Sunday, September 9, 2012

What you really need to know about Nurse-Midwifery

A Brief History of Midwifery in the United States

From the beginning, when a woman was ready to give birth, she would surround herself with women from her family and community to assist her. While midwives were respected members of the community, they were often trained only through apprenticeships and did not share or regulate their knowledge. Because of this, some midwives practiced unsafely. In the 1800s, more doctors began attending births. They would give pain medicine to women who were overwhelmed and knew how to use tools such as forceps which can save babies and mothers lives. However soon these practices were used by doctors for all women, instead of only the ones who needed them. This also was unsafe and put mothers and babies at risk for unnecessary complications.

In the 1920’s a American nurse named Mary Breckinridge discovered the wonderful care given to women by Nurse- Midwives in England. These midwives had gone through extensive training in both nursing and midwifery. Mrs. Breckinridge decided to bring this model of care to the United States. She formed the Frontier Nursing Service to provide care for the people of Appalachian Kentucky. These midwives we able to save many lives and made birth much safer for the women in the area. Eventually others took notice of the improved outcomes with the Frontier Midwives and slowly schools were created to train Nurse Midwives in America. In the 1960’s the natural childbirth movement created some recognition for midwives and research such as the National Birth Center Study has shown that midwives provide excellent and safe care to women. However midwifery still has to fight the idea of the uneducated and unsafe midwives of older times. See this video for more information about Frontier Nursing Service and University- )

In other areas of the world, such as the Netherlands, midwives provide the care for most women, and many more women give birth at home. The Netherlands enjoy some of the lowest rates of death and injury for mothers and babies. Australia and New Zealand are both working to increase midwifery care for their women and Japan, which has some of the best infant mortality rates, has many midwives that attend most births in the country.

LACE: Licensure, Accreditation, Certification and Education of Midwives

There are actually several different types of midwives in the United States: Certified Nurse Midwives (CNM’s), Certified Midwives (CM’s) and Certified Professional Midwives (CPM’s).

The most well known group of midwives are Certified Nurse Midwives (CNM’s). These midwives are registered nurses who have completed a nationally accredited graduate level program of study approved by the Accreditation Commission of Midwifery Education to become midwives (ACNM-b,, 2012).

Another type of midwives are Certified Midwives (CM’s) who are not nurses but have background in an area of health before studying to become midwives. They also reach the graduate level of study in midwifery and have the scientific studies background shared by the CNM. Both CNM’s and CM’s take the same national exam from the American Midwifery Certification Board to become certified in midwifery and therefore are responsible for the same body of midwifery knowledge (ACNM-b, 2012).

The third type of recognized midwives are Certified Professional Midwives (CPM’s). These midwives are not required to have health backgrounds before studying midwifery. Their education is usually a year or so in length after which they study as apprentices under other CPM’s or CNM's for experience. They achieve certification in midwifery through a different national exam, given by the North American Registry of Midwives. CPM’s tend to practice in out-of-hospital births, while CNM’s and CM’s often practice in hospitals but also attend birth center and home births. 95% of births by CNM’s occur in hospital (ACNM-b, 2012).

Certification of Certified Nurse Midwives and Certified Midwives must be renewed every 5 years after completing specific independent study courses provided by the American Midwifery Certification Board.

Licensing of all types of midwives occurs on the state level and involves initial licensure through applying for license once education and certification are complete. Licensure also requires periodic renewal of license which in some states requires that midwives show proof of continuing education in that time period.

All 50 states in the United States require licensure of Certified Nurse Midwives which is often done by the state’s Board of Nursing in many places. Certified Nurse Midwives are considered advanced practice nurses along with nurse practitioners and registered nurse anesthetists. Licensure of Certified Midwives is a new consideration as this is a newer type of midwife, so most states have not begun licensing Certified Midwives as of yet. In fact, licensing of these midwives currently occurs only in the state of New York. Certified Professional Midwives are licensed in 24 states but are recognized to practice in 26 states, granted by specific Midwifery Boards of Licensure.

In states where licensing is required for different types of midwives, they are only allowed to practice once they’ve been licensed.

