Lessons Learned – A Decade of Leadership

— by Sarita Bennett —

I was a young midwife when the Midwives Alliance of North America (MANA) was incorporated in 1982. I had been meeting with other like-minded midwives in my state since the late 1970s when our organization incorporated in 1985. One of our members, Ruth Walsh, was serving as a MANA regional representative when she announced that she had signed us up to host the 1986 MANA Conference.  I served as registrar for the event, giving me the opportunity to meet early midwifery leaders, educators, and community midwives.  It was there that the idea to create the Certified Professional Midwife (CPM) credential was brought to life and approved.

The leadership for this task was given to that same Ruth Walsh, who began serving as chair of the Interim Registry Board, which later became the North American Registry of Midwives (NARM). I was impressed by her commitment to maintaining the integrity of the profession.  When she convinced me to take the first NARM registry exam in 1991, I asked her what I should study in preparation.  She responded, that she was confident that, if, after 10 years of practice, any midwife couldn’t pass the test, there was something wrong with the test. That conversation laid the foundation for my support for the CPM credential.

I was in Osteopathic Medical School in the mid-1990s when NARM began accepting applications for CPM certification.  I didn’t have the money or the time to complete the documentation, so I put it on a shelf and forgot it.  After graduation I completed a family medicine residency then returned to my community, where I provided full spectrum family-centered health care including birth services. I began accepting students, including CPM students, interested in learning reproductive physiology from a midwifery perspective. Although I had been given an exemption by NARM for the midwifery credential requirement for preceptors, I was encouraged to complete my PEP documentation and submit it to NARM before the Experienced Midwife pathway to the CPM closed.  Out of a sense of sentimentality and solidarity, I did so, and was issued the certification in 2012. I have since chosen to let it expire.

Prior to becoming a CPM, I was nominated for the position of secretary on the MANA Board. I accepted, was vetted, and was invited to join the MANA board in 2011. I hadn’t been a member of MANA for many years so wasn’t “in the loop” of national midwifery politics. I had been told by the former MANA board member who had nominated me that there was a board hierarchy to be aware of and that I would figure it out. I was grateful that Linda McHale was my “board buddy”, helping me understand the issues on and below the surface.

The first days of my first MANA Board meeting were workshops on equity and racism.  I met PaKou Her, a consultant, hired by MANA to help guide the board in their stated “strategic direction” of social justice.  At the end of her contract, PaKou gave the board her detailed report that contained many suggestions for moving forward.  One of my tasks was to present the major findings of the report to the board who then asked me to present a version to the membership during the 2013 annual conference.  A foundational concept that I learned was that for an organization to be socially just, three things must exist:  transparency, access, and protocols.  I understand this as a requirement for clear communication and the commitment to full disclosure, especially financially; that everyone involved has equal access to the decision making power; and that the agreed upon guidelines are applied to everyone in the same way, guarding against privilege being used inappropriately.

I learned that MANAs acceptance into the International Confederation of Midwives (ICM) had occurred shortly after the organization was incorporated and was unusual in that the USA would become the only country with two membership organizations (ACNM was already a member) and MANA would be the only organization who had members that did not meet the ICM definition of midwife. The International Section of MANA had been created to be populated only by MANA members that met the ICM definition of midwife by holding licensure or certification. That Section became the actual member of ICM, not the entire MANA organization. One perspective of MANAs early years is documented in the book “Circle of Midwives” by Hillary Schlinger, CNM. Currently, USA midwifery is represented within ICM by a third organization, the National Association of Certified Professional Midwives (NACPM).

I learned about MANAs participation in the 2011 ICM Triennial in South Africa at my first board meeting. The ICM buzzwords “education, regulation, association” had come to the USA as a result of a conversation between the ACNM and MANA presidents.  It was at the 2011 MANA conference that a closed door meeting of USA midwifery leaders resulted in a commitment to create the coalition labeled US-MERA (United States – Midwifery Education, Regulation, Association).

Leadership from seven organizations – American College of Nurse Midwives, American Midwifery Certification Board, Accreditation Commission for Midwifery Education, Midwifery Education Accreditation Council, North American Registry of Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives – met in the Spring of 2013 for the first official US-MERA meeting. I didn’t attend, but was told by the MANA president after the meeting, that she saw potential for moving in a positive direction supportive of the CPM credential including the acceptance of the Portfolio Evaluation Process (PEP) pathway. It was the last time I heard anyone say that potential existed.

I attended the 2014 US-MERA meeting and realized that the words in the vision and mission leading me to believe that the coalition would be a “unified, credible, recognized voice for issues that affect midwifery education, certification, accreditation, regulation, association and practice”, were code for restricting CPM education to MEAC schools in exchange for a resolution to support new CPM licensing legislation. The document entitled “Statement on Licensure of the CPM” was adopted in 2015 and can be found at www.usmera.org.  There was no going back. Keeping unlicensed midwives from being arrested was the justification for the compromise.  It is not lost on me that the people who used that justification were not involved in any public support for the midwives who had experienced legal prosecution.

