Do all midwives have the same credentials?
Not all midwives have the same credentials or licenses. It's very important for the public -- and especially pregnant women who go to midwives for care -- to understand the differences and choose carefully.
In the United States there are basically three types of midwives: ACNM accredited, MANA accredited, and nonaccredited. They have different educational backgrounds, certifications, licensure, privileges, and scope of practice.
There are two kinds of ACNM-accredited midwives: certified nurse-midwives (CNMs) and certified midwives (CMs).
Certified nurse-midwives (CNMs): CNMs have completed an accredited program of the American College of Nurse-Midwives (ACNM). RN and BSN degrees are required for admission into any of the 46 accredited CNM programs. After completing the program, they must pass the ACNM certification examination. It is a national examination. All 50 states accept this certificate, although each midwife must additionally apply for a license to practice in the state she chooses to practice in.
This educational pathway and certification is the only one accepted by ACOG (American College of Obstetricians and Gynecologists), HMO provider panels, hospital credentialing committees for hospital privileges, and malpractice liability insurers throughout the country.
Most CNMs deliver babies in the hospital. Other CNMs attend births in a birthing center or in homes. But no matter where they provide care, it is with the same very high standard of care that has gained them such wide professional acceptance. All certified nurse-midwives and certified midwives have a physician backup.
Certified nurse-midwives may provide primary care, gynecological care, family planning, STD treatment, preconceptional, prenatal, postpartum, and newborn care, as well as labor management and delivery. They may write prescriptions, order an epidural anesthesia, and manage Pitocin for the laboring woman. Some midwives also assist with a cesarean section delivery, if needed.
Certified midwives (CMs): CMs have also completed an accredited program of the American College of Nurse Midwives (ACNM). A bachelor's degree is required, but not necessarily in nursing, and they do not have an RN license. There are many prerequisites that must be completed before entering the core competency part of the program. After completing the program, the candidate must pass the same ACNM certification examination that CNMs must pass. CMs basically have the same legal status as CNMs, but because this is a new pathway into midwifery, there are some licensing issues that need to be clarified in most states.
MANA (Midwives' Alliance of North America) accredited
Midwives who are accredited by MANA are called Certified Professional Midwives (CPMs).
CPMs have a combination of schooling and apprenticeship. There are four educational routes to earning their credentials. Upon completion of their training, the candidate must pass an examination. This credentialing program is through Midwives' Alliance of North America (MANA). Their educational requirements and examination are different from those of the ACNM. MANA and ACNM certificates are not interchangeable -- there is no reciprocity. CPMs primarily practice in out-of-hospital settings. The education, certification process, and standards are less rigorous than the standards for CNM/CMs.
Nonaccredited midwives are often referred to as lay midwives or empirical midwives.
These midwives receive their training through apprenticeship and self-study. They are not certified through any national organization, and they are not required to uphold any regulations, protocols, or standards of care. They may be skilled, but there is no way to document their knowledge or skills. Because they have no certification or license, these midwives work outside the main health-care system. They carry no malpractice insurance, have no hospital privileges, and are held to no standard of safe, quality care. They do not qualify for HMO provider panels or third-party reimbursement. They do accept cash and barter. Home births are their focus, but if the laboring woman needs to be transferred to the hospital, the lay midwife has no hospital privileges, so her midwife may only be able to act as her doula for labor support. If she has a backup physician, he or she will take over at the hospital. Otherwise a hospital physician will take over.
Choosing your midwife
If you choose to receive your care from a midwife, check her credentials to be sure she is a certified nurse-midwife (or certified midwife) and licensed to practice in her state. Meet her backup physician and find out which hospital she has admitting privileges for. A tour of the hospital is very helpful, so you'll know exactly where to go -- especially in the middle of the night. It would also be helpful to know if the backup physician would take over your care in the hospital if you are transferred in from a birth center or home, or if the midwife could continue to manage labor. (Midwives who routinely deliver in the hospital are usually able to manage Pitocin and epidurals and just keep their backup physician informed.) Does the midwife have first-assist privileges for a cesarean, should you need one with her backup physician? If you are planning to deliver in a birth center or at home, you may experience less anxiety about a potential transfer if you know where to go and understand the process involved.
If you are considering an out-of-hospital birthing center, look for one with accreditation by the Commission for the Accreditation of Birth Centers (CABC) as a sign of excellence and for licensure if it is available in that state. Be sure you understand what the criteria are for transfer to the hospital. This should be in writing, so there is no confusion or discussion when a decision must be made during labor. Who decides if the decision is a little less clear? Is there an ambulance available for the transfer process? Who is responsible for making these arrangements? Will your support person be expected to provide his/her own car and drive you to the hospital?
Home births have a few other issues in addition to those reviewed above. The midwife should have an assistant to help her. She needs to bring all her resuscitation equipment with her, in case the newborn is unexpectedly in need of assistance. There should be a telephone in the room where the mother will deliver, in case an emergency call needs to be made. There should be a car outside in case an urgent transfer is necessary. The criteria for transfer from home to hospital needs to be crystal clear and agreed upon by all persons involved. Most, but not all, home birth midwives are CPMs or lay midwives. They cannot follow their patients into the hospital, except possibly as a labor support person or doula. Be sure that you understand what their role will be if you need to be admitted to the hospital in labor. There are some CNMs who also do home births.
As you can see, all midwives are not the same. CNM/CMs have extensive educational backgrounds and always work in a collaborative relationship with a physician. I am a CNM, and I feel that CNMs are the best and safest choice when choosing a midwife. Please choose carefully.