Scope of Practice of a Certified Nurse Midwife

Certified Nurse Midwives (CNM’s) are specialists in birth, as well as in the health of women throughout life. The type of care provided by a CNM includes wellness exams, pap smears and other gynecologic care including pelvic and breast exams, sexually transmitted disease counseling and treatment for both partners , and family planning including prescribing contraception, and prenatal/birth/postpartum care. A CNM will often care for the infant for the first 28 days after birth after which care will be turned over to a pediatrician or pediatric nurse practitioner. To put it simply, a CNM provides primary care for women from adolescence through menopause (ACNM, 2012).

Midwifery care emphasizes education of women so they can be involved in their care and the care of their families. Midwives provide teaching about healthy practices, disease prevention, and counseling for each woman about her wellness and according to her needs and situation (ACNM, 2012).

Certified Nurse Midwives provide care for women not only in the office but from admission through discharge in the hospital as well as many other public and private settings where health is addressed, including major medical centers, the United States Military and rural locations. CNM’s prescribe medications including controlled substances as well as ordering, interpreting and treating based on lab tests when appropriate (ACNM, 2012).

Certified Nurse Midwives are skilled in providing complete care for healthy through low to moderate complexity needs and are also skilled in identifying when to refer women and infants to physicians and other health professionals when certain needs are specialized in by other clinicians.

Certified Nurse Midwives are involved in so many aspects of women’s lives, valuing the relationship with the women they care for and supporting and guiding women toward becoming experts in their own care. CNM’s believe that a woman who is familiar with her body and her needs can do more to keep herself and her family healthy.

The philosophy behind midwifery is summarized at the end of this brochure in the Hallmarks of Midwifery. The Hallmarks of Midwifery is what drives midwifery care and what sets us apart from physician-provided care. For more information about what a Certified Nurse Midwife does, the American College of Nurse Midwives’ website is a great place to start:

How Midwifery is Different than Obstetrics...Why Do We Need Midwifery?

Over the history of midwifery the safety and efficacy of midwifery care has been questioned and doubted by many. However, in reality, midwives are very skilled at caring for women. Studies have shown that compared to care provided by physicians, midwifery care resulted in fewer epidurals placed, episiotomies performed, and labors induced or augmented. Studies have also shown that there were no differences between the two types of providers when looking at NICU admissions, low birth weights and low APGAR scores (a method of assessing the well-being of a newborn). There were differences noted in rates of breastfeeding and perineal lacerations. More lacerations were seen with care provided by a physician and higher rates of breastfeeding were seen with midwifery care.

Midwives are less likely to employ labor and birth interventions. Research shows that midwife-attended births are less likely to have outcomes requiring cesarean section or operative vaginal deliveries, and the women they care for use less analgesia than those cared for by physicians. These studies show that midwife-provided care can have the same, if not better outcomes, than physician-provided care when a woman, her fetus and the pregnancy course lie within the criteria for normal through low-complexity health. Therefore, midwives are also more cost effective than physicians due to this decreased rate of interventions and complications.

Research about Safety and Outcomes of Certified Nurse Midwife-Provided Care

The midwifery model of care views pregnancy and childbirth as a normal and natural process that a woman goes through. However, the medical model of care that obstetricians follow view pregnancy as a disease process that requires management and intervention: it must be “cured”.

While the obstetrician is a surgeon who specializes in complicated pregnancies and anomalies, the midwife specializes in the care of a woman from puberty through menopause including normal pregnancy and childbirth. A midwife is also trained to determine if there are any complications and to collaborate, consult, and possibly refer the woman to a specialist if she should need one. This is when the obstetrician would step in to partner in the woman’s care. The midwife views the woman as a whole person who has not only physical needs but emotional, psychological, and spiritual needs as well. Midwives take the time to really get to know the women they care for, to develop a bond with each, and give them the personal care that they are entitled to. The midwife also takes into account the needs of the family that surrounds the woman. Without this comprehensive view of caring, women would not truly receive the care that they deserve.

Women need midwifery because it focuses on the relationship between the midwife and the woman and her family. The bond between a midwife and a woman is one that encompasses trust, confidence, support and empowerment. The midwife is there to educate the woman on her choices regarding her care and acknowledges her freedom to make the choices that she feels are best for herself and for her family. The midwife then respects and supports any decisions that the woman makes and works to empower and encourage the woman in her journey toward her goals. Midwives enable each woman to realize her power and inner strength.

