TWO ROADS INTO MIDWIFERY
by Cordelia S. Hanna-Cheruiyot, CCE, CBA, MPH, CHES
“A Midwife Should Possess A Lady’s Hand, A Hawk’s Eye and A Lion’s Heart”
- from A 16th Century Midwifery Textbook
Nurse-Midwifery | Direct-Entry Midwifery
©Shawna Wentz Photography Sacred Womb Artistry
Routes of Entry into The Midwifery Profession
In the United States today, there are two pathways into the midwifery profession: The Nurse-Midwifery Route and the Direct-Entry Route. Midwives are the experts in normal pregnancy and birth, and care for pregnant women giving birth at home, birth centers or in hospitals. Midwives also offer contraception, gynecological services and menopausal care to women. Nurse-Midwives are trained in both the disciplines of nursing and midwifery and attend 5-6% of births in America and primarily work in hospital and clinic settings, as well as birth centers and homes. Direct-Entry midwives, who are not trained as nurses, attend approximately 1-2% of births in America and primarily work in out of hospital settings, including clinics, birth centers and homes.
Nurse-Midwives who work in hospitals do so under supervision of Obstetrician-Gynecologists, and there are a few model practices with midwives and doctors around the country. For midwives who have out-of-hospital practices, hospital and doctor back-up is arranged in case the woman develops a complication during pregnancy or childbirth, so the midwife can consult with, transfer care or transport to physician and hospital as necessary.
Nurse Midwives are trained in two disciplines: nursing and midwifery. They are specialists in woman’s gynecological health care throughout the lifespan.
To become a Certified Nurse Midwife (CNM) the first step is to be a Registered Nurse. Any educational level degree in nursing is sufficient: Associates Degree in Nursing (ADN), Bachelor of Science in Nursing (BSN), or Masters of Science in Nursing (MSN). Many nursing education programs are now offering a bridge program, which allows a person with a Bachelors Degree in a non-nursing subject to earn a second Bachelor’s of Science degree in Nursing. Several years of pre-requisites in microbiology, chemistry, anatomy and physiology and general liberal arts and humanities is also required to obtain an undergraduate degree. However, some Nurse-Midwifery programs do not require a BSN, an ADN and RN license is the minimal requirement. Usually, Nurse-Midwifery education programs require one to two years of experience working in obstetrical nursing, woman’s gynecological care or labor and delivery in a hospital or clinic or work as a doula to be considered as a candidate for a nurse- midwifery program, which takes about two years to complete. Candidates may earn either a Master’s or a Certificate, or if the candidate already has a Masters Degree (in any subject), a Post-Masters Certificate. Master’s degree programs require a Thesis; Certificate and Post-Masters programs do not. The Master’s degree may be required for teaching or positions of greater responsibility. Nurse-Midwifery study consists of course work, skill development and clinical supervision by Nurse-Midwives either in a hospital, clinic or out-of-hospital setting; some programs require a combination of in-hospital and out-of-hospital clinical training. Training consists of midwifery care plus well-woman gynecology care. After completing the Accreditation Commission for Midwifery Education (ACME) program, the candidate must pass the American College of Nurse Midwives (ACNM) board examination to obtain certification as a Certified Nurse Midwife (CNM). Learn more about becoming a Nurse-Midwife.
Alternate Avenues for Nurse-Midwifery Study
Mary Breckinridge, Mother of American Nurse-Midwifery
In Kentucky in the 1920′s, Mary Breckenridge enlisted nurse-midwives to impact the crisis of maternal and fetal mortality in rural Appalachia. This background in both disciplines of nursing and midwifery was vital when caring for the impoverished pregnant women and children of this region who had a plethora of health and social problems.
These pioneer nurse-midwives were considered “unprofessional” when they rode on horseback because there were no roads, but they succeeded in lowering infant mortality to below national averages and gave birth to the modern nurse-midwifery profession. In 1939, The Frontier School of Midwifery and Family Nursing was established. (Renamed New Frontier Nursing University). Since 1982, The Community Based Nurse-Midwifery Education Program has been giving nurses who cannot relocate the opportunity to study from home. Registered Nurses who have bachelor’s degrees may pace themselves through a mentored, two year program of study from a distance by use of personal computer, modem and fax. The clinical portion of the training can be set up locally with nurse-midwife preceptors.