Eventually, ACNM moved ahead – despite a lack of US MERA consensus – with support for their state affiliates to work towards including the education restrictions in any existing legislation that came up for review or amendment as well as the agreed upon future legislation.

An ongoing MANA-led campaign to have the International Center for Traditional Childbearing (ICTC) included in US-MERA, finally resulted, with encouragement from the funder, in ICTC becoming the eighth organization in the coalition in February 2016 just before the last official meeting in April 2016.  The website includes the minutes from these meetings.

The power dynamics of US-MERA gave the advantage to the CNM organizations and MANA leadership often found themselves as the odd organization out. The goal of being the organization that unifies midwives became an illusion when the ability to be a voice for traditional midwifery and the apprenticeship model was gone. MANA’s relevance in the midwifery movement was questioned from within and without.

My personal disappointment in US-MERA led me to back away from those tables. Something seemed out of balance that made MANAs participation in US-MERA that came with a requirement to prioritize loyalty to the coalition, more important than the stated organizational value of transparency.  I also had no interest in being involved in the drama that surrounded MANAs ICM representation. Similarly, the imbalance made personal participation in ICM become more important than organization values.

While vice president, I noticed that financial reports included money coming from the Foundation for the Advancement of Midwifery (FAM) from a particular fund for two specific people to attend the 2020 ICM Triennial in Bali.  I knew there were other board members that wanted to get involved and proposed that they be able to access funding.  The response was that the FAM donor would not fund anyone but two specific people. This led me to formulate questions about process.  Why was money from an outside donor being allowed to make what I thought should be Board decisions?  We did not have consensus for how these funds were being used.  My questions certainly created tension that did not result in answers other than that I should just be grateful to the donor for the money.

In early 2020, I stepped into the president’s role at the request of the remaining board members. I agreed to one term only with intention to rebuild what had become a dwindling of people willing to run for board positions. The board discussed and agreed to suspend elections for the coming year to give us time for this rebuilding. The other priorities included improving communication between FAM and MANA and recovery of the MANA Statistics Project database.

The relationship between MANA and FAM was complicated – FAM had been created as a charitable auxiliary with the MANA membership listed as FAMs sole member.  This relationship did not require FAM to give MANA funding.  MANA had the right to approve or remove FAM board members and had legal right to review FAMs minutes and financial documents.  The relationship between the organizations had deteriorated after the 2018 MANA conference and had not improved over the following year. Monies granted to MANA came with the same donor-controlled restrictions that superseded MANA Board input.

Regardless of the MANA board’s attempts to communicate with the FAM board as a group and with an appointed liaison, the trust that comes with transparency could not be found. The FAM Board sent a letter to the MANA board requesting that MANA be removed as FAMs sole member, severing any legal relationship or obligation for transparency.  The MANA board responded that the answer could only be “no” until the proposal could be brought before the membership for consideration.  The entire FAM Board resigned the next day.

Within 24 hours, after an intense search, FAM had the potential to be repopulated with an attorney, a midwifery advocate/historian, a business woman/marketing expert, and a cybersecurity expert with an array of other skills.  The MANA Board members were given the opportunity to meet and discuss the candidates, and, with no concerns expressed, approved the nominations.

And then there was COVID.

MANA had been losing money and membership for years. The annual conferences had become a money drain for several reasons.  When the pandemic began, the MANA board decided to move the annual conference online.  We worked with Gold Online, learned many lessons, and made a modest profit.

In the midst of that 2020 fall conference, a public statement accusing me of mishandling the MANA Statistics project was sent out by Colleen Donovan-Batson, a former MANA Board member and Bruce Ackerman, a former volunteer in MANAs Division of Research. It included the suggestion that the database be given to a university or educational institution.

In reality, I had been researching options and had been advised by multiple institutional experts that the plan proposed by Ms. Donovan-Batson and Mr. Ackerman was unrealistic and not in line with the current trend among higher education institutions.  With that option closed, I began working openly with the MANA Board to find people with the skills to do what the Division of Research had been saying needed to be done: migrate the data from the original software program to a new, updated, more user friendly, and more researcher-accessible program.  It had been attempted in the past, but was unsuccessful and the search for someone with the ability to do the job had been abandoned.  After sending out requests for proposals, I had the good fortune of finding Dr. Amanda Teye and Dr. Fred Teye who, together, had the right skills for the job, loved this kind of work, and had a solid track record. The Board hired them with no concerns expressed.

