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Midwifery in the United States

From: cnmpat@aol.com (Pat Sonnenstuhl)
Newsgroups: sci.med.midwifery,sci.med.nursing,
misc.kids.pregnancy,misc.answers,sci.answers, news.answers
Followup-To: sci.med.midwifery
Approved: news-answers-request@mit.edu
Subject: Midwifery in the United States
Summary: This posting defines the types of midwives found in
        the USA, with descriptions of their similarities and
        differences, educational routes, and what the different
        types of midwives are able to do.

Archive-name: medicine/midwifery/united-states
Posting-Frequency: monthly
Version: 0.01
Last-Modified: 1995/10/14

Please also refer to the sci.med.midwifery  Introductory FAQ for more general
information about midwifery worldwide.

  1. MIDWIFERY IN THE UNITED STATES
  2. WHAT CAN MIDWIVES DO?
  3. WHAT DO MIDWIVES DO?
  4. HOW DO I BECOME A MIDWIFE?
  5. WHERE DO I FIND A MIDWIFE?
  6. HISTORY OF MIDWIFERY IN THE UNITED STATES (in development)

1. MIDWIFERY IN THE UNITED STATES

In the US there are three types of midwives.

I. Certified Nurse Midwives

CERTIFIED NURSE MIDWIVES (CNMs) are trained through approved programs of the American College of Nurse Midwives (ACNM). CNMs are trained in the disciplines of nursing and midwifery, but their primary focus is the practice of midwifery. These programs are run by Nurse-Midwives, and usually affiliated with a University or medical school. Programs are either a one year Certificate Program or a two year Master's Program. Some Masters degrees are in Nursing, some in Public Health, and some in Midwifery. Some states are requiring a Master's Degree for a CNM to practice (such as Washington and Oregon) for licensure. Some programs admit two year degree RNs, and some programs require a BS in Nursing for admission into the program. There are several accelerated programs, such as the one at Yale that admits non-nurses with a 4 year degree and in three years the individual graduates with a Masters in Nursing and become eligible to take the boards to become both an RN and a CNM . The Community Based Nurse Midwifery Education Program (CNEP) is an innovative distance learning program which allows a student to study at home and gain clinical experience locally. Some midwifery programs for RNs seeking a CNM are developing innovative curriculums and channels to increase access to education.

The list of schools for CNMs is long, and new programs are approved each year. You can contact the American College of Nurse Midwives (ACNM) at ACNM@aol.com to determine where the schools are and what the requirements for admission are. Subscribing to the Journal of Nurse Midwifery (the journal of the American College of Nurse Midwives) will provide you with updates about programs, and articles about CNMs and the issues facing them.

In the USA, Certified Nurse Midwives are growing and flourishing, numbering over 4000. They are making inroads in many ways, bringing midwifery care into the hospitals, providing care for low income families and becoming a respected provider and part of the team of providers in medical school programs, training residents in normal birthing. Usually, CNMs work in a collaborative or co- management relationship with physicians. This implies teamwork and promotes continuity of care. In some states CNMs also hold a separate title, and must use it with their legal signature. For example, in Washington state, I am an Advanced Registered Nurse Practitioner (ARNP) and Certified Nurse Midwife (CNM). I am licensed through the Board of Nursing as an ARNP because I am a licensed as a CNM. This is important for our future viability, because nurse practitioners are uniting, and someday that might be the title across the nation. I am required to use the title ARNP, and choose to use CNM also. This is confusing sometimes to the public.

II. LICENSED OR CERTIFIED (direct entry) MIDWIVES

LICENSED OR CERTIFIED (direct entry) MIDWIVES practice in a home or birth center setting. They can receive their training through a combination of formal schooling, correspondence courses, self study and apprenticeship. Although this is a non-nurse entry route for midwifery, nurses are not excluded. These midwives must show that they meet or exceed the minimum requirements for the practice of midwifery by documenting experience and passing both skills and didactic exams. In the United States, direct-entry midwifery is legally recognized in 29 states. Licensure, certification or registration is available in 17 states and Medicaid reimbursement is available 6 states. Licensed or certified midwives usually have a working relationship with the State Health Departments, do sign birth certificates, have lab accounts and usually have doctor back-up and emergency procedures lined up. Licensed or certified midwives are reimbursed by many insurance companies for birth center and home births.

