United States Midwifery FAQ
By Pat Sonnenstuhl, ARNP, CNM, MS
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, ARNP, CNM, MS. Comments and additions are always welcome: firstname.lastname@example.orgThis 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.
1. MIDWIFERY IN THE UNITED STATES
- CERTIFIED NURSE MIDWIVES
- LICENSED OR CERTIFIED MIDWIVES
- EMPIRICAL MIDWIVES
2. WHAT CAN MIDWIVES DO?
3. WHAT DO MIDWIVES DO?
4. HOW DO I BECOME A MIDWIFE?
5. WHERE DO I FIND A MIDWIFE?
1. MIDWIFERY IN THE UNITED STATES:
In the US there are three types of midwives:
I. 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. In 1999 minimum entry for an ACNM approved midwifery program is a Bachelor’s Degree. 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 ARNP (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/educ/ or email: email@example.com to determine where the schools are and what the requirements for admission are. Subscribing to the Journal of Midwifery and Women’s Health (the journal of the American College of Nurse Midwives) 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.
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) MIDWIVESpractice 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. 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) 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. More about MANA can be found at: http://www.mana.org,
The Midwifery Education Accreditation Council (MEAC) is responsible for the implementation of the accreditation process.
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.
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 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.
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.
Completing the ‘Right to Write’
Controlled Substances Prescribing
BY SALLY PETERS
http://www.merion.com/np/nparticle2.html 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.
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.
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.