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FAQs About Midwives and Midwifery

What is a midwife?

A midwife is a trained professional with special expertise in supporting women to maintain a healthy pregnancy birth, offering expert individualized care, education, counseling and support to a woman and her newborn throughout the childbearing cycle.

A midwife works with each woman and her family to identify their unique physical, social and emotional needs. When the care required is outside the midwife's scope of practice or expertise, the woman is referred to other health care providers for additional consultation or care.

The Midwives Alliance of North America, the North American Registry of Midwives, the Midwifery Education Accreditation Council and Citizens for Midwifery agreed on a short definition of what "midwifery care" means. However, just because a person is a midwife does not guarantee that they provide this kind of care; consumers looking for a midwife should ask questions to determine if a prospective caregiver will be able to provide the kind of care they seek.

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The Midwives Model of Care

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

  • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
  • Minimizing technological interventions
  • Identifying and referring women who require obstetrical attention

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

Copyright 1996-2005, Midwifery Task Force
All Rights Reserved

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Midwives in the U.S.

There are two main categories of midwives in the U.S., nurse-midwives, who are trained in both nursing and midwifery, and direct entry midwives, who trained as midwives without being nurses first. Within the category of direct entry midwives are several subcategories reflecting the varying legal status of these midwives in different states and the fact that until recently there was no nationally recognized credential available for direct entry midwives. Direct entry midwives include highly trained and very competent midwives; however, anyone may call herself a midwife at this time, and if you are looking for a midwife, it is up to you to find out if the midwife is qualified and experienced to your satisfaction. If a midwife is a Certified Professional Midwife (CPM), you are at least assured that she has met specific requirements for certification (and re-certification every three years).

Here is a brief overview:

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Direct-Entry Midwives (including Licensed Midwives)

  • Not required to be nurses.
  • Multiple routes of education (apprenticeship, workshops, formal classes or programs, etc., usually a combination).
  • May or may not have a college degree.
  • May or may not be certified by a state or national organization.
  • Legal status varies according to state.
  • Licensed or regulated in 21 states.
  • In most states licensed midwives are not required to have any practice agreement with a doctor.
  • Educational background requirements and licensing requirements vary by state.
  • By and large maintain autonomous practices outside of institutions.
  • Train and practice most often in home or out-of-hospital birth center settings.

For more information contact your state's midwifery organization or CfM.

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The Certified Professional Midwife (CPM) credential and
the North American Registry of Midwives

  • Not required to be nurses.
  • Multiple routes of education recognized; direct entry midwives and certified nurse midwives can qualify for this credential.
  • Education programs accredited by the Midwifery Education Accreditation Council prepare students to meet the requirements for the CPM.
  • Out-of-hospital birth experience is required.
  • Have met rigorous requirements and passed written exam and hands-on skills evaluation.
  • Administered by the North American Registry of Midwives.
  • Legal status varies according to state.
  • Practice most often in homes and birth centers.

For more information e-mail info@narm.org or call 1-888-84-BIRTH (eastern time).

The North American Registry of Midwives (NARM)

In 1987 educators, program directors and experienced midwives in the field of direct entry midwifery decided it was time to begin developing a national credential, the Certified Professional Midwife (CPM) credential, which is administered through the North American Registry of Midwives and has rigorous standards for knowledge, skills and experience.

As of January 2004, there are over 850 CPMs in the United States, Mexico, and Canada. The nineteen states that license direct-entry midwives to attend births out of the hospital use the NARM exam or the CPM process as the basis for licensure. States that are seeking licensure for direct-entry midwives are planning legislation which requires the CPM credential for licensure.

The North American Registry of Midwives has a free brochure "How to Become a Certified Professional Midwife (CPM)." You can request a copy or ask for more information about the CPM by contacting the North American Registry of Midwives at 1-888-84-BIRTH (eastern time), or by e-mail North American Registry of Midwives.

