CNM or CPM? Opinions/advice??

trauerweidchen · Feb 15, 2013

I am struggling with this too. I am in the middle of applying to an accredited program for CPMs, but ultimately think I may switch after all for broader scope of practice reasons and because some of the states we may eventually move to are not as CPM-friendly as our current one ( hence why I am here on AN). It is tough! I have a BA and I could go back for a BSN and on to the CNM, but I want out of hospital experience as well, so I think my educational path may be a mix ultimately.

If you haven't already read it, I'd suggest "Paths to Becoming a Midwife" which is a book published by Midwifery Today. It presents anecdotes and articles addressing the pros and cons of both pathways. Their forums may also be a resource to check out. There are many advantages to the CNM path, but in some places you may be unable to practice out of hospital for practical reasons, even if it is legal strictly speaking. Do you have local midwives you can speak with and shadow? I have found that quite helpful.

Best of luck and I'd love to hear more of your thoughts!

queenanneslace, ADN, MSN, APRN, CNM · Feb 15, 2013

I've struggled with the CNM-CPM-CNM-CPM-CNM-CPM question for at least 10 years. Hoo - Boy. Sometimes I don't even know where to start.

Where am I right now? Just finished nursing school, passed my boards, I'm a real nurse. Yay!

I used to think that nursing was just a hoop to jump through in order to become a CNM - and it seemed bothersome and needless and I thought it would have little value.

Au contraire!

I can say right now that I very much value my nursing training (though I will admit, an ADN program is rather lacking in any sort of extensive OB nursing training). I'm also looking forward to working as a nurse. My midwife-wanna-be self of 10 years ago could never have imagined the day when I would say such a thing!

I got a lot of experience attending births with home birth midwives. And I think that satisfied my wanting to be around labor and birth. But I think I lost enough nights' sleep -and enough nights' sleep in a row - that I won't sacrifice my life for 24/7 call.

I'm torn about recommending the CPM route - though I think there are some wonderful things to learn about natural labor - that you can only see when natural labor is supported and attended by a midwife in out-of-hospital settings. I have some misgivings about the credential... and the training... it's really hit-or-miss. There are some stellar CPMs out there. There are others who did not get the best training... and there's just a WIIIIIIIIIIIIIIIDE variety of practices among CPMs. You just don't know what you're going to get.

[i had my children at home with CPMs. Each one was entirely different in philosophy and practice - and I wasn't really happy with any of them as individuals... I'd wished I could make a mash-up of my midwives and create the one that would have practiced the way I wanted to practice. So there's that.]

Prior to doing homebirths I'd been enrolled in an accelerated BSN-MSN program and I HATED that. It was expensive. The instruction was poor. And there was virtually no focus (especially in the pre-MSN/CNM portion) on the thing I wanted to study which was midwifery and birth.

But, now, I'm looking at applying to complete the CNM. Such a circle.

If you can get experience in home births with a midwife. You will learn so much.... I just can't trade what I know from that experience I had. BUT - I think a CNM is a much better credential - and allows the midwife to provide full-scope midwifery care to her patients/clients. AND - not be on-call 24/7/365. There are midwives who give their lives up to be midwives. God bless 'em. It's not going to be me.

I need a day off once in a while.

Rambling.... but I don't know where to start and end with this topic. I've done it. I've done it all. And I've been doing it for too long.

Make a decision and enjoy the ride. Midwifery's great.

trauerweidchen · Feb 15, 2013

Queenanneslace, I think I'm you, 10 years ago. Thank you so much for your thoughts. I might need to print your post and tape it to my fridge.

I see my path much like yours. I am working with an excellent CPM who I respect a lot, and I so much want to learn this style of midwifery (bolstered by one of the more respected MEAC-accredited schools so I am well prepared--don't get me started on the ups and downs of CPM and DEM education), but I fear that it won't be sustainable for me long-term unless I take very few clients and schedule time off-call. How does one strike that balance as a homebirth midwife and yet remain in demand? There's a time and place for it, and I want to practice true continuity of care, but it may not be tenable for me at this point. I have two young children (which is a topic unto itself), and a husband who works long hours and is more or less on call himself even though he works from home currently. I'm not at all averse to school; I'm not intimidated by nursing school (though I probably should be; see small children, above), or by Master's level coursework. It's really more a question of how and where I want to practice when I get there.