A newer program is Philadelphia University, which offers distance learning and intensive short-term on-site training in Philadelphia, PA. Supervised clinical training is available in the students local community with CNM preceptors. They offer advanced placement for Nurse-Practitioners, and a Post-Masters certificate for those with Masters Degrees in degrees other than Nurse-Midwifery. Their minimum requirement is RN license and an Associates Degree in Nursing. They also offer credit for persons who have attended an accredited midwifery school.
There are other programs throughout the US offering distance and traditional university-based on-campus learning, often affiliated with teaching hospitals and/or freestanding birth centers. See: distance learning programs and On-campus programs in California.
The term “Direct-Entry” refers to persons who were not nurses before entering the midwifery profession. This route is sometimes referred to as “Non-Nurse Midwifery”
The Direct-Entry Midwife enters the profession not through becoming a nurse first, but by self-directed study and experience, or apprenticeship with a senior midwife or attendance at a Direct-Entry Midwifery Training Program. Many become certified and/or licensed once they graduate from their training program or school and curriculum is geared towards meeting professional standards for licensure and certification. Most programs are non-accredited, do not offer federal financial aid and are distance-learning programs. Students must find supervised clinical training with professional midwives in their own community or relocate to find a midwife preceptor.
There are few university-based programs for direct-entry midwifery. Seattle Midwifery School, one of the first midwifery schools in the United States, as of march 2010 merged with Bastyr University. Located in Seattle, Washington, the program is intended for entry-level midwifery students and is three years in length (11 quarters), culminating in either an articulated Bachelor/Master of Science in Midwifery or simply a Master of Science in Midwifery (depending on entry level of education). Completion of the program qualifies a graduate to sit for examinations to become licensed as a midwife in Washington or other states, registered in Canadian provinces, and nationally certified by the North American Registry of Midwives (NARM) as a Certified Professional Midwife (CPM). Financial aid is limited.
The first regionally accredited (Washington state and Canada), articulated, direct-entry Master of Science in Midwifery degree in the country. Midwifery students train with preceptors in a variety of clinics, homebirth settings, birth centers and hospitals in North America and overseas. The format is hybrid of on-site and distance learning; which allows students to remain in their communities and commute to Seattle at the Bastyr campus three times each quarter. When not physically on campus, students use the Internet classroom to correspond with classmates and instructors, participate in discussions, complete homework, and take tests.
Program Eligibility
The Master of Science in Midwifery is available to students who already hold a bachelor’s degree. The combined bachelor’s/master’s option is available to students who have completed at least two years at the undergraduate level (60 semester or 90 quarter credits) Graduates of midwifery schools desiring certification and licensure may become Certified Professional Midwives (CPMs) by completing the accreditation process through North American Registry of Midwives (NARM). They may also become Licensed Midwives (LMs) if their state has a mechanism for licensure. For a list of direct-entry midwifery programs of study, go to Midwifery Education Accreditation Council (MEAC).
To check on the status of direct-entry midwifery licensure in your state, go to www.mana.org/statechart.org
Certified Midwives (CMs)
The American College of Nurse-Midwives (ACNM) established a The Certified Midwife (CM) credential. Certified Midwives are individuals who have or receive a background in a health related field other than nursing and graduate from a midwifery education program accredited by the ACNM department of accreditation. Graduates of an ACNM accredited midwifery education program take the same national certification examination as CNMs but receive the professional designation of Certified Midwife. CMs must attend a university-based program to become educated in the same core competencies for basic practice as CNMs, and practice in accord with the same standards for practice, philosophy, and code of ethics as nurse-midwives. Certified Midwives are relatively new professionals to the health care field but their education closely mirrors the education for Certified Nurse-Midwives. The mechanisms to educate and credential CMs were approved in 1994. CMs are not registered nurses (RNs), but may hold other professional designations as health care providers such as a Physician Assistant (PA) or Physical Therapist. (PT) Individuals choosing this career path will likely be pioneers in the profession, much like the early nurse-midwives who practiced in the U.S.
Currently, New York is the only state which recognizes the Certified Midwife credential or offers an educational program to become a Certified Midwife, although universities outside of New York state offering nurse-midwifery education may add this option to their programs of study in the years to come. Contact the ACNM for updates.
Certified Professional Midwives
The North American Registry of Midwives (NARM) established a national certification procedure, where midwives who go through the process may become Certified Professional Midwives” (CPMs). This “competency-based credential”, recognizes midwives from all routes of education: apprenticeship, self-directed study, midwifery school, nursing programs, etc., who meet the criteria required for certification. Certified Professional Midwives are legal in some U.S. states, but not all. In California, it is not a legal recognition.