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Certified Nurse Midwives (CNMs) and
the ACNM's CM credential

Certified Nurse Midwives (CNMs)

  • Educated in both nursing and midwifery, primarily in the hospital setting; are "advanced practice nurses."
  • Must have at least a Bachelors Degree when training is complete.
  • Have successfully completed a university-affiliated nurse-midwifery program accredited by the American College of Nurse-Midwives, and passed the exam.
  • Out-of-hospital clinical experience is not required.
  • Are legal and can be licensed in all states.
  • Most practice in hospitals and birth centers.
  • In most states must have some kind of agreement with a doctor for consultation and referral; practicing without such an agreement can lead to loss of license.

Certified Midwife (CM)

The Certified Midwife (CM) is a new credential from the ACNM that does not require a nursing degree but is otherwise similar to the CNM credential. As of 1998 the CM is legally recognized in only one state (NY) and does not meet existing direct entry midwife licensing requirements in any other states.

For more information contact the American College of Nurse-Midwives at 202-728-9860, or write to 818 Connecticut Ave. NW, Suite 900, Washington, DC 20006.

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Legal Status of Direct Entry Midwives

As of 2003, 21 states recognize and regulate direct entry midwives (although for two of the states, New York and Rhode Island, only the CM credential is acceptable). Regulation varies from state to state, including licensure, certification, registration and documentation. Only 9 states and the District of Columbia actually prohibit the practice of direct entry midwives, but in 5 more states licensure is required but unavailable. In the remaining states direct entry midwives practice without any kind of state regulation, and in a few the legal status in not entirely clear. So, direct entry midwives are practicing essentially legally in about 34 states, but are considered unlawful or illegal in 14 states. However, these figures are subject to change as new legislation is enacted or new legal opinions are established that can change status in the a-legal states where direct entry midwives are neither specifically regulated nor specifically prohibited.

Refer to the CfM Legal Status Chart for the most current status of midwifery across the country.

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Points to consider if you want to become a midwife

Which kind of midwife should you become?

You need to consider how much education you want, what setting(s) you want to practice in, what state(s) you might want to live and practice in, and what income level is important to you, because these factors differ pretty much along the lines of the two categories of midwives. We recommend that you interview several different kinds of midwives with different practices before making a decision.

Setting: Are you interested in practicing in the hospital setting or primarily out-of-hospital?

CNMs practice mainly in medical settings and in almost every state are required to have some kind of agreement with a physician in order to practice (which means your work situation is dependent on the physician letting you practice, even though you may both be competing for the same clients/patients). However, since CNMs are trained as advanced practice nurses, and are under "doctor supervision" they can "do" more in terms of using drugs for pain relief, some kinds of well-woman care, even in some instances assisting at cesarean births, depending on the state and the physician they work with/for. Fewer than 2% of CNMs attend home births; in some states quite a few CNMs work in birth centers.

Direct entry midwives also usually are able to spend much more time with women during prenatal care visits and usually stay with the birthing woman throughout labor and delivery. While some CNMs are able to practice like direct entry midwives, most are limited by hospital and doctor policies, and busy practices, sometimes mandated by HMOs, may mean the CNM just comes in to catch the baby and is not able to provide the continuous hands-on care we associate with the Midwives Model of Care.

In contrast, almost all direct entry midwives attend births in homes or in free-standing birth centers, although a very few licensed midwives are now getting hospital privileges or hospital employment. What direct entry midwives are legally able to do in terms of drugs and minor interventions depends on each individual state law. On the other hand, direct entry midwives are generally much freer to use alternative methods including homeopathic, herbs, massage and imagery for pain relief and encouragement of labor

Education and accredited programs

In terms of education, while in the past a baccalaureate degree was not required to become a CNM, the trend is toward requiring this degree, and moving toward requiring a Masters Degree. For example, even now to practice as a CNM in Oregon, you must have a Bachelors Degree, even if you already got your CNM credential without that degree. The American College of Nurse Midwives has made it quite clear that they are moving toward all their midwife programs eventually requiring a Masters; they are already phasing out programs that did not require a Bachelors.

