What is a midwife?

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

A midwife works with each person and 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 client is referred to other health care providers for additional consultation or care.

The International Confederation of Midwives (ICM) defines a midwife as:

"A midwife is a person who has successfully completed a midwifery education programme that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery."

According to ICM, a midwife should be recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practice in any setting including the home, community, hospitals, clinics or health units.

ICM Key midwifery concepts:

partnership with women to promote self-care and the health of mothers, infants, and families;
respect for human dignity and for women as persons with full human rights;
advocacy for women so that their voices are heard;
cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
a focus on health promotion and disease prevention that views pregnancy as a normal life event.

Learn more from ICM

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.

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.

Midwives in the U.S.

There are two main categories of midwives in the U.S. :

Certified Professional Midwives (CPMs).
Certified Nurse-Midwives (CNMs)/Certified Midwives (CMs)

The Certified Professional Midwife (CPM):

The CPM credential is administered through the North American Registry of Midwives and has rigorous standards for knowledge, skills and experience.
The CPM is a competency based credential and multiple routes of education are recognized
Education programs accredited by the Midwifery Education Accreditation Council prepare students to meet the requirements for the CPM.
Not required to be nurses.
Out-of-hospital birth experience is required.
Have met rigorous requirements and passed written exam and hands-on skills evaluation.
Legal status varies according to state
Practice most often in homes and birth centers.

The first CPM credential was issued in November of 1994 (see NARM for more on the history of the development of the CPM credential). Several states, including Florida, licensed midwives prior to the development of the CPM credential. Those who have not chosen to get their CPM are referred to as Licensed Midwives (LMs) or Registered Midwives in those states.

Certified Nurse Midwives (CNMs)/Certified Midwife (CMs) :

Certified Nurse Midwives (CNMs)

The CNM/CM credential is administered through the American Midwifery Certification Board (AMCB).
Complete a university-affiliated nurse-midwifery program accredited by the Accreditation Commission for Midwifery Education (ACME).
Educated in both nursing and midwifery, primarily in the hospital setting; are "advanced practice nurses." Most complete their training with a graduate degree
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 many 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 2007, the CM is legally recognized in three states: NY, MA, and NJ, but does not meet existing licensing requirements in any other states. For more information visit the American College of Nurse-Midwives website or contact them at 240-485-1800, or write to 8403 Colesville Road, Suite 1550, Silver Spring, MD 20910..

Legal Status of Direct Entry Midwives?

As of 2018, 31 states have a path to licensure for CPMs. 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 non-nurse midwives, but in 5 more states licensure is required but unavailable. In the remaining states non-nurse midwives practice without any kind of state regulation, and in a few the legal status in not entirely clear.

Refer to the State by State Page for the most current status of midwifery across the country.

Are you considering becoming 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 most states 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.

CPMs 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 CPMs, 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 CPMs 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 CPMs are legally able to do in terms of drugs and minor interventions depends on each individual state law. On the other hand, CPMs 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, most CNM programs result in a masters degree. Many require a nursing degree, bachelor's degree with additional nursing classes, or other requirements to become a CNM. See ACME for more information on CNM educational programs

The Certified Professional Midwife credential, by contrast, is competency 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. However, with the adoption of the US MERA agreements that require new licensing laws to include an accredited education or the bridge certificate for CPMs after 2020, CfM highly recommends students consider an accredited program to meet these new requirements.

CPM schools and programs are increasingly being accredited by the Midwifery Education Accreditation Council (MEAC) a federally recognized accrediting agency, which as of January 2018 has accredited or pre-accredited eleven programs or schools located in 11 states (California, Idaho, Florida, Maine, New Mexico, Oregon, Texas, Utah, Vermont, Washington, and Wisconsin). Visit MEAC for an updated list of schools.

All MEAC accredited programs meet MEAC's community derived standard's for education. These standards include the ICM Core Competencies adapted by MEAC to the US setting. Accredited programs include structured curriculum with a wide variety of learning modalities. Some are online, hybrid, distance, or formal classroom settings. All include a clinical apprenticeship ("one on one learning by experience with a mentor having a significant relationship with a student"). For more information visit MEAC here.

At this time you can become a midwife and qualify for CPM certification without completing a MEAC-accredited program. Consider if you could end up practicing in a state that requires a MEAC accredited education or bridge certificate to practice and what programs or schools best meet your educational and lifestyle needs. Many midwives 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 school.

There is increasing work being done to create a more diverse CPM workforce who can provide culturally concordant care. The Grand Challenge lists scholarships for students of color here. And the Equity in Midwifery Education site provides many articles and resources on improving midwifery education in this regard.

Income

Income for CNMs ranges from around $30,000 to $80,000, depending on where they practice and what services they provide. The higher income brackets include CNMs with management positions in urban hospitals, and CNMs in teaching positions in nurse-midwifery programs. For CPMs 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 CPM 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 CPMs have their own businesses; the majority of CNMs 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 CPMs 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.