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Midwifery in the United States

Archive-name: medicine/midwifery/united-states
Posting-Frequency: monthly
Version: 0.02
Last-Modified: 1996/6/8

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

The topics addressed in this document are:






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

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

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

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. 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. (Sharon Hodges-Rust). 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


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.

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.


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.


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> or their web page:
 Phone: (202) 728-9860)
for information about schools and practices within your area or
 The Midwives Alliance of North America
 Phone: (316) 283-4543


Additional Documents about Midwifery include:

MIDWIFERY IN CANADA (in development)
MIDWIFERY IN FLANDERS (in development)


This FAQ was prepared by Pat Sonnenstuhl, ARNP, CNM, RH <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@fensende.com>: 
Childbirth educator, Nursing Mother's Council volunteer, USA

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

Ms. Marjorie A. Dacko <dacko@accessnv.com>>:
Home birth and birthing clinic practice. President of the Nevada
Midwives Association.

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, RH <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.
She recently completed the intermediate level of training to became a
registered hypnotherpaist and uses hypnosis in a variety of ways in her
practice of midwifery.

This FAQ may be reproduced freely for non-commercial purposes as long as
the author also received a copy of the posting and the reactions to the
posting that the distribution may cause.

This FAQ may be distributed for financial gain only with the expressed
permission from the author.

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