There is a movement in the United States towards Professional Midwifery: a process through which those aspiring to be midwives can proceed and at the end be called a CERTIFIED PROFESSIONAL MIDWIFE (CPM). The North American Registry of Midwives (NARM) is the first certifying body to offer both a national examination and a national validation process for professional direct-entry midwives, and CNMs who assist with birth at home, who come to their practices through multiple educational routes. NARM has been offering a registry examination of entry-level midwifery knowledge since 1991. NARM has just completed a pilot project for a certification process which validates skills, knowledge and experience. This certification is now being offered nationwide and the new credential is for Certified Professional Midwife. The CPM has successfully completed prescribed studies in midwifery accomplished through a variety of educational routes. The examination is based on Core Competencies established by the Midwives' Alliance of North America (MANA)Manainfo@aol.com the national organization representing midwives. The CPMs then practice in accord with the MANA Standards and Guidelines for the Art and Practice of Midwifery.

III. LAY or EMPIRICAL MIDWIVES

LAY or EMPIRICAL MIDWIVES, also referred to as direct entry midwives, obtain their training through a variety of routes. These are midwives who have chosen not to become licensed or certified for a variety of reasons, ranging from the lack of experience necessary for licensure to not wanting to work under any type of mandated protocols or guidelines. Some are part of a religious group, and practice only within a specific community. In some areas they cannot charge for their services, and can be prosecuted for doing so.

Community-based midwives have been providing care for pregnant women across North America for many past years. Currently there are two to three thousand independent midwives in the US alone. There are many types of providers providing prenatal care and birthing assistance in the United States: Midwives with different sorts of titles and qualifications, Physician Assistants, Family Practice or General Practitioners, and Obstetricians. As you can imagine, the process and outcome of a birth will be different, depending upon the provider chosen to assist the birth.


2. WHAT CAN MIDWIVES DO?

This will depend on the type of licensure and the laws and restrictions within the local area.

CNMs can obtain hospital privileges, in some states can prescribe most medications needed by women, and can attend birth in the home, hospital or birth centers. They can provide family planning and women's health care in addition to the full scope of prenatal and birthing care. How they practice will depend upon their work setting. Some CNMs practice in large, busy Level III hospitals. This is usually episodic care, and they might work shifts and specific clinics, and be able to work a limited 40 hour week.

Some CNMs have a solo private practice and others work in group practices with other CNMs and/or physicians. Most CNMs provide total midwifery care, with a physician for consultation and co-management as needed. CNMs can earn a consistent income, and can also practice as an RN if she cannot work as a CNM. Sometimes CNMs work for a family planning agency such as Planned Parenthood or the Health Department providing family planning services and women's health care. Some CNMs practice midwifery internationally on special projects for the American College of Nurse Midwives. Present projects include work in Ghana, Egypt, Uganda, Indonesia, Morocco and Bolivia and include work with family planning agencies and the training of training of Traditional Birth Assistants and working towards improving the overall standard of living for women and their families.

Obtaining hospital privileges in the United States is a critical element in a midwife's ability to practice and use the resources found within the hospital, such as the lab, radiology and the emergency room. Hospital by-laws can be written to either include or exclude this non-physician provider. Some by-laws require physician supervision and sometimes their presence at the birth. Other by-laws are more liberal. CNMs have made many strides over the past few years, and many hospitals are receptive to midwives. Women are requesting the care of midwives, and hospitals choose to offer this option.

Non-physician providers in some institutions, can independently admit and discharge their clients, however cannot vote on any committees. CNMs attend the perinatal committee, which discusses the rules and regulation of the particular obstetrical unit, but they are not allowed to vote on rules which might affect them. CNMs attend these meetings, and their visible presence makes an impression at some level to their viability. The by-laws limit who can practice. Each candidate is carefully screened for accuracy of licensure and educational program. Probationary periods exist for different practitioners, and requirements for non-physicians might differ somewhat from what is required for a physician. Hospital administrators are looking at different models of health care, and at countries where midwives provide most of the care.