Ultimately the question is so very individual based on one's circumstances, local and state politics, availability of schools, and willingness to relocate, that my research has been difficult to generalize and I keep going round and round in my head. I don't want to shortcut the midwifery portion or be indoctrinated into a highly technological or interventionist model of birth, so the longer road of RN then CNM makes sense to me so I can hand pick a CNM program. Frontier is high on my list, if I get that far. Choices, choices...

midwifetobe85 · Feb 15, 2013

Hi Ladies! I was exactly where you are now a few years ago. It was SUCH a difficult decision. I went back and forth between the CNM and the CPM. I too feel birth usually belongs out of the hospital - whether at home or in the birthing center and I want to provide true midwifery care, not the mini-OB form that so many CNMs have to become in the hospital. I ultimately went the CNM route though for the following reasons.

1.) I kept hearing about CPM burnout. Not only had I heard of CPMs ultimately pursuing the CNM route, but I had heard of midwives quitting altogether, which I found very sad. The 24/7 on call lifestyle sounds very hard and while I do plan to embrace that someday in a homebirth practice I worried about spending the large amount on the NARM-approved CPM programs ($30,000+) only to potentially burnout. I figured that with the CNM I could also work in a birth center (or start one!) and this would in many ways fulfill my desire to attend OOH births. Also, I am very interested in fulscope midiwfery and providing well-woman care. As a CNM I could eventually transition into just doing gynecological work when I have young children or when I'm older and ready to retire from births. While a CPM could take this approach I think it would be near impossible to earn a living at it.

2.) I want to work with a board population of women. Not only do I want to support women interested in home birth, I also want to help women who don't actively seek out a midwife (but who would still equally benefit from one). I want to work with teenagers in particular, and not many teenagers seek out a home birth. I think that spending some time in a hospital practice or working in a clinic setting may be frustrating in many ways but I also think I could make a big impact.

3.) I wanted to have the flexibility to work in any state and in any setting as well as financial stability. Being a CNM means you can work in any setting and any state. Plus you can join a practice, share call and earn a great salary. If you want to only do OOH you can do birth center work or home birth but if you start to burn out or are struggling financially there are other options. As a CPM, its a lot of training, a lot of money and there's really only one way to practice - on your own.

I decided in the end that I could decide to be whatever kind of midwife I wanted. I did not need to do a CPM training (although they look wonderful) to be a CPM at heart. I firmly believe in direct entry midwifery, even though that is not what I will be. I completed an accelerated BSN last May, passed the NCLEX and just applied to Frontier for their midwifery program. They are incredibly supportive of OOH birth and require you to attend the AABC's 'How to Start a Birth Center' workshop. Nursing school was tough in many ways for me because it is very rooted in the medical model, not the midwifery model. But, I made it and now plan to do everything I can to become the kind of midwife I want to be. I hope to do my clinicals with a home birth CNM and also at a local birth center. Plus, after graduation I plan to go to Maternidad La Luz to immerse myself in lots of physiological birth. I also plan to complete an herbalist program. I can't tell you what is right for you, but I do feel that in the end it's not about the letters after your name, but what you believe about birth.

EmmKay · Feb 15, 2013

Wow. I think anyone who has ever wanted to do midwifery has struggled with this- what it makes me realise is that the whole fragmentation between where CPM's practice and where CNM work is kind of ridiculous....ultimately, it's in every woman's best interest that she can go to a practice where they can offer her ALL the choices- homebirth, hospital birth- natural, epidural whatever.

For me midwifery is about supporting women's choices in birth and it's sad that you need to be in one school or the other...

Most other countries now separate midwifes from nurses completely- you still need a 3 year midwifery degree, but it's not taught the same way as general nursing plus two years NP

I feel for you, I'm struggling with this too- I've decided I have to go the CNM route like Queenanne, because I just can't work around the clock or be in a situation where the family needs to move and suddenly I am unemployable. But like you, I feel I will have to fight to keep my holistic focus on birth. Maybe we can set up a support group for people like us?

