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Types of Midwives: A Discussion

2: Longer corrections with info about schooling
by Marina Alzugaray

Introduction to discussion of types of midwives
Back to:Short list of corrections by CNMPAT
Forward to: Information from Daphne Singingtree

Subj: Re: Midwives in the USA
Date: 94-12-15 22:17:24 EST
From: Midwife

Dear Midwifery-list readers,

This is an update on the description of midwives in the USA to add to the Midwifery Today's WWW-Homebirth Page, there exist according to that document three kinds of midwives in the U.S.A. I would like to add a few more types of midwives to the list, and also add to the description of the 3 basic types of midwives as described by Midwifery Today.

This is how it's is written on the WWW-Homebirth Page (Original text in italics):

-- Types of Midwives. There are three basic types of midwives:

1.- CERTIFIED NURSE MIDWIFE A CNM is a registered nurse who has completed her master's degree in midwifery. She usually works through a hospital, obstetrician's office or birthing center. She works under the direction of a physician.

A Certified Nurse Midwife is a person educated in two disciplines nursing and midwifery. A registered nurse who has completed a course leading to a certification in midwifery approved by the ACNM, and passes the National ACNM boards becomes a CNM. CNMs a re able to work in hospitals, offices, birthing centers, and at home.

Homebirths are also part of the history of CNM's in the USA. Do not forget that the first Nurse Midwife in the USA Mary Breckenrige began with homebirths for the first 30 some years of her practice in the mountains of Kentucky. In the 1960's Frontier nur sing (her service) discontinued homebirths because there was no reimbursement available for homebirths from medicaid.

The ACNM has a committee on Homebirths, CNMs involved with homebirths (at least 17% of the ACNM membership has been involved with homebirths according to a survey in 1992) usually work independent since it is extremely difficult to find a supervising M D for homebirths. The agreement is a verbal one and more like an affiliation vs. a supervisor relationship. For example I was able to have my own independent practice in California for 9 years doing homebirths. After consulting with a lawyer regarding the problems with supervision my lawyer adviced that as long as I had an affiliation with a physician as consultant and I was actively searching to comply with the law I will not have any problems if the issue ever came up. The customary practice of home birth CNM's at least in the State of California is that they work independent and do not have supervision, only a consulting relationship. This issue has never come up for us yet. Hopefully it will not. The direct entry midwives and CNM's of California are working together to rewrite the law and change the word supervision to collaboration. We hope that the law changes soon.

As far as I know there is no Masters degrees in Midwifery in the USA. I completed a Master program in Nursing this last June at UCSF and searched to find one in Midwifery anywhere in the USA, Called the ACNM, and also spoke to the ACNM president regarding the lack of academic degrees in midwifery. Master programs are in Nursing with a midwifery focus. Anyone interested may get a list from the ACNM headquarters in Washington DC.

Here are the different ways one can become certified as a CNM:

One year Certificate program.
The 1 year programs grants a Certificate in Midwifery to Registered Nurses. To enter you need either an AS degree or a BS in Nursing and some years of experience in the field, either as a OB nurse, nurse practitioner, or in midwifery. This was the first route I took even before I had a BS and without hospital experience (only i n clinic) I entered a program, and I was certified as a CNM.
Two year Master in Nursing with a Midwifery certificate.
This programs are for RN's that have a BS in Nursing or RN's with any kind of BA or BS. The first year is academic work at a master level, subjects include research, theory, etc with the second year focus in midwifery. Many schools like UCSF have th eir one year students and two year student together for this part of their program. In other words the midwifery component of the 2 year program is the same as the one year program the only difference is that the MS students take academic courses during their first year.
Three year program.
This programs are rare in the USA but are nevertheless, available. These programs are for those who already have a BA or BS in another field and want to become midwives. They usually have midwifery experience already. Durin g their first year they take nursing courses leading to a RN license; the second year is post graduate educatio;, and the third year midwifery. The students end up with an RN, a MS in Nursing, and a Midwifery Certificate. Except for their first year, the ir education is like that of the two year programs.

There are two programs EPA in California and CENAP from Frontier Nursing in Kentucky that provide a different model.

EPA grants credits to those who have had midwifery experience, they also will certified a nurse as a OB/Gyn nurse practitioner to give pr e natal care, post partum checks and family planning. When the nurse practitioner is ready she/he can go back to school and take the Intrapartum part of the program and receive their certification as a CNM. Or if the person is not an RN they can do a si milar program to become a PA (physician associate) these PA's can take the midwifery component and receive a license that allows them to attend births. There are not too many states that acknowledge the PA with a Midwifery certificate. In the State of California it is possible.

CENAP is a modular program that registered nurses can take. The education happens via modem, the students stay in their areas, all over the USA and they have preceptors that help them with their clinical practicums. This is mor e like the apprenticeship model of midwifery. To enroll the students do have to have a BA.

Both EPA and CENAP grant certificates only. To continue on for their MS they have to complete extra courses.


