This is a helpful bit of info to differentiate between the kinds of midwives.
By Jacque Shannon-McNulty
Midwifery is enjoying an explosion of popularity with moms-to-be. More and more women are choosing to give birth with midwives. The term “midwives” used to be a one size fits all label for a woman helping another woman give birth naturally. In the United States, however, there are now several classifications of midwives, making it finding the right midwife complicated for even the savvy mom-to-be.
Choosing the right kind of midwife is critical to assuring that you have the best birth experience possible. Every birth is unique and every mom-to-be has different needs in pregnancy and birth. Understanding the differences between different types of midwives will go a long way to helping you to choose the right midwife for your pregnancy and birth.
All midwives have a number of commonalities; these characteristics in general are what distinguish the care that midwives provide from a doctor’s care. Midwifery literally means “with woman” and is a holistic, woman-centered care philosophy. Midwives spend more time in prenatal appointments with their clients than most doctors do. Midwives are trained to prevent many common pregnancy complications through preventive care practices. Midwives spend time educating their clients about nutrition, exercise and stress reduction to help maintain healthy pregnancies. Midwives tend to be less interventive, relying less on technology and more on personal care to attend to the needs of their clients. Midwives also tend to provide more individualized care, offering more flexibility and open discussion of your personal preferences and your birth plan.
Certified Nurse-Midwives are nurses who continue on to complete an advance practice graduate degree program in midwifery. Certified Nurse-Midwives (CNMs) are trained in hospitals and generally practice within the medical system. CNMs attend just over 10% of births in the United States, according to the American College of Nurse-Midwives, and 96% of CNM attended births are in hospitals. Though most CNMs have never witnessed birth outside of a hospital, a small number of CNMs attend births at independent freestanding birth centers and a handful attend homebirths.
Certified Nurse-Midwives often work in teams with physicians and are required to have physician back up. This enables easy continuity of care should your pregnancy or birth develop problems. Conversely, it can add some extra restrictions for a CNM to practice under physician supervision. Due to medial malpractice insurance restrictions, hospital policy or rules laid down by supervising doctors, many CNMs are unable to attend VBAC births (Vaginal Birth After Cesarean), even healthy and uncomplicated VBACs. Most CNMs are unable to attend breech births or twin births in hospitals, though some are able to at birth centers and at home. In hospitals, some CNMs can even attend births where a mother chooses to use an epidural or other medication, though most CNMs prefer to practice with a focus on natural childbirth.
Certified Professional Midwives are apprentice-trained midwives (direct-entry midwives) who have completed the certification process through the North American Registry of Midwives. CPMs practice holistically outside of the medical system, they are not dually trained in the medical system and nurses and they usually practice independently, without physician supervision. This freedom from institutional restrictions enables many CPMs to provide individualized care without blanket risk-out protocols. Many CPMs attend healthy VBAC births and some very experienced and specially trained CPMs even attend healthy, uncomplicated twin births and breech births.
CPMs are experts in homebirth. The credentialing process for CPMs is the only educational route that requires homebirth experience to achieve certification; no CNM or MD program has this requirement, and the vast majority of CNMs and MDs have never even witnessed an out of hospital birth. With this extensive training and specialized experience in homebirth, CPMs are uniquely qualified to attend homebirth. CPMs tend to embrace waterbirth as a healthy birth option and support their clients who are interested birthing in the water. CPMs have a strong working knowledge of gentle, natural healing modalities like herbs and homeopathy. CPMs act as guardians of the natural process of pregnancy and birth. They are trained to detect problems before they occur and to manage emergencies during birth. When they can’t prevent a pregnancy or birth complication, they refer their high-risk clients to a physician.
Direct-Entry Midwives are apprentice-trained non-nurse midwives and receive their training from more experienced midwives. DEMs are midwives who have not undergone the certification process that CPMs have. They may be highly skilled and well-trained, or they may be less experienced. Because the term direct entry midwife encompasses such a wide array of midwives with very different types of training and experience, it is up to the mom-to-be to ask many questions, check referrals and carefully assess the individual training and experience of a DEM.
Direct-entry midwives and even Certified Professional Midwives are sometimes referred to in the media and by physician groups as “lay midwives.” This term is essentially pejorative, and is not a professional classification of a certain type of midwife. Other kinds of midwives, such as traditional midwives, granny midwives, traditional birth attendants or independent midwives also are types of direct-entry midwives.
Licensed Midwives are usually CPMs or other direct entry midwives who have passed a licensure exam and have received a license to practice midwifery in their state. While many states do license CPMs and DEMs, several still have not enacted licensure legislation. The qualifications for the LM credential vary from state to state.
While many midwives are deeply committed to the Midwives Model of Care, some midwives practice with more of a medically-inspired model of care. Do your research. Ask lots of specific questions. Check out referrals. Most importantly, trust your instincts. Only you can decide which midwife best suits your needs.
Whatever your birth plan entails, if you would like to experience your birth as a healthy, natural, joyful life transition, a midwife is a great choice to support and care for you through your pregnancy and birth.
- What is your general philosophy about pregnancy and birth?
- Do you let us do whatever we want during labor? (Food, positions, water, etc.)
- What is your education and training as a midwife?
- How many years have you been practicing?
- Are you a mother yourself? How old are your children now?
- How were your babies born?
- Do you work alone or with a partner or assistant? If you work with someone, what is their experience?
- Do you participate in a local midwife peer review group? How many meetings have you attended in the past year?
- How many births have you attended as the primary caregiver?
- What is your experience with breech births? How many have you attended?
- What is your experience with twins? How many have you attended?
- What is your experience with VBACS? How many have you attended?
- How many births are you attending now? Do you have a maximum, and how do you manage to avoid too many commitments?
- If I am planning a home birth, do you come to my home any time before I go into labor? Do you provide supplies or literature to help us prepare?
- How often will I see you? What do your checkups consist of?
- What are your guidelines concerning weight gain, nutrition, prenatal vitamins, and exercise? What are your standards for pre-eclampsia?
- Do you require that I take a childbirth education class? Do you teach such a class?
- Who takes over for you if you go on vacation or get sick?
Hospital and Obstetrician
- Do you attend births in a birthing center, home or hospital?
- How do you handle emergencies? Under what circumstances would you transfer?
- What is your transfer rate?
- Would you stay with me in the hospital?
- Do you require that I see a physician during my pregnancy even if everything is all right?
- Do you have guidelines or restrictions about who can give birth at home?
- Under what circumstances do you induce labor with pitocin?
- What is your protocol to induce labor naturally?
- What is your c-section rate?
- What is your episitomy rate?
- What kind of equipment do you bring to a birth?
- Are you permitted to administer any drugs during labor?
- How many people are allowed to be around?
- When should I call you after my labor begins?
- Do you wait until the cord has stopped pulsating before it gets cut?
- Will you allow my partner to be as active at the birth as he desires?
- How much time do you allow for the delivery of the placenta?
- What are your fees and what do they include?
- Can you submit your charges to my insurance company?
- What payment arrangements do you make?
- Have you ever had to resuscitate a baby?
- Do you examine the baby after birth?
- Do you give eyedrops or shots to the baby?
- Do you have a pediatrician you work with or recommend?
- Will you help me with breastfeeding?
- How do you feel about circumcision?
- How often do you come to see me after I give birth?
- Do you provide or know of anyone who will help new mothers after birth?
All over the world there exists in every society a small group of women who feel themselves strongly attracted to giving care to other women during pregnancy and childbirth. Failure to make use of this group of highly motivated people is regrettable and a sin against the principle of subsidiary. - Dr. Kloosterman, Chief of OB/GYN,