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So You Want a Midwife…What Kind?

Not every midwife is the same; there are actually four different types of midwives. This article explains the differences between them all so you can know which will be right for you.

midwife and client

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In the United States, only 12% of births are attended by a midwife. In the United Kingdom, over 70% of births are attended by a midwife.

You may be thinking, “So what?” Well, if you put those numbers side-by-side with another statistic, all of a sudden they seem more significant. 

In the US, maternal mortality (the number of mothers that die of pregnancy- or childbirth-related causes) is 24 out of every 100,000 births. In the UK it’s only 7, less than a third of America’s number. 

The attendant at a birth isn’t the only factor that can affect maternal mortality, but it definitely plays a big role.

You Want a Midwife…but Which Kind?

If you’re here, you’ve probably decided that you want to hire a midwife rather than an OBGYN.  Now you have another choice to make: what kind of midwife?

When I was pregnant with my first daughter, I didn’t know that there were different kinds of midwives. (I didn’t know a lot of things… ha!) But there are! And it’s important to know the differences because it can really change the way your birth goes.

The most obvious difference between the four types of midwives is the educational background each midwife has.

Education for Midwives

Midwifery education and licensing in America is relatively new. That said, efforts have been steadily increasing to provide nationally-recognized accredited programs.

Those efforts have made it possible for mothers who want to be cared for by a midwife instead of a doctor to have that choice. Pregnant women can now hire someone other than a doctor that they are confident has a sufficient background and the proper certification to provide the kind of safe, competent care they need. 

Multiple organizations exist to provide education, certification, regulation, and accreditation for midwives and midwifery. If you’re interested in learning about any of them, here are several:

These organizations provide certification, but certification is only part of the picture when it comes to the legal status of midwives.

Certified vs Licensed

When we’re talking about qualifications of midwives, we need to talk about certifications and licensing. Certification comes from meeting specific educational requirements and passing an exam – it’s the thing that shows that a person is qualified to do what they’re certified for.

Licensing requires passing a state-administered exam and is like the legal stamp of approval for a healthcare professional to practice. Licensing laws vary depending on the state.

For the most part, it is a midwife’s certification that can vary. Licensing is like an add-on that only applies to some, so this article focuses mostly on different types of midwife certifications.

Four Types of Midwives

The different certifications a midwife can have can get confusing. To make it easier, let’s start with two basic groups.

The first group is what I’ll call the “medical group.” Midwives who fit in this category have a graduate-level degree (meaning more than a bachelor’s degree) and have passed a certification exam from the American Midwifery Certification Board (AMCB). 

The second group, what I’ll call the “non-medical group,” includes midwives who have formal education related to childbirth but not a medical degree and midwives who don’t have any formal education at all.

Between the two groups, four separate types of midwives exist.

First, certified nurse-midwives (“medical” group).

Certified nurse-midwives (CNMs) are the most medically-trained midwives. This certification requires a 4-year bachelor’s degree in a health-related field, a registered nurse (RN) license, and completion of a 2- to 3-year nurse-midwifery graduate degree.

After their schooling, a certified nurse-midwife must pass the certification exam from the American Midwifery Certification Board (AMCB). 

CNMs have the broadest range of ability as far as who they can care for, from teens all the way through women in menopause. 

They also have the most freedom in prescribing and carrying medications when attending births, compared to other midwives.

CNMs are licensed and regulated in all 50 states and all US territories.

CNMs most often attend hospital births.

Second, certified midwives (“medical” group). 

Certified midwives (CMs) are equal to CNMs in the type of care they can provide, they just arrive at their certification differently.

CMs are not registered nurses (RNs) but are required to have a bachelor’s degree and a nurse-midwifery graduate degree. They also must pass the certification exam from the American Midwifery Certification Board.

Currently, only 9 states recognize the CM certification (Delaware, Hawaii, Maine, Maryland, New Jersey, New York, Oklahoma, Rhode Island, and Virginia, plus the District of Columbia). 

Third, certified professional midwives (“non-medical” group).

Certified professional midwives (CPMs) are a sort of middle ground, in my mind. They aren’t medically trained – meaning they don’t usually have a healthcare background – but they certainly aren’t uneducated.

CPMs are certified through the North American Registry of Midwives (NARM). If you’re interested, you can read through their candidate information booklet here.

(I’m the only one that would read an information packet that doesn’t apply to me, you say? ha!)

That information booklet makes it clear that CPMs are not just doing whatever they want or making judgements solely based on personal experience. It explains that all educational routes that lead to a CPM designation “include clinical [on the job] and didactic [in the classroom] education.”

That clinical part of their training has to be at least 2 years long. Including the didactic training, most apprenticeships (their version of schooling) are an average of 3 to 5 years long. 

Requirements of each apprenticeship are extensive and include minimum numbers for the amount of births, prenatal appointments, and postpartum exams (among other things) that each midwife must attend before being eligible for certification.

(If you want to see those numbers, they’re on page 9 of the candidate information booklet.)

Interestingly, CPM is the only midwife certification that requires out-of-hospital experience.

Most often, CPMs attend births in homes or in birth centers. 

Direct-entry Midwives

Another term you’ll hear tossed around when talking about midwife certifications is “DEM” or “direct-entry midwife.” Direct-entry means that these midwives don’t have a nursing background but rather obtained their credentials another way. 

CPMs fit in this category, as do CMs. It also includes lay midwives, which I’ll explain later on.

Are CPMs licensed?

Like I explained, healthcare professionals are often required to obtain a license before beginning to practice medicine.

To reiterate, CNMs are licensed as registered nurses. CMs are not licensed as nurses but can be licensed as a midwife through the state (in those 9 states where this certification is available).

Certified professional midwives, on the other hand, can choose to be licensed or to not be (depending on the state they practice in). 