EMily

EmmKay · Feb 15, 2013

midwife tobe,

Can I just tell you how awesome you are? You really articulate my thoughts for me! I am sending you a big big cyber hug- and I'm going to harass you over PM, be warned!

I'm really struggling with the ABSN option too because I KNOW that will be 100% medical model and I will really struggle there

Is it true that you need one years L and D eperience before Frontier will accept you? Also, how hard it is to find a preceptor? I was really worried when they said you have to find your own because I don't know how that would happen....plus do you have to pay the preceptors separately?

queenanneslace, ADN, MSN, APRN, CNM · Feb 15, 2013

I don't want to ... be indoctrinated into a highly technological or interventionist model of birth

I want to respond to this comment specifically, because it was a great, big fear of mine prior to nursing school and way, way back when when I was first considering midwifery.

YOU WILL NOT BE INDOCTRINATED BY NURSING SCHOOL.

I promise.

There are so many personalities in nursing - you will learn from nurses who have styles that you like and you will learn from nurses who you'd rather not have as your nurse if you were ever hospitalized. You'll learn from everyone you come across. If you know what type of provider you want to be - what type of midwife you want to be - you will not be indoctrinated by learning nursing. I just want to dispel that belief. You can - and will - do good things for your patients in your role as a nurse. One of the roles of the nurse is patient advocacy - and I've seen some stellar advocacy done on behalf of patients by their RNs. I have so much respect for what nurses do.

You know, there are great people in every profession -and there are not-so-great people in every profession. If you want to be a patient advocate, you will be, regardless if you're a CPM, CNM, RN. You won't be indoctrinated. I promise.

I have a lot more to say - so many topics, here! But I wanted to cover this one. Because I totally relate to that fear.

trauerweidchen · Feb 15, 2013

You know, there are great people in every profession -and there are not-so-great people in every profession. If you want to be a patient advocate, you will be, regardless if you're a CPM, CNM, RN. You won't be indoctrinated. I promise.

I absolutely agree with this. I know it's a somewhat irrational fear--much like those fears that creep into your head at midnight lying in bed. I know intellectually that it's true about any group; some people I will admire, some I will identify with, some I will seek to not emulate. I don't hold CPMs on a pedestal across the board any more than I do CNMs or OB/GYNs; it's just that of the practice styles I have seen, I personally identify more with the holistic and low-intervention CPMs I have met. I think my fear stems less from nursing school and more from hospital birth training, but that is partly why Frontier appeals to me (the discretion to find a preceptor might help in this area). I know that I can bring some of those values to CNM practice.

I have an enormous amount of respect for nurses and for birth workers on every level. The patient advocacy and more holistic viewpoint that many NPs I have run into have held is something that resonates with me. I have also spoken with a friend who echoed these same thoughts--she has been a nurse for some time and is just finishing up her clinical work through Frontier on her way to be a CNM. She is living proof that it's so much more than just the training you choose, and it's very comforting.

BrittK, CNA · Feb 15, 2013

WOW @midwifetobe85! I LOVE your comment! I feel pretty much the exact same way as you about birth..eventually, I would love to spread the word about midwifery to women that haven't experienced home birth or even just OOH. Thank you SO much for taking the time to write that..definitely gives me something to think about! :)

BrittK, CNA · Feb 15, 2013

I feel exactly as you do trauer..I too resonate more with the holistic, low-intervention birthing style. I think I am gonna end up doing the CNM route..I too, am afraid of the nursing school aspect of it all but mostly just don't like the idea of having to be trained in a hospital doing things the "hospital way" I just feel like so much of it is unnecessary intervention (some yes, is necessary..but not all) but I suppose in the end, it can help me not only with stability, but in becoming a better midwife.

BrittK, CNA · Feb 15, 2013

I live close to Houston, TX and I haven't looked into speaking with any midwives here or even shadowing..do any of you know of any that would be good to speak to? I'm also torn about a nursing/nurse-midwifery program/school to attend once I get my associates degree then bachelors. I was looking at Maternidad La Luz but they are really more for CPM certification (though, I would still love the extra knowledge and training!) There's a part of me that is unsure about my ultimate goal as to whether I want to be on-call 24/7 or work in a birthing center..I DO know that I DO NOT want to work in a hospital though.