How to become a midwife.

An apprentice CPM charting at a birth.

An apprentice CPM charting at a birth.

Part I- Types of Midwives:

The first thing you need to decide is which kind of midwife you want to be. There are two main types of midwives recognized in the United States, the Certified Nurse Midwife (CNM) and the Certified Professional Midwife (CPM). There is also a tiny population of Certified Midwives (CM), that are only recognized in 4 states. Finally, there is the Traditional Midwife (TM), or Traditional Birth Attendant. The differences are quite significant and you will want to choose wisely.

Certified Nurse Midwife (CNM)

The CNM is an advanced practice nurse with a masters degree in midwifery after becoming an RN. CNMs work mostly in hospitals and medical clinics. Only 3% of CNMs do births outside of the hospital setting.

CNM route Advantages:

  • You will have access to the highest level technology and training. From working in a high tech NICU to assisting in cesarean surgeries. You can work in hospitals and thus be able to serve high risk clients and those wanting anesthesia for their births.

  • The training is through major university nursing programs which is eligible for loans and grants. The path is fairly straightforward.

  • Accessibility. RN programs are everywhere across the country. There are about 40 CNM programs across the country and a number with distance programs.

  • Respect. You will be accepted and integrated into the mainstream medical system.

  • Legality. CNMs are legal in all 50 states. Scope of practice may vary but you can work in all 50 states and are recognized internationally.

  • Full scope of care. You will be able to offer well woman care and in some states provide primary care to women of childbearing age and have prescriptive authority.

  • Access to jobs with benefits, livable working hours, vacation and reliable pay.

  • Degree is recognized around the world. Will be able to teach at university level and further your degree expand to other nurse practitioner roles like the doctor of nurse practice (DNP) or neonatal nurse practitioner (NNP).

  • Availability of scholarships and loan repayment through future employers including Hospitals and the National Health Service.

CNM route disadvantages:

  • The training can be lengthy and expensive- 6 to 8 years unless you have a previous nursing or bachelors degree or get accepted in one of the few accelerated programs. The standard track is to earn a 4 year bachelor degree in nursing, then work for a year as a registered nurse, ideally in L&D . Then you earn a masters which takes 2 more years. (In contrast, in other developed countries it takes a maximum of 4 years after high school and often just 3 years to be registered.)

  • You will be expected to practice the standards of care of our highly medicalized obstetric system which has the worst outcomes for mothers and babies in the developed world. If you are holistically minded or are gentle of spirit, the desensitized and profit centered, defensive medical environment can be hard to deal with. You may spend your whole career swimming upstream, fighting antiquated practices and harmful protocols. The upside is that you can help change the system from within.

  • Another issue is autonomy. You may have to work under the direction of doctors and do things in the medical model of care rather than the Midwives Model of Care.. According to the International Conference of Midwives, midwives are defined as autonomous practitioners. Midwives get excellent outcomes only when allowed to practice the Midwives Model of Care. But many states and most hospitals require the direct supervision (control and management) by doctors. Working under them or for them in a private practice, you may be treated like a second class citizen or have no real authority. Some CNMs have great relationships with their supervising docs and run the show in their labor ward but it is highly variable between hospitals and practices.

  • Along the same lines, you may find an amazing job situation or help build up a hospital birthing center, only to have it close and yanked out from under you. This happens over and over all across the US, the latest one in New York City. Uncomplicated and healthy birth is not profitable to hospitals, and as it gets more popular, it becomes a financial liability to the hospitals. No matter what good work you do, it can end in a flash.

For the sake of simplicity of this article, I am going to speak of CNMs and CMs as hospital based since over 97% of them work in hospitals.

The Certified Midwife (CM)

The CM is educated and trained as a CNM, graduating from a CNM accredited school but enter with a bachelors degree in another field and without a nursing background. It was created in response to the demand for a non-nurse, or “direct-entry” path to midwifery. CMs are equally trained and qualified as CNMs.

Unfortunately, there are only a handful of states that recognize CMs: New York, New Jersey, Delaware, Missouri, Maine & Rhode Island. They are further limited by only having prescriptive authority in NY, RI and ME. Furthermore, there are only 2 schools that offer CM programs in the entire US.

The CM credential was created in the early 90s but is limited in use to the a small section of the US- the northern seaboard with no expansion in sight. Some CMs say that they are looked down upon in the workplace because they don’t have a nursing background and treated as “second class” midwives.

I personally think it is a shame that the ACNM has not supported and expanded CMs programs nationwide. It could be the solution to much of the shortage of midwives and controversy regarding the quality of training in other direct-entry programs.

But, if you live in one of those handful of states, the CM is a great option.

The Certified Professional Midwife (CPM)

The CPM is a non-nurse community midwife that works in birth centers and in private homes. The clinical training is based on the apprenticeship model, with a separate didactic education. Course of study lasts a minimum of 3 years full time or 5 years part time. The focus of the training is serving normal, low risk births in out-of-hospital setting.

32 states currently license CPMs. Depending on the state they may also refer to you as a Direct-Entry Midwife (DEM or CDM) or a licensed midwife (LM) or licensed direct-entry midwife (LDM), all given by the respective states that license them.

CPM ROUTE Advantages:

  • You are able to practice the real deal Midwives Model of Care. You get to know your clients well with long visits, forging deep bonds. You will be part of a much smaller team than in a hospital. Even the largest birth center practices only have a handful of midwives. Clients often become lifelong friends and come back baby after baby.

  • You get to serve the most motivated and proactive populations and facilitate gorgeous, often orgasmic Instagram worthy births. Tears of joy shed regularly.