The ACNM's Department of Accreditation accredits nurse-midwifery programs. For more information about direct entry midwifery education programs, especially those accredited by MEAC, email MEAC or call 928-214-0997.

The Certified Professional Midwife credential, by contrast, is not degree-oriented or program-based. A college degree is not required, and the emphasis is on what you know rather than how you learned it. The rigorous credentialing process validates that you have all the knowledge, skills and experience necessary to practice as an entry level midwife, as determined by a comprehensive task analysis involving hundreds of midwives encompassing the full range of midwifery from CNMs to apprentice-trained rural midwives. The CPM credential is available to any kind of midwife, including CNMs, who meet the requirements.

Direct entry midwifery programs increasingly are being accredited by the Midwifery Education Accreditation Council (MEAC) a federally recognized accrediting agency, which as of January 2004 has accredited or pre-accredited nine programs located in 11 states (Arkansas, Florida, Maine, New Mexico, Oregon, Texas, Utah, Vermont and Washington). All include a structured curriculum, mostly in formal classroom settings, as well as apprenticeship elements ("one on one learning by experience with a mentor having a significant relationship with a student"). Pre-accredited programs have met all requirements for accreditation except that they do not yet have the required number of graduates who are certified or licensed. For more information about direct entry midwifery education programs, especially those accredited by MEAC, email MEAC or call 928-214-0997.

At this time you can become a midwife and qualify for CPM certification without completing a MEAC-accredited program. Ask actively practicing direct entry midwives for their suggestions on how to go about becoming a midwife. For example, many start out being childbirth educators or doulas first, and there is also a lot of "book learning" you can do even before you are in a position to actually apprentice or go to a program.

Some midwives end up with combined training - they either started out as direct entry midwives, but at some point went back to school to become a CNM in order to practice legally, or for income or job security, or to be able to serve more and higher risk women, or for some other reason. So they are CNMs but retain their direct entry midwife orientation. Alternatively, other women become CNMs, but wanting to acquire a less medicalized fear-based approach to birth, subsequently work with direct entry midwives in an apprenticeship-type arrangement.

Income

Income for a CNM ranges from around $30,000 to $80,000, depending on where she practices and what she does. The higher income brackets include CNMs with management positions in urban hospitals, and CNMs in teaching positions in nurse-midwifery programs. For DEMs the income range generally is lower, and depends on factors like the location (urban or rural), which state (legal or not, insurance coverage or not), and how many births a DEM does in a given period of time.

Another consideration is whether you want to work for someone else or have your own practice (ie, your own business). Almost all direct entry midwives have their own businesses; the majority of nurse-midwives are employees of hospitals or doctors or birth centers and even those in private practice must of necessity be closely aligned with one or more doctor practices - relatively few are entrepreneurs in the way that most direct entry midwives are. Being an employee often means regular hours, vacations and employee benefits. Being self-employed can mean longer and more unpredictable hours, but also more flexibility. Either way is likely to affect the kind of care you are able to offer to your clients.

Legal Status

On the CfM web page is a Legal Status Chart showing the legal status of direct entry midwives in every state. Direct entry midwives practice in all states, but are vulnerable to investigation and arrest in those states with no functional regulatory law.

While CNMs are legal in all states, the need for doctor collaboration or practice agreements means most CNMs are vulnerable to the ability of doctors to terminate or refuse to participate in practice agreements with midwives, and their ability to influence hospitals to refuse privileges to midwives (who in many cases are competing for the same clients as the doctors are).

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A little about Citizens for Midwifery!

CfM is a national, grassroots organization of midwifery advocates dedicated to promoting the Midwives Model of Care so that it becomes universally available and recognized as the optimal kind of care for childbirth.

For more information about CfM click here.

For membership information and form click here.

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