Editor’s note: This article first appeared in Midwifery Today, Issue 79, Spring 2006.
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Business is second nature to me; I really enjoy it. I have been making lemonade for 32 years now and have always known that if I wanted to be rich I could have franchised my successful lemonade stand, Family Homesteader. The calling of midwifery got in my way, though. It got lodged in my heart and I just had to follow that dream. We direct entry midwives do business by the very fact that we must. No hospitals or doctors have implored us to come to work. Seldom will anyone hire us, other than the moms who need our services!
For nurse-midwifery to survive as an authentic form of midwifery and not give in to the pressure to become medicalized, large numbers of its practitioners must go into business for themselves—I think their very survival depends on it. Unfortunately, a number of barriers are in the way.
The first barrier is that the medical system got things backwards: Nurse-midwives should be hiring the doctors, or at least consulting equally with them. They have the calling and often cellular knowledge; with training in normal birth only they can keep the profession from being co-opted. They are the experts in normal birth; most doctors have never even witnessed a normal birth!
Certified nurse-midwives (CNMs) need to rise up, take the reins of their calling and start businesses. Starting a business in the US is easy: You just need to choose and register an assumed business name, keep records and pay taxes. This will allow you to take back your profession from those who don’t understand it, collaborating with rather than being under the thumb of doctors. You should also work to ensure that midwives are not required to have physician approval to practice. CNMs are trained professionals, not handmaidens.
The job satisfaction obtained from owning your own business, or working with a partner, will make you a better midwife. (Having said all of this, midwives are still badly needed in the mainstream until the mainstream becomes a humane, well-working system.) If you are entrepreneurial, feel free to become your own boss or find a partner in business. If you have questions, talk to the experts: the direct entry midwives who have had no choice but to make their work into independent businesses. Helping each other to succeed will also have the benefit of creating reciprocal relationships that will unify us and help us to work together in harmony.
Another barrier is the lack of unity within the profession. When I first started midwifery I believed that CNMs would be the first line for the complicated cases that required women to be transported to the hospital. In my innocence I saw us working together for a common goal. While I haven’t lost that innocence, I think that we have a long way to go. However, I am optimistic that with Catharine Carr as ACNM president we will make some progress toward that common goal.
At the Midwifery Today conference in Eugene in 2005, Catherine and MANA’s president, Diane Holzer, taught a session in which they discussed the ways that these organizations could work together. Failure to do so in the past has hurt the field of midwifery in many ways. In order to reverse this trend and strengthen the profession we need to put the past behind us and work together.
The third barrier we face is a deep flaw in the US higher education system. Most students come out of college owing huge student loans. This makes it difficult for new CNMs to make enough money to start a business and pay back loans. In contrast, students in the UK are paid a small stipend for attending school, in addition to having school fees covered.
Perhaps we need to analyze midwifery education to determine the minimum requirements for entry-level independent practice. Business may be an important part of the curriculum. Perhaps nurse-midwife trainers should look at the curriculum to ensure that it focuses on keeping birth normal by including non-medicalized ways of practicing. Homeopathy, herbs, alternative practices for complications and learning from traditional midwives around the world might replace some of the usual medical curricula. Lay midwives, direct entry midwives and nurse-midwives need to work together to make midwifery a profession not dominated by medicine but by using medical practice for only the truly complicated cases. Let’s reclaim authentic midwifery.
The final barrier I want to mention is the separation of midwives in practice by their route of learning. Why not include CNMs, certified professional midwives (CPMs) and even lay midwives in the same practice? We had a practice like that in Oregon for many years. We all brought different strengths to our work, which was remarkably helpful to the families we served. Marion McLean, a CNM, enriched the knowledge of the other midwives and made our learning enjoyable. We were amazed when she said she learned as much from us as we did from her. Together we seemed to have a better practice than when we were in practices with only one route of entry. This unified us in ways that are now lacking in US midwifery.
I want to finish by quoting a line from the musical Oklahoma. It took place in the Old West when the farmers wanted to fence the land and the cowboys wanted to have free range for their cattle. “The farmer and the cowboy can be friends.” And just maybe they should go into business together. Now don’t start fist fighting like they did in the movie. I really believe we can work together. Indeed, I think it is the only way we will advance midwifery.
Toward Better Birth,