Amanda began scouring the Division of Research documents, learning the history and details of the project.  She and I spent hours together weekly, piecing together the history and envisioning the new version of the project. I began to understand why there were so few researchers who had accessed data.  The original software – cutting edge at the time – was labor intensive both on the “data in” side and the “data out” side. The Division of Research had been populated by dedicated volunteers, with many working towards entering and validating data.  The labor required for the “data out” was even more intensive because of the original limitations of the software.  All data had to be “cleaned” to be made useful by researchers.  A simple explanation:  if there are 200,000 entries of newborn weights and the researcher wants to know what the average weight was, the program didn’t calculate the required average.  Rather it spit out 200,000 answers that the researcher then had to sort and manipulate.  This explains why the research was dominated by a team who had the resources of a university department to help with labor.  And, it explains why that research team had an attachment to the data such that other researchers can’t access it.

Bruce Ackerman continued to hold the keys to the MANA Stats project, unwilling to share passwords or access. Even without his cooperation, Fred diligently worked to unlock the puzzle of the old software and create a new program that could hold the potential for what was being envisioned.

We were close to finishing the initial phase of the project with an outline for the work of the next phase when, on a Friday morning in July 2021, the MANA board received a letter from an anonymous group of people demanding that I resign from the MANA president position within 48 hours due to words I had said at a private business meeting in my state that had nothing to do with MANA. The board secretary acknowledged the letter and responded that it would be addressed at our already scheduled board meeting the following Monday with a response given that day. This would have met the 48 hour timeline when considering business days.  By Sunday morning, I became the target of an online defamation campaign led by a NARM board member.  She used words I had spoken at the private meeting out of context to create an image of me that was in direct contrast to everything I had stood for and worked for as a mother, midwife and physician – birth autonomy supported by autonomous midwives.

By Monday, MANA board members, who up until that point had been expressing their support for my continued leadership, were unwilling to give me an unbiased chance to speak.  I took a leave of absence that gave the vice president an opportunity to lead the board back to an understanding of due process and consensus decision making.  Over the next weeks, I mostly remained silent, and watched.  It was no surprise that the FAM donor- and NARM board member – who had been controlling MANA board decisions before the new FAM board took over, was one of the most consistent voices calling for my removal in letters, emails to the MANA board, and social media comments. After the board secretary and vice president resigned, I was removed and replaced by someone who had not been substantially involved in any of the MANA Stats project work, later stating at a regional MANA conference, as MANA president, that she thought birth certificate data was sufficient.

Other than a two month period in 2018 when I resigned as vice president and was encouraged by the president to return, I found myself, after a decade of volunteer service, with enough time on my hands to look at the organization I had been working within from a new perspective.  Admittedly, the words I had spoken at that private business meeting were heated and reflected my lack of trust for the people who had appointed themselves as leadership in a movement that would ultimately affect my personal business. I don’t regret the lack of trust – my instincts in that regard have been confirmed.

It doesn’t mean that the experience wasn’t painful – it definitely was as I navigated learning to not take it personally.  I realized that very few people had any clue what was really going on within MANA. Their idea of MANA was often based on the vision that was present at the beginning- a voice to unify midwives – without the understanding that MANAs voice now represented a very select group of privileged people.

At first I regretted being unable to complete the work on the MANA Stats project that was so close to becoming a reality, then realized that I had accomplished my goal – the software had been updated and the data was migrated and safe.  I have not seen any news of the continuation of the next phases of the project which would allow access to researchers in an equitable way while maintaining IRB requirements.  Another option envisioned was an annual report that could be incorporated into a personal report with individual practice statistics.  Fulfilling the potential of the project will require visioning, commitment, and, of course funding.

I also knew that FAM was in good hands with skilled people who were making sure the organization reflected a standard of integrity essential to MANAs values – another goal accomplished.  Observing the recent conflict between the current MANA and FAM boards over funding for attending the 2023 ICM Triennial in Bali (see FAM Facebook posts), I see the fingerprints of the same dynamics that gave a specific group of people the benefits of MANA Board decisions priority over the needs of the organization. The justifications from the MANA board for the exorbitant request for funding ring hollow in my ears.

I wrote this in 2023 while looking at pictures of the people who represented MANA at the ICM Triennial in Bali – people who worked to get any obstacle out of their way to get there.  Me.  An entire FAM board.  As the midwifery community absorbs the news that as of March 1, 2024, MANA has dissolved, these same people point their fingers at me and the defamation petition from nearly three years ago.  My public rebuttal at the time ended with this question: “who does it serve to discredit my voice?” that is still pertinent.

I observed that MANA suffered from a version of Founder’s Syndrome that created barriers to the profession while the midwives it said it represented continue to struggle to practice autonomously. More importantly, families continue to have limited options regardless of an increasing number of state-regulated midwives while our country’s maternal and infant health statistics climb in the wrong direction.

There are many unanswered questions left by MANAs dissolution:  MANA Statistics Project, FAM, representation of traditional midwifery.  I believe that it is time for an objective and authentic look at the pivot points that turned MANA from a grassroots organization with a stated goal of being a voice for all midwives into an organization that represented the privilege of a select few.  There is value in learning from our decisions and making more sustainable ones as we move forward. Let’s shift the paradigm instead of repeating history.