Although midwives have practiced in countless cultures across the globe since time immemorial, for many years in the United States the practice of midwifery struggled to remain an accepted practice. Beginning in the 1930s, competitive medical markets and hospital births threatened to jeopardize the practice of midwifery, with many physicians and medical establishments going as far as to criminalize the practice.
Today, however, midwifery has successfully re-integrated to become a recognized and valued element of the maternity care model. Women from all walks of life now seek out this unique blend of care and support, which views birth as a natural process rather than a medical procedure. In fact, according to the American College of Nurse-Midwives (ACNM), the number of midwife-attended births in the United States has more than doubled since 1991.
The rise of the medical care model, the practice of obstetrics, and the clash of care models, cultures, class, race, and gender dynamics throughout the years have shaped the practice and spurred the creation of different pathways and professional bodies.
Although there are a number of professional designations under the umbrella of midwifery, all midwives share a similar view on the importance of focusing on the physical, psychological, and social well-being of the mother throughout the childbearing cycle, minimizing technological interventions, providing hands-on assistance during labor and delivery, and providing postpartum support.
However, not all midwives share the same education, training, credentials, scope of practice, and state recognition. Today’s midwives fit into one of two categories:
- Nurse-Midwives: those trained in both nursing and midwifery
- Direct-Entry Midwives: those trained in midwifery without first being nurses
Credentialing and Scope of Practice for Certified Nurse-Midwives
The vast majority of midwives in the United States are Certified Nurse-Midwives (CNMs), with more than 11,000 active CNMs counted as of February 2015.
Certified nurse-midwives are advanced practice registered nurses (APRNs) backed by the American College of Nurse-Midwives. To become a CNM, registered nurses must graduate from a master’s or higher-level nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) and pass the national Certified Nurse-Midwife Examination through the American Midwifery Certification Board.
All CNMs must hold state licensure, usually issued through their state board of nursing. They must also meet specific continuing education requirements to maintain state licensure and the CNM designation.
All U.S. states recognize and license CNMs and allow them prescriptive authority. Eighteen states allow CNMs to diagnose and treat without physician supervision, while the remaining states require CNMs to enter into a collaborative practice agreement with a physician. Medicaid reimbursement for CNM care is mandatory in all 50 states, and most states mandate private insurance reimbursement for their services.
All ACME-accredited nurse-midwifery programs include didactic coursework and clinical experiences that prepare students to work in any number of settings, including hospitals, health clinics, birth centers, and OB/GYN practices, among others. Their advanced practice nursing background allows them to work as part of a medical team that may include MDs such as gynecologists and obstetricians. Many of today’s OB/GYN practices and hospitals have CNMs on staff.
Because of their dual training in nursing and midwifery, CNMs are well qualified to provide care to women not just during the childbearing years, but also across their lifespan. They provide regular well woman visits, gynecologic checkups, contraceptive and family planning services, and treatment of STDs, among other services. CNMs are also qualified to provide neonatal care during the first 28 days of life.
Credentialing and Scope of Practice for Direct-Entry Midwives: CPM, CM and Doula
Although direct-entry midwives still practice in the U.S. today, they comprise a small fraction of practicing midwives when compared to CNMs. This is likely because direct-entry midwives are limited according to the legal stipulations set forth by their state and because no nationally recognized credential existed for these midwives until about 20 years ago. In the past two decades, national certification in the form of the CM (Certified Midwife) and CPM (Certified Professional Midwife) credentials have allowed highly trained, competent midwives to set themselves apart from others in the field and validate their advanced knowledge.
Certified Midwives – The Certified Midwife (CM) credential denotes a master’s-prepared healthcare professional trained in the discipline of midwifery. Like CNMs, CMs receive representation through the American College of Nurse-Midwives and must therefore meet the same standards for certification. The CM is a relatively new credential developed in 1997 for individuals seeking a pathway to midwifery that does not require a nursing background.
Candidates for the CM designation must complete a graduate-level midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) and pass the national certification examination through the American Midwifery Certification Board to earn the CM designation. To maintain the CM designation, they must be recertified every five years and meet specific continuing education requirements.
Like CNMs, CMs may provide a full range of primary healthcare services, from adolescence to beyond menopause. Certified midwives work in a variety of settings, including hospitals, health clinics, OB/GYN practices, birth centers, and private homes.
As of 2016, just a handful of U.S. states (New York, New Jersey, Missouri, and Delaware) legally recognize and license CMs.
Certified Professional Midwives – The Certified Professional Midwife (CPM) credential is available through the North American Registry of Midwives (NARM). The CPM credential is the only midwifery credential that requires the holder to demonstrate knowledge and have experience in providing midwifery services in out-of-hospital settings. Most CPMs work in their clients’ homes and in private birthing centers, providing care to women throughout their childbearing cycle.
To earn the CPM designation through NARM, applicants must possess a high school diploma or the equivalent and complete NARM’s Portfolio Evaluation Process or graduate from a midwifery education program accredited by the Midwifery Education Accreditation Council (MEAC). Applicants may also qualify if they already possess the CNM or CM credential.
MEAC-accredited programs may grant a certificate, associate’s degree, bachelor’s degree, master’s degree, or doctoral degree. Most graduates attain a certificate or associate’s degree.
As of 2015, 27 states had some kind of legal recognition for CPMs (licensure, certification, registration, permit, or voluntary registration), with 17 of these states offering licensure based on the CPM certification.
Missouri, Maine, and Mississippi have statutes protecting the unregulated practice of CPMs, and Florida is the only state that requires CPMs to carry malpractice insurance.
Doulas – Doulas are NOT maternity care providers, although they do provide informational support to mothers during childbirth along with physical and emotional care.
Many doulas also provide support to mothers and infants in the weeks following childbirth, and still others specialize in providing emotional support to families regarding abortion, adoption, infertility, miscarriage, and stillbirth. Some doulas also provide end-of-life care services to families. While some doulas work directly for birth centers or hospitals, most are hired directly by expecting mothers and provide services in the home.
Because doulas provide non-medical support, there are few legal requirements regarding their practice. Many doulas choose to receive formal training and certification through nationally recognized organizations such as the Doulas of North America International (DONA International) and the Childbirth and Postpartum Professional Association (CAPPA).