In last week’s post, I wrote about doctors that provide care during pregnancy and birth. This week, I offer information and clarification about the different types of midwives that practice in the United States.
A midwife is a trained health professional who helps healthy women during pregnancy, birth, and after the birth of their babies. Midwives were, and in many places around the world today continue to be, the traditional birth attendants for women. Midwives are trained in maintaining healthy pregnancies and the normalcy of the birthing process. They are also trained to identify warning signs of health problems in the mother or the baby. Midwives work in collaboration with obstetricians. If a mother or baby experiences a problem that is outside the scope of the practice of midwifery, the midwife and doctor may work together to help the client, or the client may transfer for appropriate care by the doctor.
Ok – here’s where things get a bit confusing – There are different classifications of midwives, based on their training, their certification credentials, and licensing, but they all use the term “midwife.” Certification refers to the training and testing they completed to learn their midwifery skills, and licensing refers to the state regulations regarding the practice of midwifery.
A Certified Nurse Midwife (CNM) is a nursing specialist with an advanced practice degree, such as a Masters degree or a PhD, in the practice of Midwifery, and has passed the certification exam from the American College of Nurse Midwives (ACNM). Because they are nurses they have training working in hospitals, and most CNMs continue their work in the hospital environment. They are licensed health care providers in all 50 states. CNMs may work in practices with OB/GYNs, or they may maintain practices separately and have working agreements with one or more doctors should a client need to step up to a higher level of care. CNMs care for all aspects of pregnancy and birth, and also well-woman care throughout the life cycle, so you can see a midwife for your annual check-ups starting as a teen and continue to see one through menopause for your gynecologic care. They can order blood tests, ultrasounds, narcotic pain relief, epidurals, and more, so you can still have an epidural when you have a CNM attending your hospital birth. CNMs can also work in birth centers and attend home births, depending on the regulations in your state.
A Certified Midwife (CM) is a health professional who has received a degree in a health-related field other than nursing, attended a midwifery program accredited by the ACNM, and passed the same certification examination as a CNM. CMs are licensed to practice in hospitals in some states, and can work in birth centers and attend home births. CM is a fairly new credential, so there are not a lot of them practicing, although the numbers are likely to grow in the coming years.
A Certified Professional Midwife (CPM) is one who did not attend nursing school, but has learned midwifery skills and passed the North American Registry of Midwives (NARM) certification process. The Midwives Alliance of North America offers lots of information about CPMs. At the time of this writing, CPMs may either attend a midwifery school or learn through an apprenticeship arrangement with another CPM. However, work is being done to establish one clear training pathway under the International Confederation of Midwives (ICM) standards and the apprenticeship route soon may not be acceptable. The concern is that the training through apprenticeship may not be uniform, and midwives who learn through apprenticeship may not be exposed to training for certain unusual occurrences if those occurrences do not happen during the births they attend as student midwives. CPMs work in birth centers and attend home births.
A Licensed Midwife (LM) is one who has passed a state-level licensing process. That process may have included a state-run training program, may require passing an exam to show a certain level of knowledge, or simply require filling out some paperwork and paying a fee. Licensing varies state by state, and some states do not have any licensing requirements at all, so LMs are not in practice in every state.
Direct Entry Midwife (DEM) is a term used to describe a midwife who does not have a nursing or other health-related degree, but has learned the skills of midwifery. That learning may have come through an accredited midwifery training program, apprenticeship with a CPM, CM, or self-trained midwife, or through self-study. DEMs may or may not have state licensure. As you can see, DEM is a very broad term. It can be used to refer to a CPM, who has a midwifery degree from an accredited midwifery school, and can also refer to a self-trained person who just starts attending out-of-hospital births without any formal training. If you are interviewing a DEM midwife to attend your birth, you should question them thoroughly about their training and education.
Lay Midwife is another term that can be confusing. Again, it usually refers to a midwife who does not have a nursing or other health-related degree. Some people (including other midwives) will refer to any other midwife without a nursing degree as a lay midwife, regardless of whether or not they have any type of certification, such as CPM or CM. Others may use the term ‘lay midwife’ to refer to only ones who are self-trained or train through apprenticeship, without regard to whether or not they are certified. Still others will use the term for midwives who are self-trained or apprenticeship-trained with an uncertified midwife and remain uncertified themselves.
Furthermore, some states have laws on the books that make the practice of out-of-hospital midwifery legal, others have laws that make it illegal, and a few have no laws on the books at all about it. This has an impact on licensing, and can affect how midwives may practice in your state, how easily they can get medical back-up arrangements, and how smoothly transfer to the hospital may go. So, the out-of-hospital midwives in your state may be certified and licensed, uncertified and licensed, certified and unlicensed, or uncertified and unlicensed, depending on which state you live in and which midwife you choose.
Very confusing, right?
So, if you are planning an out-of-hospital birth, either in a birth center or at home, know the laws about out-of-hospital midwifery in your state. It is very important to interview the midwives carefully about their training and education, their certification, and their licensure. Ask to see documentation. Check references. And talk with others in your birth community to see what others say about the midwife you are considering for your birth. There is usually a range of positive and negative buzz, and it can help you determine if that midwife is right for you.
Every midwife should have a working arrangement with an obstetrician, so that if transfer is necessary, it will go more smoothly. When interviewing a midwife, ask about their medical back-up arrangement and their relationship with the doctors and the local hospital where you would transfer if necessary. Make sure you have a clear understanding of how those transfers usually go, and how you can expect to be received by the doctor or hospital if you need to interact with them. Because out-of-hospital birth is not the norm in our country, some communities are more accepting of it than others.
Midwifery care can be a great option for healthy women experiencing healthy pregnancies. Let this information guide you to the type of midwife that works in the setting you choose, and which works best for you!