| 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:
cnmpat@attbi.com
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.
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: info@acnm.org 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) 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. Midwives' Alliance of North
America (MANA) maintains these statistics, and the most
current information can be found at: http://www.mana.org/statechart.htmlMore
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.
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 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.
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.
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.
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.
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 info@acnm.org
or their web page: http://www.acnm.org
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: MANAinfo@aol.com
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