The Scoop on California Midwifery
In California, licensure has been available since 1993 with the passage of the Licensed Midwifery Practice Act legalizing non-nurse-midwives. Licensed Midwives (LMs) are regulated and licensed by The California Medical Board, the same entity which regulates and licenses other medical professionals, including obstetrician- gynecologists. For more information on Licensed Midwives in California, go to The California Medical Board Division of Midwifery Licensing. In California, the apprenticeship route is not a legal pathway. Students must be formally enrolled in a California Medical Board approved midwifery school and obtain supervised clinical training under a California Licensed Midwife whose license is free and clear of restriction and has been in practice for a minimum of two years. Furthermore, the preceptor midwife must be formally approved by the student’s school to be an instructor. Contact the California Medical Board Division of Midwifery Licensing for a list of approved schools.
The California Midwifery Challenge Process
The challenge process is a mechanism which permits Certified Professional Midwives (CPMs) to become licensed in California. In the state, Certified Professional Midwives (CPMs) are not legally recognized. Certified Professional Midwives who opt for legal recognition in California must go through the Challenge Process to become a California Licensed Midwife (LM). The Medical Board has approved several schools to administer the Challenge Process. Contact the approved schools to learn about their California Midwifery Licensing Challenge Process. For a list of schools approved to administer the challenge, see California Medical Board Midwifery Licensing Challenge Process.
The Future of Midwifery in the United States
Three decades after the homebirth renaissance in America, the trend is towards standardized educational and experiential requirements for non-nurse-midwives, and obtaining legal status and professional certification. (See: The Big Push For Midwives, a national legislative campaign to legalize non-nurse midwifery in all 50 states). The benefit of this is that now expectant parents will be assured that the midwife they have chosen has a minimal level of competency and midwives will maintain standards of quality and professionalism. Though the absence of a license or certification does not necessarily mean that a midwife is incompetent, likewise, the presence of a license or certification does not mean the midwife has the wisdom gained from many years of practice. Many traditional “lay” midwives (some who are”conscientious objectors” to licensure or practice in communities where legality is not an option or cultural tradition) have the good judgment that comes from years of experience. Some of their colleagues would agree that they are qualified and competent. In fact, due to licensure, restrictions on practice have emerged such as prohibition of Licensed Midwives to deliver twins, breeches or a VBAC mother at home. In these cases, it may the lay midwife who attends the birth. However, practicing midwifery without a license is considered a misdemeanor or felony in some states and unlicensed midwives who attend births are at risk for prosecution.
The path that you choose to take to become a midwife is as personal as a woman’s decision of where to have their baby. Nurse-Midwives are having a positive impact upon hospital births; many women feel secure giving birth in a hospital where emergency equipment, pain medication and medical doctors are readily available, yet want the quality, personalized care they receive from nurse-midwives. Yet, there will always be women who feel most comfortable giving birth outside the hospital, in their own homes or in birthing centers. Today’s upcoming midwives have many opportunities for formalized training that our midwife-ancestors did not because of the trailblazing efforts of midwives who have tirelessly campaigned for legalization, trained apprentices, established schools, established protocols for practice and certification. The midwives of tomorrow will establish independent birth centers, deliver babies in homes and in hospitals, work in clinics with women’s health care practices, work overseas to help reduce maternal and infant deaths, become midwife-educators and public health policy-makers.
“As steadfast guardians of life and blenders of the best of science and tradition, midwives hold the promise of a world of health for all in their hands.”-Robbie David-Floyd, Ph.D., Medical Anthropologist
About the Author
Shawna Wentz Photography Sacred Womb Artistry
Cordelia Hanna-Cheruiyot, MPH, CHES, CCE, CBA, has been a midwifery activist and student of midwifery and childbirth for two decades. She has attended births in hospitals, birth centers and homes since 1991. She has been a primary midwife under supervision and has assisted several homebirth midwives in Los Angeles and Orange Counties. She is also a hospital labor
companion and monitrice and postpartum doula and breastfeeding counselor educator and has taught childbirth preparation classes to hundreds of parents for two decades. She trains aspiring midwives, doulas and breastfeeding peer counselors. She has a Masters in Public Health in Health Education and Promotion/Maternal Child Health from Loma Linda University and a Certified Childbirth Educator and Certified Birth Assistant. She is passionate about promoting mother and baby friendly care in the U.S. and working to reduce perinatal health disparities in America and Africa.
