Abstract
This eloquently written and extremely well-researched book brings much-needed attention to the development of the certified professional midwife (CPM) in the United States and to home births—the only births that CPMs are allowed to attend besides births in freestanding birth centers. Cramer’s research for this book spanned 14 years and took her all over the United States to interview midwives and to attend midwifery gatherings, conferences, and legislative sessions. Her book lays out the sociolegal issues that CPMs must deal with, and provides a thoughtful history of the demise and renaissance of U.S. midwifery—often through the stories of midwives who played key roles in that renaissance. These stories make it a particularly compelling and engaging read.
Cramer demonstrates extensive knowledge of U.S. midwifery in all its complexities—the United States is the only country in the world that is split in terms of professional midwifery education and certification. As Cramer explains, there have often been battles between U.S. certified nurse-midwives (CNMs) and the organization that represents them—the American College of Nurse-Midwives (ACNM)—and CPMs and the organizations that represent them—the Midwives Alliance of North America (MANA) and the National Association of Certified Professional Midwives (NACPM). These battles have principally focused on what constitutes appropriate educational routes to midwifery. CPMs used to be primarily trained by apprenticeship, while CNMs have long been trained in university-based educational programs.
Yet, as Cramer shows, these battles have ended via the efforts of a group called US-MERA (Midwifery Education, Regulation, and Association), whose members consist of midwives from all relevant organizations. During US-MERA meetings, ACNM agreed to support licensure for CPMs only if they were graduates of MEAC (Midwifery Education and Accreditation Council)-accredited programs, and the organization that certifies CPMs—The North American Registry of Midwives (NARM) agreed to support licensure efforts in states that chose that requirement. MEAC is a federally recognized organization that accredits educational programs for CPMs. As Cramer explains, in many states, to gain both licensure and ACNM recognition as professional midwives, CPMs must go through MEAC-accredited educational programs. Yet she is wrong here on one important point: She says that NARM had ended its apprenticeship route in 2020, whereas in fact, according to Ida Darragh, NARM Board Chair, NARM “will always keep open its apprenticeship route” (personal communication, March 2022).
Cramer states that her book “is a sociolegal story that weaves together legal pluralism, legal mobilization, legal consciousness, and legal implementation to better understand their constitutive interactions in the creation of professional boundaries and disciplinary boundaries” (p. 11). Yet the complexity of this statement belies the simplicity which with most of her book is written. There are a few more factual errors, such as when Cramer speaks of maternal “morbidity” when she means maternal “mortality,” and when she says that CNMs are “accredited” by ACNM—they are not; instead, they are certified by the American Midwifery Certification Board. Yet these are minor compared with the wealth of accurate information that Cramer conveys, along with engaging stories of CPMs’ practices and legal struggles. Like many others, Cramer insists that planned, low-risk, midwife-attended out-of-hospital birth is as safe, if not safer, than in-hospital births and provides evidence to back up this claim. She describes her own, laudable participation in attempts to legalize CPMs in Iowa, showing that she is part of birthing the movement for homebirth and for CPM legalization in all states.
Cramer’s description in chapter three of how CPMs finally gained legalization in Missouri, after years of work, is particularly engaging—She explains that they secretly added the word “tocology,” which means “the branch of medicine concerned with childbirth” into the bill; no one noticed, and the bill was passed. She also provides detailed descriptions of how midwives in many other states got their bills passed—or didn’t. Thus, this book constitutes essential reading for CPMs and their advocates who are still striving for legislation in the 13 holdout states. It will also be of great interest to all those interested in understanding the complexities of U.S. midwifery—specifically regarding the intersections of gender, reproductive medicine, and the law. I love this particular sentence, which captures the power of midwifery to understand broader social processes: “Many birthkeepers held science gently, in the same hands that practice traditional women’s ways of knowing,” meaning that CPMs’ practices are evidence-based and are also based on multiple ways of knowing about birth.
In short, this book takes us on a fascinating journey through the sociolegal landscapes of contemporary midwifery in the United States, while demonstrating the author’s passion for bettering the status and regulation of CPMs across the country—a passion that I share!