2 CERTIFIED MIDWIFE A CM is certified by her state or midwifery organization. She has generally passed both oral and written tests, and has had her practice scrutinized. She may have received her training in a school, or in a manner similar to the lay midwife (below).

There is now one program open in South Florida (Miami Dade Community College) granting a AS degree in Midwifery. This program opened this fall and might become a model for professional midwifery. There is the possibility that a BS in Midwifery will be created as well, but that is in the future. This new professional midwives wi ll work in health clinics, offices, birth centers, and at home. In the State of Florida they are called LMs Licence midwives.

One LM in Florida, is currently applying for hospital privileges, she is the first one to try that, so lets see what happens.

There is also a program in Toas, New Mexico, The National School of Midwifery which grants a BA, Masters, or PHD in Midwifery, so far the program is accredited in New Mexicoonly but they are applying for National accreditation.

The new name for CMs, or LMs according to the last MANA news is CPMs. Certified Professional Midwife. This title has been agreed upon by the ACNM and MANA this year. The laws in each state is a bit different for these midwives and their names will be confusing but so be it.

I hope that ultimately we will all be called MIDWIVES.


3 LAY MIDWIFE or EMPIRICAL MIDWIFE This is a woman who has apprenticed with an experienced midwife and may have attended additional workshops and classes to supplement her education. Her focus is on homebirth or she may have a birthing room available in her own home or clinic. She may be affiliated with a physician, but is not under the physician's directive.

Lay midwifery is a phenomena due to the demise of midwifery and homebirths in the USA and other industrialized countries and has served us extremely well in the US because the heart of midwifery has been preserved by the continuation of homebirths and the courage of these women. These midwives can be highly trained or have very little experience but they fill a need in their communities. In some states they have no status in the law like in Tennessee where the Farm Midwives practice they can do so with no fear of persecution.

However in other States like California lay or empirical midwives are eligible according to the state Status and are often persecuted and placed in jail, there have been many tears, and wasted time over this problem. Many of the se midwives continue practicing and are attempting to either change the law in their states or are getting their LM, CM, or CNM license when they can. Others will remain lay midwives, empirical midwives or spiritual midwives and do not belief in any kind of certification of licence even in states where direct entry midwifery is legal, more power to them.


There is yet another category not to be forgotten. These are the Granny midwives or traditional midwives. They are trained in the apprenticeship style and survived in the USA into this century attending homebirths specially in the Southern States and in poor areas. They were the ones who experienced the pressure of the AMA during the 30's to stop practicing, many did, others slowly aged and discontinued their practices, a few survived.

They were only able to survive because they provided services for a population that was either poor or in isolated areas. There is only a hand full of them left in the US. However in places like Mexico there are traditional midwives in great numbers.


In summary:

Before the 1930's in the USA there were only granny midwives or traditional midwifery with a few states granting Licenses (like Florida). In the 1930's birth in the US moved from the homes to the hospitals and from the hands of midwives to that of the OB 's. Nurse Midwifery Began in the 1930's as well with the first Nurse Midwife opening her independent practice doing home and latter hospital births. (By the way Mary Brekenrige opened her own hospital, named after her and run by midwives. She also ope ned a school for nurse midwives, now known as CENAP after many changes over the years). Nurse midwifery progressed slowly from the 30's into the 60's the few nurse midwives worked in public health position, in maternal health, and hospitals.

Birth in America went through a period called the "Knock them out and pull them out" Home births in general had experienced a demise, midwifery education was impossible, granny midwives aged, and midwifery was almost only a memory. During the late 60's the homebirth movement took form. With women who decided to take birth back. Midwives like Ina May from the Farm and many other of our currently experience midwives were then birthing their own babies at home and helping each other, and recreating midwi fery. The lay midwifery movement took hold once books became available in the 1970's.

Midwifery has grown into a real force in the last 20 years with many titles and many avenues. It will take a little longer to truly establish ourselves as independent professionals but it will be done. To those of you involved in developing models for yo ur own countries. Be careful to recognize the true body of knowledge of midwives, and our domain of practice. We have a body of knowledge as rich as many other professions.

Where are the old midwives before the medical system came in? what can they teach the new ones? how can you help your elders? And remember do not sidetrack yourselves by having to become something else to become a midwife, let several avenues be open ye t understand that midwifery has existed since ancient times and that our history and knowledge needs to be recognized, supported, and available to mothers and families all over the world.

If you are going to develop academic avenues make sure that they lead to degrees in midwifery (so that you do not repeat what has happened in the US namely no higher education for midwives in midwifery) work on theory development, do midwifery based rese arch, and do not forget the apprenticeship route to midwifery. Look to the Netherlands and New Zealand for advice in how to write the law and conduct your training.

Best wishes
Marina Alzugaray, Midwife

Introduction to discussion of types of midwives
Back to:Short list of corrections by CNMPAT
Forward to: Information from Daphne Singingtree


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Last updated Mar 6, 1996 by
Donna Dolezal Zelzer