History of Certified Professional Midwifery and NACPM

The National Association of Certified Professional Midwives (NACPM) is the membership organization specifically representing Certified Professional Midwives (CPM) in the United States. NACPM directs its influence toward promoting, developing and strengthening the profession, improving outcomes for childbearing women and their infants, and informing public policy with the values inherent in CPM care.

CPMs are part of a long and multifaceted tradition of midwifery in the United States, though the credential has a particular history that is rooted in the home birth movement of the 1970s when women began seeking alternatives to the hospitalization and over-medicalization of birth. The preliminary organizing and professionalization of the midwives who responded to this need took place over the next two decades. The CPM credential was created to define and support these midwives and the first CPM was recognized in 1995. NACPM was then founded in 2000 to ensure a powerful and unified voice for CPMs.

Background: Midwifery in the United States
Midwives attended the majority of births in the U.S. until the early 20th century, when a multiplicity of factors converged to undermine the vital role that midwives played historically in community life.

Despite evidence that midwives often had better outcomes than physicians, the “midwife problem” was a focus of debate among physicians, public health advocates and social reformers who were concerned about infant mortality and the well-being of childbearing women. Racism, sexual discrimination, and anti-immigrant fervor often fueled these debates. At the same time, social change, increasing prosperity and technologic developments, including new methods of pain relief, led some women to seek care in hospitals where physicians could administer anesthesia. Public education campaigns touted the benefits of modern medicine and women were encouraged to embrace the increasingly dominant medical model of care. By 1935, less than 20% of all women were attended by midwives and by the end of World War II it was less than 5%. Eventually, elimination of the midwives became a matter of public policy as one state after another passed legislation to restrict practice.

Midwives continued to practice in certain populations that actively chose to maintain their traditions of midwifery for religious or cultural reasons and in those communities that were denied access to medical institutions and physician care because of segregation laws. In some instances, the midwives were exempted from restrictive laws and in others they were careful not to reveal their practice. Anti-immigration laws reduced the number of new immigrant midwives and the assimilation of second and third generation women further contributed to the decline of midwifery. In the case of Japanese-American midwives, internment during the Second World War virtually ended their service. African-American and Hispanic midwives served their ethnic communities and some white women well into mid-century. In 1950, while midwives attended less than 5% of all births in the U.S., they still attended one-fourth of all non-white births.

By 1975, the number of midwife-attended births reached its lowest point at less than 1% of births overall and 2.4% of non-white births. The few remaining traditional midwives were being forcibly retired and the legacy of race, gender and class injustice surrounding midwifery was deeply embedded in the dominant American cultural beliefs about birth and midwifery.

As the tradition of midwifery was lost in the U.S. and physicians became the primary maternity care providers, so was the wisdom and expertise of the community midwife lost to the system. In the first part of the century, this led to a net increase in poor birth outcomes as puerperal sepsis became common in hospitals and interventions resulting in birth-related injuries rose dramatically. Although aseptic technique, improved surgical options, and other medical innovations have since contributed to improvements in care, women in the U.S. still experience far too many unnecessary interventions, health disparities persist and the rate of infant mortality is the worst among the world’s wealthier countries.

The need for midwives and the midwifery model of care is greater than ever. But in order to more effectively serve all women, we must continue to learn more about the history of midwifery in the U.S. and the tragic consequences of the disrespect and destruction of the traditions of midwifery in our diverse communities. The leadership of NACPM has adopted a statement of intent to address racism and racial disparities in maternity care and has undertaken several initiatives to increase our understanding, ensure that women of color hold leadership positions in our organization, expand access to midwifery education for women of color, and advocate for national health policy changes to increase access to quality maternity care and the care of midwives for all women.

Nurse-midwifery originated in the 1920s through the efforts of public health nurses and other advocates who believed nurse-midwives could play an important role in meeting the needs of underserved populations. While thousands of direct-entry midwives were becoming increasingly marginalized through the first half of the 20th century, the number of nurse-midwifery grew gradually to approximately 1000 in the 1970s when national standards for education and certification were established by the American College of Nurse-Midwives (ACNM), and federal funding was provided for nurse-midwife training. Since then, nurse-midwives have achieved recognition in every state and the percentage of nurse-midwife attended births has continued to rise. The majority of nurse-midwives today are employed by physicians or medical centers and attend births in hospitals.

Read more about the history of nurse-midwifery.

Origins of the CPM
In the 1970s a new generation of midwives emerged to serve those women who were rediscovering normal birth and choosing to give birth at home. The professionalization of these midwives began in 1982 with the founding of the Midwives Alliance of North America (MANA), an organization that brought together midwives from all backgrounds who were committed to unifying and strengthening the profession. MANA’s role was central to the development and evolving philosophy of contemporary direct-entry midwifery, and MANA provided the forum for essential discussions about the re-professionalization and credentialing of direct-entry midwives in the U.S.
In 1986 MANA established an Interim Registry Board to develop a written examination based on the MANA Core Competencies. The first exam was offered in 1991, laying the foundation for the later development of a certification process. By the early 1990s, several states actively regulated the practice of direct-entry midwifery. Many more states were interested in licensing direct-entry midwives. There was a growing consensus among midwives that national standards for the education and certification of direct-entry midwives would serve as useful tools for defining their particular expertise for the public and increase women’s access to their services.