Birth Centers: Definition, Services, Safety
What is a birth center?

Birth centers are facilities that offer a home-like environment for pregnancy, birth support, and family-centered wellness. They are places of health, that strive to support principles such as safety, cost-effectiveness, and consumer satisfaction while celebrating normal birth. Birth centers follow the midwifery model of care. Individualized provider-client partnerships for healthy women are achieved by providing discussion and education to women and their families and empowering them to make meaningful and informed decisions about their care. All of this is achieved by providing time intensive care for one-on-one visits, labor management, and post birth mom and baby wellness.

For more information on birth centers or to find an accredited birth center in your area go to

What services do birth centers offer?

In addition to individualized and time-intensive care, birth centers and midwifery care provide education and discussion that begins with the first prenatal appointment. This empowers women to thoroughly explore all the options available to them. Most birth centers have book and DVD libraries available. Many birth centers provide outsourced maternal education classes so women and their support person can explore all childbirth options with minimal provider bias. Birth centers offer modern maternity care with a balance of technology and personalized holistic care. Another key component of birth centers are the options available for birth positioning and non-pharmaceutical pain relief. Hydrotherapy and waterbirth are available at most birth centers. Seminars, support groups, mom/baby groups, and customized lactation support are often available through most birth centers. Many birth centers offer a home mom and baby visit in the first 1-2 weeks after baby is born (AABC, 2011)

Are birth centers safe?

Birth centers provide access to a complete network of women’s health services and are covered by most major health insurance plans. To ensure the safest and highest quality of care, ask about your provider about the individual and facility licensing and accreditation. Birth centers should have basic emergency equipment on hand for both mothers and babies and a plan for hospital transfers. All births should be attended by at least two people and birth staff should be trained and licensed in CPR and newborn resuscitation. (AABC, 2011)

What do midwives stand for?

The Hallmarks of Midwifery:
1. Recognition of pregnancy, birth and menopause as normal physical and developmental processes.
2. Advocacy of not intervening if there are no complications.
3. Incorporating scientific evidence into clinical practice.
4. Promoting family-centered care.
5. Empowerment of women as partners in health care.
6. Facilitation of healthy family and interpersonal relationships.
7. Promotion of continuity of care.
8. Health promotion, disease prevention, and health education.
9. Promoting a public health care perspective.
10. Care to vulnerable populations.
11. Advocacy for informed choice, shared decision-making, and the right to self-determination.
12. Cultural competence.
13. Familiarity with common complementary and alternative therapies.
14. Skillful communication, guidance and counseling.
15. Therapeutic value of human presence.
16. Collaboration with other members of the health care team.

Helpful Links to More Midwifery and Pregnancy/Childbirth Information

Belly Tales: The Diary of a Midwife Blog: 
A blog that targets anyone interested in midwifery with multiple topics.

Childbirth Connection:
This website has great information about midwives and a lot of helpful information about pregnancy, childbirth as well as many more links to other helpful sites.

The Rosebud Midwifery Blog:
 A blog with more information on the benefits of a midwife and a variety of other topics.

“Why Choose A Midwife”: Youtube Presentation by the American College of Nurse Midwives
Why midwife-provided care can be beneficial for pregnancy, birth, and supporting the transformation into familyhood.

Please see below for references to source information used in this brochure

American Association of Birth Centers. (2011). How to start a birth center: exploring innovation in maternity care. Perkiomenville, PA.

American College of Nurse Midwives (ACNM) (2012-a).  Definition of midwifery and scope of  practice of certified nurse midwives and certified midwives.  Retrieved from                                                      

American College of Nurse Midwives (2012-b).  Our credentials.  Retrieved from

American College of Nurse Midwives. (n.d.). Up close and personal: Midwives offer personalized care. Retrieved from

Dama, B., Reynolds, T., & Kilmer-Sterling, E. (2012). Midwifery Blogs Evaluation Worksheet. Unpublished manuscript.  

Holderread, M., McAlister, V., Asturrizage, V., & Smith, R. (2012). Midwives: embracing and supporting women and their families. Unpublished manuscript.
Rooks, J. P. (1997). Midwifery & childbirth in America. Philadelphia, PA: Temple University    Press.

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