The issue of hospital privileges affects non-CNMs, if they were to want privileges, or even to use the services available at the hospital. The midwife without privileges would need to go through a physician or other provider to get an ultrasound ordered, and the results would go to the physician, not the midwife. Many midwives do not seek hospital privileges, but others want to be able to transition their clients into the hospital should the need arise, and be able to continue care within the hospital. Some DEMs also sit on various committees in their states and are able to promote change in obstetrical care, along with the consumers in the community.

Midwives without a formal license practice in a variety of ways and with a variety of tools. Some use homeopathic, herbal and other non-allopathic therapies within their practice, such as massage, accupressure and reflexology. They assist births in the home or within a birth center. Some midwives are considered to be practicing illegally in their state by some authorities. It is not illegal to have a home birth, but it might be illegal for a midwife to attend the birth without appropriate licensure. A good example is in Washington State, where there are CNMs, Licensed Midwives and non-licensed midwives. If the non- licensed midwife charges for her services, this is considered illegal by state law. Licensed midwives and CNMs can bill for their services through the state, and be reimbursed by insurance plans.

Many midwives practice independent of any major medical community, consulting with a specific physician if necessary that is supportive of their cause, or having the client seek a consulting physician should problems arise. In some situations, midwives contact whatever back-up is available, using the hospital's on-call physician should transfer be necessary. A hospital's reception of a midwife's transport may vary. Sometimes the midwife and parents face a physician or nurse who disapproves of the intended birth at home. However as midwives and out-of-hospital birthing have become more common, the hospital staff has become more likely to greet the transport with professional respect. Licensure or certification provides a minimum standard to which midwives adhere. The intention is to protect the consumer from harm by a practitioner without adequate training, but is no guarantee of competency. Licensure and certification also imply a peer review process to help midwives feel accountable for their actions.

In the USA, CNMs usually work from standing protocols that they have developed themselves. These are reviewed by their consultant physicians, and guide care. Generally these are of a medical or allopathic orientation, however there are CNMs who use herbs and non-allopathic treatments within their practice. The ACOG (American College of Obstetrics and Gynecology) has well documented and clearly presented guidelines for practice, and most seem respectful of the diversity of practice within the USA. Following these guidelines are not required for practice, but are considered part of the "standards of care" within the community. Should legal action be taken against a physician or midwife, these guidelines will be reviewed, and used as a standard against which the outcome could be judged.


3. WHAT DO MIDWIVES DO?

Midwives teach, educate and empower women to take control of their own health care. In most communities, they provide prenatal care, or supervision of the pregnancy, and then assist the mother to give birth. They manage the birth, and guard the woman and her newborn in the postpartum period. Most midwives encourage and monitor women throughout their labor with techniques to improve the labor and birth. Reassurance, positive imaging and suggestions to change positions and walk helps labors progress.

Many midwives provide family planning services and routine women's health examinations such as pap smears and physical examinations. They teach women about sexually transmitted infections, and focus on prevention of the spread of infections. What specifically midwives do will depend upon: her training, her licensure, and what is allowed in the state, province, or country in which she practices. Certified Nurse Midwives (CNMs) in most states within the USA can prescribe most medications, and in some areas also provide women's health care throughout the menopause years. CNMs can attend birth in the hospital, birthing center, or home.

All midwives specialize in understanding normal aspects of the childbearing cycle. They are trained to recognize deviations from the normal, recommend holistic means for bringing the situation back into the realm of normal, or refer to another practitioner when necessary. Midwives believe it is important is to provide time for questions, teaching, and time to listen to the concerns and needs of the women they care for.


4. HOW DO I BECOME A MIDWIFE?

There are many different paths to becoming a midwife. Which path you choose will depend on many factors: where you live, what the rules and regulations are in your state or country which govern midwives, your age and education, and what sorts of experiences you have had with birthing. The most important thing is that you need to look at your reasons for wanting to become a midwife are, both short term and long term. This will help you determine which path is best for you. The resource published by Midwifery Today Getting an Education: Paths to Becoming a Midwife gives good guidance and information about the various paths to becoming a midwife.