In 1992, The Interim Registry Board incorporated as a non-profit corporation named the North American Registry of Midwives (NARM). From 1993-1995, NARM, MANA and the Midwifery Education Accreditation Council (MEAC) sponsored five Certification Task Force (CTF) meetings held around the country, which included consumer representation, to gather input from midwifery educators and practitioners from diverse backgrounds, geographic areas and cultures to guide the development of the certification process. The result of that consensus-building process was the creation of an innovative and credible new mechanism for certification, the Certified Professional Midwife (CPM) credential. With roots going back several decades, NARM’s implementation of the CPM credential was a milestone marking the need to organize and represent a force of nationally-certified direct entry-midwives to bring to bear the influence of the natural childbirth and home birth movements to improve the system of care for all women.

Growing Need for CPM-Specific Professional Representation
The new credential also sparked a debate over the need for a professional association specific to CPMs. This debate took place during MANA membership meetings at MANA conferences in 1999 and 2000, when a proposal was presented for a vote of the members to require voting MANA members to be credentialed midwives. A majority of MANA members defeated this proposal. This decision left unanswered the question of how to support this emerging new credential and to engage the midwives who held it.

Then in 2000, CPMs and CNMs in Massachusetts brought forward ground-breaking legislation proposing the formation of a board of midwifery that would govern both groups of midwives in the state.  The request by the Massachusetts legislature for Standards of Practice specific to CPMs to support this legislation lit a match to this debate and prompted the incorporation of NACPM in 2000.  An interim board of directors called for a Task Force Meeting in September 2001 to discuss the future of NACPM, and CPMs were invited to join NACPM as charter members. An interim executive committee was formed at the Task Force Meeting to prepare for elections and to initiate a process for developing Standards of Practice for CPMs.

Over the next 2 years the discussion about the need for a CPM-specific association continued within the midwifery community: were CPMs best served by an independent NACPM or by a CPM section of MANA? By the fall of 2002, NACPM had decided to remain an independent organization, providing CPMs the specific representation requested by NACPM members, and the first elected Board of Directors was installed.

The NACPM Standards Committee and the Standards Advisory Committee were formed in the fall of 2002 and initiated a process to develop Standards of Practice for NACPM that gave all CPMs the opportunity for input into these important defining documents. The Essential Documents, including Philosophy, Scope of Practice and Standards of Practice, were adopted by the NACPM Membership in 2004. The benefits to the profession were quickly evident, as several states in quick succession referred to these Essential Documents in successful attempts to license CPMs and define the practice in those states.

Setting the Direction for NACPM:
Removing Barriers, Access for Women, Improving the System

In 2004, NACPM took up the work of removing barriers to practice for CPMs to increase all women’s access to the care of CPMs and began investigating issues related to reimbursement. In 2006, as national health care reform debate heated up, NACPM began strategizing how to position CPMs in this national conversation, by joining national health care coalitions, visiting Congress to seek advice, and hiring consultants to assess the landscape for CPMs. In 2008, NACPM developed a plan for achieving federal recognition for CPMs. In 2009, NACPM invited a coalition of partners (MANA, NARM, MEAC, CfM, and ICTC to launch the Midwives and Mothers in Action (MAMA) Campaign. The initial goal of the MAMA Campaign has been to amend the Social Security Act to mandate Medicaid reimbursement for CPM services, an essential step in the integration of a provider group into the health care system in the U.S. Passage of this amendment will also support private payer reimbursement, support state licensure, and ensure that CPMs will be able to participate in health care reforms that will define who is able to provide care and be reimbursed for services over the next decade. Click here to read about the MAMA Campaign, including successes and how you can help.

What began with participation in health care reform coalitions led NACPM to recognize the power of building and participating in coalitions to multiply its influence on policy, practice and outcomes. Today, NACPM partners with midwives, consumers and other stakeholders to unify and strengthen midwifery in the U.S. and to influence state and national policy to improve maternity outcomes throughout the country.

Read here about NACPM’s leadership to influence and foster the development of professional identity and the contributions that CPMs can make to transforming maternity care in the U.S.

NACPM’s growing recognition of the enormous impact that racism and racial disparities have had and continue to have on the midwifery profession in the U.S. and on the maternity care system as a whole, led NACPM to make a series of commitments to address racism in our leadership, educational systems and in our profession. Following the 2012 CPM Symposium and the power of the conversation about the influence of racism that emerged at that event, NACPM, in July 2012, published these commitments and pledged to work more effectively to eliminate racial disparities in the health of mothers and babies in the U.S.

Read about NACPM’s Pilot Chapter Project to engage members in setting the direction of the organization, support for the practice of CPM midwifery and opportunities for CPMs to engage in the innovative reforms of the Affordable Care Act.