman’s labor, so they are immediately available in the event of an emergency? The truth is, emergent situations are only taken seriously when they happen outside a hospital.  When they occur within the hospital, they are deemed unpreventable and unavoidable tragedies.  As a midwife and former labor nurse who has witnessed thousands of hospital births, I would place my own personal safety in the hands of a CPM that is with me continuously throughout labor, than in the hands of an OB who checks in by phone and arrives moments before my baby is born.

The author continues, suggesting careful collaboration may be reasonable–if the collaboration occurs with the “right” type of midwives.  She shows her ignorance of the CPM credential by stating that a CPM need not have graduated from high school.  This is untrue, as a visit to the North American Registry of Midwives will attest.

The author also argues that CPMs have not adopted home-birth candidate selection processes based on medically approved evidence.  Hmm, maybe they could do so if medical doctors would start publishing evidence based information about home birth, rather than discounted studies “proving” the danger of home birth.

The article further states that unless a midwife is certified by the AMCB, medical doctors are cautioned by the American College of Obstetricians and Gynecologists, not to support them.

So is collaboration with CPMs risky for MDs?  Is this why they continue to distance themselves from collaborative relationships?  Much evidence has been presented that refutes the idea of vicarious liability–the concept that a doctor can be liable for what a CPM does prior to arriving at the hospital, if he accepts care for her patient.

If the MD cannot be liable for what a CPM who is not his employee does prior to bringing her patient to the hospital, then what is the fear that holds them back from collaboration?  Could it possibly be a matter of control and economics?  Nurse-midwives are nurses.  Nurses must operate under the supervision of a physician.  While there are a few nurse-midwives engaged in independent practice, and in home birth settings, the vast majority work within a hospital, where they must have the support of an OB on staff to back their privileges.  This allows the MD to maintain control, to a degree, of what the CNM offers and how much her practice can support a  woman’s choice.  If she strays too far from the norm, the MD simply has to threaten to withdraw his/her support, and the CNM will be without privileges.  What a simple strategy to keep midwives under their control!  Require all of them to be recognized by the AMCB, or they will not collaborate!

If the goal was truly “first, do no harm”, as every young doctor takes as an oath, wouldn’t physicians be eager to collaborate in order to enhance the safety of the mothers and babies them claim to be so concerned about?  Richard Waldman and Holly Powell Kennedy, presidents of ACOG and the ACNM, respectively, stated:  ”Collaborative practice [is] the provision of health care by an interdisciplinary team of professionals who collaborate to accomplish a common goal, and is associated with increased efficiency, improved clinical outcomes, and enhanced provider satisfaction.” ¹

As a midwife, I am concerned with efficiency and provider satisfaction, but I am especially interested in anything that improves clinical outcomes.  If OB-Gyn’s are, too, I believe that OBG Management should reconsider their stance on collaboration with “lay” midwives.

1.  Waldman RN, Kennedy HP. Collaborative practice between obstetricians and midwives. Obstet Gynecol. 2011;118(3):503–504.

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