Some women start as childbirth educators and/or doulas to see how it feels to them. I started as a childbirth educator, and offered to labor support births with my students. It reaffirmed my decision to become a midwife, and the fire within me became very strong. I lived in California at the time, and already had a 2 year degree in nursing, so decided upon sought a Certificate program, through the University of Mississippi, which was one year. I could have done things differently, but this path seemed the best one for me at the time. While teaching childbirth classes and gaining experiences with childbirth, I soon met midwives and others interested in birthing. I observed many different types of births and began develop a personal philosophy about birthing. I also became good friends with a midwife, and she mentored me to help me gain experience. She was an unlicensed midwife who became an RN at 35 and then a CNM. She has practiced in every type of setting as a midwife, including a private home birth practice and large Health Maintenance Organization (HMO) practice.


5. WHERE DO I FIND A MIDWIFE?

Seek midwives in your community, state and country of province. Speak with local childbirth educators about midwives they know, and of course, talk with your friends about their birth experiences and their particular choice of provider. Watch for health fairs in your area, check with herb and health food stores and ask questions of other types of health providers such as massage therapists and doulas.

Call the local hospitals and ask about midwives, childbirth educators and doulas. Some systems have referral systems for midwives well thought out, and you can easily locate a midwife. In other areas you may need to ask lots of questions. Ask La Leche League leaders for names of midwives they know, as would any other groups that work with mothers and infants. There might be a listing within your phone book for midwives, but some midwives are not listed there due to finances or legalities. In Georgia, in the US, only CNMs are found in the yellow pages and none of them attend homebirths. Contact nurse practitioners in your area, and also your local Health Department and Planned Parenthood. They will usually tell you their favorite providers first. Contact the American College of Nurse Midwives ACNM@aol.com Phone: (202) 728-9860) for information about schools and practices within your area or The Midwives Alliance of North America Manainfo@aol.com Phone: (316) 283-4543) 6. HISTORY OF MIDWIFERY IN THE UNITED STATES (in development)


Additional Documents about Midwifery include:

This FAQ was prepared by Pat Sonnenstuhl, ARNP, CNM cnmpat@aol.com with the supportive assistance and contributions of the following individuals. Suggestions for topics to add to the FAQ are always welcome.

  • Ms. Sabrina Cuddy < swnymph@fensende.com > :
    Childbirth educator, Nursing Mother's Council volunteer, USA
  • Ms. Elizabeth Couch < kindredspirit@shop.medchem.purdue.edu > : DEM, USA.
  • Ms. Marjorie A. Dacko < WVUY22@prodigy.com > :
    DEM, birthcenter practice, USA
  • Ms. Cheri Van Hoover < CheriVH@aol.com > :
    CNM, hospital practice, USA.
  • Mr. Patrick Hublou < phublou@innet.be > : Midwife, Flanders, Belgium
  • Ms. Deirdre E.E.A. Joukas < 065620@pc-lab.fbk.eur.nl > :
    Consumers-viewpoint, The Netherlands
  • Ms. Debbie Pulley < ManaMW@aol.com > :
    MANA Legislative Chair CPM, homebirth practice, USA

Pat Sonnenstuhl, ARNP,CNM has been an RN since 1965, and CNM since 1981. She became interested in midwifery in the 1970's when it began to flourish again in California and has practiced midwifery in the home, birth centers and hospitals. She is the the Internet spokesperson for a combination CNM-Licensed Midwife group in Washington State called the Midwives Association of Washington State (MAWS). She supports safe birthing with qualified practitioners and encourages empowerment and self- knowledge for women <

This FAQ may be reproduced freely for non-commercial purposes as long as the author also received a copy of the posting and the reactions to the posting that the distribution may cause.

This FAQ may be distributed for financial gain only with the expressed permission from the author.


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This Web version was last updated May 14, 1996 by Donna Dolezal Zelzer, djz@efn.org