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Midwifery in the USA |
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This
FAQ was originally created for the newsgroup Sci.med.midwifery in 1996.
It has been revised to reflect current trends within the United States.
It was originally written through the collaborative efforts of many
individuals, and not the writing of one individual, nor of one
organization. Permission to reprint this document must be obtained from
the WebMidwife, Pat Sonnenstuhl, CNM, MS. Comments and additions
are always welcome:
webmidwife1@comcast.net |
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This document defines the types his
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. An excellent book that was published in 1997
Midwifery and Childbirth in America by Judith Pence Rooks,
covers these topics in great detail. This document is intended to be a
synopsis of Midwifery in the United States. |
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1. MIDWIFERY IN THE
UNITED STATES |
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2. WHAT CAN MIDWIVES DO? |
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3. WHAT DO MIDWIVES DO? |
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4. HOW DO I BECOME A
MIDWIFE? |
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5. WHERE DO I FIND A
MIDWIFE? |
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1. MIDWIFERY IN THE UNITED STATES: |
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| I.
CERTIFIED NURSE MIDWIVES (CNMs) and CERTIFIED MIDWIVES (CMS)
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. In 1999 minimum entry for an ACNM approved
midwifery program is a Bachelor's Degree. Several innovative programs
provide eligibility for midwifery and nursing certification in three
years. There are also several distance learning options for education.
See:
Innovative Education
Programs |
There are still
one-year Certificate Program, but most ACNM approved midwifery schools
lead to a Masters Degree. Some Masters degrees are in Nursing, some in
Public Health, and some in Midwifery. More and more states are requiring
a Master's Degree for a CNM to practice (such as Washington and Oregon.
This is called "Advanced Practice", and commonly the practitioner is a
CNM and ARNPs (Advanced RN Practitioner)). Some programs admit two-year
degree RNs, and ACNM guidelines now 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. More
information about the American College of Nurse Midwives can
be found at:
ACNM: http://www.midwife.org |
| There are several programs
that require a Bachelor's Degree for minimum entry, but not nursing. The
graduates of these programs are called Certified Midwives (CMs), and
become ACNM Certified, taking the same courses and examinations as the
nurse-midwifery students. Physician's Assistants can also become ACNM
Certified through a specific ACNM mechanism. Please check with ACNM for
the details about these options. |
| There are
several innovative routes to Nurse Midwifery. Several offer
Distance Learning Programs, which allow 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
http://www.midwife.org/edu/index.cfm
and
http://www.midwife.org/edu/students.cfm to determine where the
schools are and what the requirements for admission are. Subscribing to
the Journal of Midwifery & Women's Health t(The journal of the American
College of Nurse Midwives, and formerly the Journal of Nurse-Midwifery)
will provide you with updates about programs, and articles about CNMs,
CMs, and the issues facing them. |
| In the USA, Certified Nurse
Midwives are growing and flourishing, numbering around 5000. 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. CNMs, in some states, practice
independently. In some states CNMs also hold a separate title, and must
use it with their legal signature. Current research suggests that
midwives assist over 10 % of the births in the USA |
| 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. |
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II. LICENSED OR
CERTIFIED (direct entry) MIDWIVES |
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II. 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. |
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Midwives' Alliance of North America
(MANA) maintains these statistics, and the
most current information can be found at:
http://www.mana.org/statechart.html
More and more states are seeing the value of providing a mechanism for
CPMs to practice legally. Licensed 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 midwives are more and more being
reimbursed by insurance companies for birth center and home births. |
The North American Registry of Midwives (NARM)
is a certifying body that offers 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. After successfully completing a course of study and a
certification exam, the midwife obtains the title of CERTIFIED
PROFESSIONAL MIDWIFE (CPM). The NARM certification process 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)
info@mana.org
The CPMs then practice in accord with the
MANA Standards and Guidelines for the Art and Practice of Midwifery.
More about MANA can be found at:
http://www.mana.org |
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The Midwifery Education Accreditation Council
(MEAC) is responsible for the implementation of the accreditation
process. |
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III. LAY or EMPIRICAL
MIDWIVES |
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III. LAY or
EMPIRICAL MIDWIVES, also referred to as direct entry midwives, obtain
their training through a variety of routes. This category may also
include very experienced and well trained midwives who practice in
states where there is no reciprocity for the license they already have,
such as Oregon, where certification is not required unless one wants to
get medical funds for low income clients. This category does not exclude
nurses from its ranks. These might also be 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. |
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2. WHAT CAN MIDWIVES DO? |
| What specific
midwives do will depend on the type of licensure, political climate and
economic environment, 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, acupressure 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 or practice guidelines that they have developed
themselves. 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. |
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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 watch over 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. The ability
to prescribe allows the CNM to provide comprehensive care, and in many
areas CNMs provide primary care. A recent Article in Advance, a journal
for nurse practitioners, describes the safety with which nurse
practitioners prescribe. |
| 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. |
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The American Public Health Association (APHA)
in 2001 passed a resolution titled:' Increasing Access to
Out-of-Hospital Maternity Care Services through State Regulated and
Nationally-Certified Direct Entry Midwives. It is hoped that this will
improve the political climate for the practice of midwifery outside of
the hospital setting and provide more choices for women.
Details
of this resolution are available on the APHA web site. |
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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 individual who want to be midwives,
start as childbirth educators and/or doulas to see how it feels to them.
My story is a good example of this path: 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 a good friend with a midwife,
and she mentored me to help me gain experience. She was an unlicensed
midwife who became a 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. |
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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. |
| You can contact the
American College of Nurse Midwives
http://www.midwife.org/ and
http://www.midwife.org/about/staff.cfm
Phone: (202) 728-9860)or 1-888-MIDWIFE (1-888-643-9433). |
| The Web Site address for
The Midwives Alliance of North America is:
http://www.mana.org
or email: info@aol.com |
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| This revision of this FAQ
was prepared by Pat Sonnenstuhl, ARNP, CNM, RH
webmidwife1@comcast.net. Pat's story about her journey to midwifery,
and how to become a nurse practitioner can be found at:
http://www.obgyn.net/yw/articles/pats_roadtoNP_1099.htm Suggestions
for changes, or for topics to add to the FAQ are always welcome. |
| The original FAQ was published in 1996,
with the supportive assistance of the following contributors: |
| Ms.Sabrina Cuddy |
Mr. Patrick Hublou |
| Ms.Elizabeth Couch |
Ms. Deirdre E.E.A. Joukes |
| Ms.Marjorie A.Dacko |
Ms. Debbie Pulley |
| Ms.Sharon K. Evan |
Ms.Cheri Van Hoover |
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About Midwives