Both choosing to become licensed and choosing not to allow for different freedoms in how a CPM practices.

A licensed CPM (often seen denoted as LDEM, or “licensed direct-entry midwife”) can carry medications like lidocaine (for numbing in case you tear and need stitches) and Pitocin for hemorrhaging, among other things. 

On the other hand, LDEMs cannot work with mothers who are carrying twins or whose baby is in the breech position. This is one reason CPMs may choose to remain unlicensed. (Yes, some midwives are comfortable delivering breech babies and twins at home.)

Another potential restriction on LDEMs is that they cannot always work with moms who are trying for a VBAC (“vaginal birth after cesarean“).

Fourth, lay midwives (“non-medical” group).

The word “lay” in this context is defined as “not having professional qualifications or expert knowledge, especially in law or medicine.” Lay midwives, then, are those who do not have any official credentials or education but rather rely wholly on experience and informal teaching they have received.

Sometimes lay midwives are simply referred to as “direct-entry midwives,” which is technically correct but must be distinguished from other DEMs such as certified midwives and certified professional midwives who do have formal certifications and education, as explained above.

It is legal (in some states) for lay midwives to practice and to care for clients. They often have valid experience and know many aspects of birth that could be helpful to clients.

However, I would caution against hiring a lay midwife.

Home births can be very safe and are a great option for many mothers. Importantly, however, those positive outcomes are only recognized when the birthing mom is being supported by a highly-trained person who knows how to spot problems and signs of emergencies. 

A lay midwife simply doesn’t have the training necessary for me to be confident that they would be able to do so as accurately and consistently as is essential.

Midwife vs Doula

Now, we’ve talked about midwives. But what is a doula? How are they different from these four types of midwives?

Put simply, a birth doula is a person, usually a woman, who supports women during labor in a non-medical way. They are an essential part of some women’s positive birth experiences.

A doula is not a midwife. A midwife provides medical care from conception to birth and through postpartum. They are certified and have extensive experience and education relating not only to labor, but to all aspects of pregnancy and postpartum and caring for moms and newborns.

Doulas are not medical professionals. It is not within their scope and qualifications to give any sort of medical advice or diagnosis. A doula provides supportive care, mostly during labor. Doulas do not have the training or authority to evaluate the health and vitals of you and your baby.

This is essential to understand. You may want to hire a doula, but your doula certainly needs to be in addition to a midwife. 

To learn more about doulas, check out What is a Doula and How Can They Make Your Birth Better?.

So Who Should You Hire?

Now we come to the crux of the issue: what kind of midwife should you hire?

Before I make my recommendation, I want to make one thing clear: I can make a recommendation. I can tell you what I did. I can show you the stats. But I could never know all the details about your situation or pretend to be a more reliable source than what you feel is right for you.

The most important factor in being confident in the choices you make for your birth is figuring out what you feel is right for you and for this pregnancy.

Now, you may be one who prays. You may not be. I believe it’s God that helps us feel that surety. Some people call it the universe. Some people call it a gut feeling. Whatever it is to you, be intentional about seeking it out.

Once you’ve received that confirmation and confidence in your choice, it won’t matter what anyone else says because you know what’s right for you.

My Recommendation

All that said, here is my recommendation. It has two parts. Because it is my belief that unmedicated home births have benefits unmatched by any other birth scenario, these recommendations reflect that opinion.

1. Hire a certified professional midwife (CPM).

I recommend hiring a certified professional midwife. As I explained above, CPMs are highly trained and fully qualified to be the primary attendant at a birth. They’ve gone through years of training, passed an intensive exam that includes medical knowledge, and have hands-on experience outside of a hospital setting.

For me, the fact that CPMs are not medically trained (meaning they don’t have a nursing background) is a positive. I am so grateful for hospitals and doctors and nurses and the care they can provide when needed. But inherent in medical training is a bias toward expecting emergencies. 

Nurses, and therefore nurse-midwives, are trained to know what can go wrong and how quickly.

Though valuable in some settings, this knowledge can have some negative effects. Simply put, a certified nurse-midwife may have a very different approach to challenges that arise in labor than a certified professional midwife would.

(Plus, medical school provides very little training about important preventative topics such as nutrition.)

2. Hire a CPM who either is licensed or who partners with an LDEM.

I also recommend hiring a CPM who is either licensed herself or who partners with a licensed CPM. (Most midwives don’t attend births alone; they have a partner midwife who comes with them.)

Your unique circumstances will be the determining factor in your decision here.

For example, if you’re carrying twins and would like to give birth at home with a CPM, you’ll need to hire an unlicensed midwife. In that case, ask your midwife if she partners with a licensed midwife (she likely will) so that you have access to Pitocin and other medicines in case of emergency.

On the flip side, if you would feel more comfortable and confident laboring at home knowing that your primary midwife carries Pitocin and (possibly) IV solutions, you’ll want to hire a licensed CPM (LDEM). 

Another reason to make sure you have an LDEM at your birth is in case you tear. An unlicensed CPM is fully capable of stitching you up but is not able to carry lidocaine for numbing.

In The End…

Overall, every mother is different and so is every midwife. Though I feel that my recommendations are applicable to many moms, they won’t apply to everyone and they might change based on which midwife we’re talking about. 

It‘s a good idea to meet with multiple midwives and “interview” them about their beliefs and about the way they practice. 

In the end, my goal is, as always, for you to have a wonderful birth experience that you can look back on with satisfaction and gratitude. Choosing the right midwife plays a big role in that.

Until next time,

Allison

Any Questions?

I’d love to have a conversation with you! Let me know if you have any questions in the comments below.

READ MORE:

65 Questions to Ask a Midwife Before Hiring Her

How Much Do Midwives Cost?

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