In America there are three primary kinds of midwives, Certified Nurse Midwives, Certified Professional Midwives, and Direct Entry Midwives. It’s kind of confusing, so here’s a fairly long explanation of the types of American midwives as well as a bit about my path and training as Certified Professional Midwife (CPM).
The Early Years
Let’s just start at the beginning. In the beginning there was your neighbor lady who had more babies than you did. After she had six or seven (or twenty) of her own, she had an idea what was going on with labor and birth. So when it was time for you to have your first baby your husband would run next door and bring her back to help. Some of these women perhaps showed more aptitude, or just got more experience than others and they became the women everyone called on to help during labor. They became midwives, and everyone agreed they were midwives because they did the work of a midwife. There was no paper to “certify” these women, and most people probably couldn’t have read it if there was.
Mostly this type of midwifery is considered historical, however in rural areas where access to hospitals has been (and still is) limited people still remember these midwives. As birth started to move to the hospitals and women got prenatal care from family practice doctors and then obstetricians these midwives were called Lay Midwives. At this point in time “lay midwife” wasn’t necessarily a derogatory term, it basically meant, “does the work of a midwife but has no book learning, and no papers”. Some states did issue papers and limited training to these midwives for a while in the form of permits, but that is history now.
Certified Nurse Midwives
So while all that is happening, (and it’s still happening all over the country) nurse midwives become a thing. Think black and white photos of women on horses, that was Frontier Nursing Service in Kentucky. Certified Nurse Midwives (CNM) have been to nursing school and then go on for additional schooling and training as a nurse midwife. They are required to attend of minimum of 20 brith in their training, although often attend more.
CNMs can attend births in hospitals, at home, or in birth centers. Most of them work in hospitals, and their training typically takes place in a hospital, but that in no way means they are less skilled at home birth. Some nurse midwives have both home and hospital practices which means if a home birth needs to become a hospital birth they can remain the provider through the transfer.
In addition to pregnancy and birth CNMs also are trained to provide well woman care, and have some prescriptive abilities. CNMs are most likely of all midwifery types to accept insurance for their services too.
Certified Professional Midwives
Then, in the 90s we get Certified Professional Midwives (CPM). Just to make it confusing these midwives are often called Direct Entry Midwives, but that term is coming to mean a different type of midwife that we’ll get to later, so just try to forget it for now. CPMs come from many different educational backgrounds. They are not required to have a college degree, although many do, and some end up with a bachelors degree in midwifery. It’s actually really useful to think of CPM schooling as a trade school degree, but since it’s healthcare that still makes some people a little uncomfortable.
CPMs are not nurses, they go directly to midwifery school/training (hence the direct entry). CPMs cannot work in hospitals, they attend primarily home birth, and sometimes also work in birth centers. They are trained to care for low risk women during pregnancy, birth, and postpartum, and the first six weeks of newborn care. CPMs do more than this though. They are also trained to provide well woman care, can run labwork, do pap smears, test for STIs, everything you would expect from well woman care. In addition some provide fertility counseling, intrauterine insemination, and some types of birth control. CPMs do not have prescriptive authority, however they do typically care anti-hemorrhagics, Vitamin K, Rhogam, and sometimes IV Fluids (and in some states antibiotics for GBS).
There are two ways to become a CPM, the Midwifery Education Accreditation Council (MEAC)accredited schooling route, or the Portfolio Evaluation Process (PEP). Both of these routes end in the same place. The student midwife must attend a minimum of 55 births (most attend many more). She must then submit a huge amount of paperwork (and usually tears) to The National Association of Registered Midwives (NARM). NARM is the certifying organization nationally for CPMs. NARM then reviews this giant stack of papers (perhaps audits the student, resulting in a lot more tears), and then approves her to take the NARM exam. This is a six hour exam over practical midwifery skills and knowledge taken at a testing site. When this exam is passed she’s a midwife!
Before all that though you have to pick MEAC or PEP route. The MEAC route, which is the path I took, means you enroll in a MEAC accredited midwifery school. Probably this will be a distance based school where you travel to the campus a few times a year, but sometimes it means relocated across the country to a campus based school. Classwork covers fundamentals of healthcare, and then focuses on pregnancy, birth, postpartum, breastfeeding and newborn care. At the same time, or immediately after the course work, the midwife student has to find an apprenticeship somewhere in the country where she will work under an experienced midwife getting her hands on experience.
The PEP route is fundamentally the same as the MEAC route, the difference is that these women aren’t in an accredited school. They should be learning the same things in a self study manner during their apprenticeship. Before they can take the NARM exam they will need to physically demonstrate mastery of certain skills (the MEAC student did this in front of her instructors at school). After that they have the same requirements to take the NARM exam, and become a CPM just the same as someone on the MEAC route. Well, almost just the same. Some states are requiring CPMs who became CPMs using the PEP route to complete additional training (called the Bridge Certificate) to be licensed by the state. There is also a growing push from some states to stop accepting PEP route CPMs in the future for licensure.
Which bring us to licensure. CPM is a national certification. As with many other things the states have some autonomy in deciding what they will implement from the national level. Once a midwife has her certification, the individual state decides whether it will issue her a license based on that. The licensing requirements differ by state, and some states will not issue a license at all. Currently 35states offer a license. Kentucky just voted for licensure last year. Visit Kentucky Birth Coalition for more information on that.
In all honesty I haven’t always supported licensure, but I did help campaign for it in Kentucky and I still feel good about that decision. Licensure helps to legitimize CPMs in the larger medical establishment which makes for better care in general. Licensure will make consultation easier, and hospital transports smoother. For example right now I can’t call and make an appointment for an ultrasound for a client, and when I transfer to the hospital no one knows what I am, and may not accept my charts as legitimate records. Licensure will also make it much easier for me to order necessary medications and supplies. Overall it makes for better, easier care for most people in most situations.
Direct Entry Midwives
The last of the main midwifery types is the Direct Entry Midwife (DEM). This isn’t a credential, it just gets used as one. There is no certifying body or authority that says “yes, we are sure this woman is a DEM”. Direct Entry Midwife simply means “woman doing the work of a midwife”, just like back in the early years. This doesn’t mean they aren’t experienced or qualified (my children were delivered by a DEM), it just means they haven’t trained as a CPM or a CNM. Often they have a great deal of experience because they have been practicing since before the CPM credential existed. Unfortunately it can also mean that they went to a few births, said to themselves “I can probably do this” and declared themselves midwife. You just have to do your own research and ask around.
NARM had a path for DEMs to become CPMs without having to go back to school. That option however closed at the end of 2019. To become a CPM in this manner they had to submit a huge amount of paperwork proving that they had the experience required to become a CPM as well as letters of recommendation, and then take the NARM exam.
I hope that helps some to clarify the different types of midwives you may come across or consider becoming. We are at a very critical time as a country with regard to our midwifery system. As more states issue licenses for CPMs, and home birth becomes more common again, it’s so important that we make sure our voice is heard (whatever your voice may have to say) about how we want maternity care to look in the future.