Subject: Midwifery in the United States
Supersedes: <smm$9602.faq.united-states@cony.gsf.de>
Date: 27 Mar 1996 09:48:32 +0100
References: <smm$9603.faq.intro@cony.gsf.de>
Summary: This posting defines the types 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.
Message_ID: <smm$9603.faq.united-states@cony.gsf.de>

Posting-Frequency: monthly
Version: 0.01
Last-Modified: 1995/10/14

Please also refer to the sci.med.midwifery  Introductory FAQ
for more general information about midwifery worldwide.

The topics addressed in this document are:

1.  MIDWIFERY IN THE UNITED STATES

I.  CERTIFIED NURSE MIDWIVES   

II.  LICENSED OR CERTIFIED MIDWIVES
..
III.  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?
6.  HISTORY OF MIDWIFERY IN THE UNITED STATES (in
development)

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.  
Programs are either a one year Certificate Program or a two
year Master's Program. Some Masters degrees are in Nursing,
some in Public Health, and some in Midwifery. Some states
are requiring a Master's Degree for a CNM to practice (such
as Washington and Oregon) for licensure.  Some programs
admit  two year degree RNs, and some programs 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 . The Community Based Nurse Midwifery Education
Program (CNEP)  is an innovative distance learning program
which allows 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  <info@acnm.org>  to determine where the
schools are and what the requirements for admission are.
Subscribing to the Journal of Nurse Midwifery (the journal
of the American College of Nurse Midwives) will provide you
with updates about programs, and articles about CNMs and 
the issues facing them..
.
In the USA, Certified Nurse Midwives are growing and
flourishing, numbering over 4000.  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.   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.   In the United States, direct-entry
midwifery is legally recognized in 29 states.  Licensure,
certification or registration is available in 17 states and
Medicaid reimbursement is available 6 states. Licensed or
certified 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 or certified
midwives are reimbursed by many insurance companies for
birth center and home births.

There is a movement in the United States towards
Professional Midwifery: a process through which those
aspiring to be midwives can proceed and at the end be called
a CERTIFIED PROFESSIONAL MIDWIFE (CPM).  The North American
Registry of Midwives (NARM) is the first certifying body to
offer 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.  NARM has just completed a pilot
project for a certification process which 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.

III. LAY or EMPIRICAL MIDWIVES, also referred to as direct
entry midwives, obtain their training through a variety of
routes.  These are 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 that
they have developed themselves.  These are reviewed by their
consultant  physicians, and guide care.   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
guard 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. 

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 women start as childbirth educators and/or doulas to
see how it feels to them.  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 good friends with
a midwife, and she mentored me to help me gain experience. 
She was an unlicensed midwife who became an 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.  Contact the 
  American College of Nurse Midwives 
  <info@acnm.org> 
  Phone: (202) 728-9860
  Fax: (202) 728-9897
  818 Connecticut Ave NW, Suite 900
  Washsington, DC 20006
for information about schools and practices within your area or
  The Midwives Alliance of North America
  <Manainfo@aol.com>
  Phone: (316) 283-4543

6.  HISTORY OF MIDWIFERY IN THE UNITED STATES (in
development)

Additional Documents about Midwifery include:

BIBLIOGRAPHY OF BOOKS AND RESOURCES ABOUT THE PROFESSION OF
MIDWIFERY
INTRODUCTION TO MIDWIFERY
MIDWIFERY IN AUSTRALIA (in development)
MIDWIFERY IN FLANDERS (in development)
MIDWIFERY IN THE UNITED KINGDOM (in development)

***********************************************************

This  FAQ  was prepared by  Pat Sonnenstuhl, ARNP, CNM 
<cnmpat@aol.com> with the supportive assistance of the
following contributors. Suggestions for topics to add to the
FAQ are always welcome.

Ms.  Sabrina Cuddy <swnymph@abekas.com>: 
Childbirth  educator, Nursing Mother's Council volunteer,
USA

Ms.  Elizabeth Couch <kindredspirit@shop.medchem.purdue.edu>
DEM, USA.

Ms.  Marjorie A. Dacko <WVUY22@prodigy.com>:DEM, birthcenter
practice, USA

Ms. Sharon K. Evans <BirthRite@aol.com>: writer and and
licensed DEM, birth center practice.  Co-chair for the NARM
Qualified Evalator Committee

Ms.  Cheri Van Hoover <CheriVH@aol.com> CNM, hospital
practice, USA.

Mr.  Patrick Hublou <phublou@innet.be>: Midwife, Flanders,
Belgium

Ms.  Deirdre E.E.A. Joukes <065620@pc-lab.fbk.eur.nl>
Consumers-viewpoint, The Netherlands

Ms.  Debbie Pulley <ManaMW@aol.com> MANA  Legislative Chair
CPM, homebirth practice, USA

Pat Sonnenstuhl, ARNP,CNM <cnmpat@aol.com>  has  been an RN
since 1965, and CNM since 1981.  She  became interested in
midwifery in the 1970's when it began to flourish again in
California and has practiced midwifery in the home, birth
centers and hospitals. She is the the Internet spokesperson
for a combination CNM-Licensed Midwife group in Washington
State called the Midwives Association of Washington State
(MAWS).  She supports  safe birthing with qualified
practitioners and  encourages  empowerment and self-
knowledge  for women. 
