In the United States, there are 4 different types of midwives with a varied range of training, scope of practice, and experience. Of those, 3 hold national certifications and credentials. The history of the word midwife is derived from two Middle English elements: mid meaning with, and wife meaning woman. Therefore, it simply means being “with woman,” specifically during childbearing.
Traditional/Lay Midwives (TMs)
According to the Midwives Alliance of North America (MANA), TMs are those who for various reasons choose not to hold certifications and/or licenses. They may or may not have training (formal or informal) in the art and science of midwifery. Many believe that they are responsible to their communities, midwifery is a contract between a woman and her midwife, the practice of midwifery should not be legislated at all, or women have the right to choose their care provider irrespective of legal status. They practice solely in out-of-hospital settings.
Midwives have been the traditional attendants of birth dating all the way back to Biblical days in Exodus. In colonial America, many were charged as witches and executed in the Salem Witch Trials. In the South during the 19th and 20th centuries, TMs were referred to as “Granny midwives.” Most were of African Americans or Appalachian descent. The title was given them by the government and was derogatory, suggesting ignorance. However, some referred to themselves in this way to redeem the offensive term, making it one of honor as a “granny” is someone whose age and wisdom are to be revered. They were regarded as elder healers, not just midwives. They had a certain spiritual authority, and considered midwifery a deep calling, just as many of today’s midwives do.
As doctors specializing in obstetrics and gynecology gained popularity in the20th century, the campaign against midwives (especially the African American/granny midwives of the South) began to impose various restrictions on TMs’ practice through legislation. In the South, Jim Crow laws further outlawed midwifery.
Women like Onnie Lee Logan and Margaret Charles Smith from Alabama have long since died, taking many of the secrets of traditional midwifery with them. I recently read a letter of one midwife who is returning to the roots of traditional midwifery. Though it is not the path I or many others would choose, her story brought tears to my eyes while deepening my commitment to become a midwife and promote the instinctive nature of birth again. There are some traditional midwives left, however they are becoming fewer and further between.
Certified Professional Midwives (CPMs)
According to MANA, this a type of direct entry midwife (one who does not have prior education as a nurse) trained in out-of-hospital settings. CPMs are credentialed by the North American Registry of Midwives (NARM) and trained in the midwifery model of care, practicing in freestanding birth centers and homes. One desiring to pursue this path obtains an experienced CPM as a mentor/preceptor with whom they will work side-by-side to learn the skills necessary for practice. Some who obtain this credential have degrees from schools accredited by the Midwifery Education Accreditation Council (MEAC) while others do not and have been trained via self-study of the same books and materials as Certified Midwives (CMs) and Certified Nurse Midwives (CNMs).
These midwives complete an extensive apprenticeship (even if they attend a MEAC accredited school) similar to what other healthcare professionals call clinical internships. Apprenticeships generally last 3-5 years, sometimes longer. When the necessary requirements are complete and both student and preceptor have agreed that she is ready, the application is submitted to NARM. Upon review, the certification exam is scheduled, along with a skills validation. If both are passed, the CPM credential is awarded.
As of 2017, Alabama joined a growing number of states who license and regulate the practice of CPMs. Prior to this, CPMs could be prosecuted and convicted of a class C misdemeanor, incurring fees and jail time. Women wanting the option of home birth were (and are) forced to drive out of state for this type of midwifery care. Though the law has been passed, it will take time to set up a state midwifery board and begin issuing licenses.
Certified Midwives (CMs)
This is another type of direct entry midwife who has a bachelor’s degree in a health-related field who attends graduate school, obtaining a master’s degree. The training is similar to that of a CNM. Practice standards are also similar but without the nursing component. They can practice in any setting (hospital, freestanding birth center, or home). These types of midwives are still relatively rare and not utilized in many states.
Certified Nurse Midwives (CNMs)
Certified Nurse Midwives are midwives trained in the disciplines of both nursing and midwifery. They hold a bachelor’s degree in nursing and a master’s degree in midwifery. They are mostly trained in hospitals, and most CNMs practice there; however, their scope of practice allows for practice in any setting. They care for women across the lifespan, from puberty to menopause and beyond. They are classified as primary care providers, specifically in the realm of women’s health. Many hold a dual certification as a Women’s Health Nurse Practitioner (WHNP). WHNPs function essentially the same as CNMs, but are not trained in labor, birth, or newborn care. CNMs are legal to practice in all 50 US states, as well as many other countries due to the vast scope of their training.
In spite of the recent passage of the CPM law, CNMs in Alabama are not currently able to practice in out-of-hospital settings due to the Alabama laws governing advanced practice nurses. Very few in the state are able to practice to the full scope of their training, even in the hospital. It is my hope as a CNM student that this too will soon change.
By: Rachel Clark, RN, BSN