  • Unless you work for a big practice, you get to set your own schedule, choose your own population you want to serve and and even hand pick your individual clients.

  • Training and practice is based on a preventative, health centered model. You will be able to learn and use plant based medicine, traditional Chinese medicine, massage, nutrition, vitamin therapy, homeopathic medicine, essential oils, yoga, biomechanics/physical therapy and all things holistic in your practice.

  • CPMs are very prepared for working in their field because they spent their entire apprenticeship essentially doing “on the job” training. We log around 3500 clinical hours to graduate. You will be participating in prenatal care, postpartum visits and births from the very first weeks of training. RNs that have done CPM training say that they get more hands on clinical care experience in the first few weeks of apprenticeship than in their entire nursing school career.

  • You get the satisfaction of knowing that you made a difference every time you go to work. You will be able to safely rock a 5% c-section rate, 90% breastfeeding rate, low tear/episiotomy, low hemorrhage rate. I can’t count how many times I know a birth would have ended in c-section had they just signed up with a hospital based practice. Your clients will thank you with sincere and deep gratitude that you made a difference in their lives.

CPM ROUTE disadvantages:

  • Schooling choices are limited. There are only 11 accredited midwifery schools (MEAC) for CPMs in the US, and only a few with distance programs. There are also a handful of non-accredited schools. Even most MEAC accredited schools are not “regionally accredited” so your credits will NOT transfer to other universities if you want to get higher degrees or change tracks. Also, only 2 or 3 schools qualify for Pell Grants and federal loan programs.

  • It is difficult to get quality clinical training as a CPM. Apprenticeships with well trained midwives are very hard to come by. Most CPMs end up studying distance for schooling and struggle to put together the necessary experience. They sometimes train with older established midwives that have questionable clinical practices and judgement. Others have to leave their families for months at a time unless you live in a state that is a “hotbed” or has a long history of integrated and educated midwifery, For this reason, your training can drag on for years and years (5-7 years is not uncommon) working to get enough clinical training to certify.

  • Because of the extensive hands on clinical hours required to be certified, you are essentially working full time with your preceptor, being on call 24/7, on top of full time schoolwork.

  • You will not being able to follow your clients into the hospital as their provider when there is a complication or if they risk out of home or birth center care. You may invest 8 months of time and attention into a client and have them not go into labor by our 42 week cut off. You then have to hand over your client to the hospital provider, act as their doula and hope for the best.

  • Because of the limited scope of care, you will not be able to serve the majority of the population. CPMs cannot write for even the most basic prescriptions like an antibiotic for mastitis. Depending on the state, you may be limited to only seeing women within a certain age range or no one with a history of preterm labor, or any number of restrictive regulations. Every state has different regulations, scope of care, access to insurance billing and drugs. If you are interested in going CPM, be sure to research the laws and climate in the states you may ever want to practice and live in.

  • Insurance billing can be tricky or even impossible. In Alaska, CPMs can bill all major insurance including Medicaid. We are extremely fortunate. In most other states you may be limited to cash pay which means you either only serve people that have money or keep your rates very low and barely make ends meet.

  • When you don’t work in a hospital, you have to do ALL the things. This means on top of clinical midwifery you are: scrubbing floors-sterilizing instruments-cooking-billing-laundering linens-promoting on social media-ordering supplies- scheduling- following up with other providers- faxing orders- washing towels-fielding phone calls-shopping for equipment-reporting with government agencies….ad nauseam. Unless you work at a big and prosperous birth center, CPMs do the work of many people, often all at once.

  • You may be criminally charged for mistakes or bad outcomes, regardless of fault. The common belief that if something bad happens in the hospital, “they did everything they could”. Usually you just come to work the next day. If the same event happens at home, you will be accused of being irresponsible or negligent at the very least and your practice may be destroyed.

  • It’s more likely that you will be on call 24/7 and not be paid for it. Being on call is highly stressful and will limit your life. You can’t really imagine how taxing it is until you have lived it.

  • Due to the lack of universal licensure, you may end up living in a state where it’s either a grey area or illegal for you to practice.

  • In unregulated areas, there are poorly trained and irresponsible CPMs. propagating their poor practices and giving all midwives a bad name. Since non-nurse midwives were shunned and excluded from the medical field, and without access to necessary drugs and training, our elder midwives were forced to learn by the seat of their pants, in trial by fire or make things up as they went along. Modern midwifery with access to continuing education and having supervisory boards makes this a non-issue in states with mandatory licensure. If you live in one of the states without accountability, you may end up training with or have your reputation affected by a midwife that is operating on old woo woo techniques like calling in spirits or giving enemas during a massive hemorrhage instead of giving an IV, drugs and transporting.

Traditional Midwives

Traditional midwives are a less well known but controversial type of midwife. They are the remnant or a revival of the old school practice of midwifery, working outside of the bounds of governmental or institutional control. They tend to reject formal diplomas, certifications and licensing although some do have formal training as CPMs. They use only classical techniques and natural remedies, herbs, homeopathic remedies, energy work, etc. They cannot legally use IVs, drugs, do vaginal repairs, order labs, etc. and most don’t even want to…. rejecting the need for even the most accepted medical interventions like ultrasound. TMs tend to work underground or in a legal grey area, often in states that do not license midwives. Many times they will call themselves Traditional Birth Attendants, Independent Midwives, Birth Helpers or Birth Keepers to avoid prosecution or being confused with more medically minded midwives, (whom they call pejoratively call MED-wives…).

To many they are the bane of the midwifery community since there is no outside accountability in their practices. To others they are the heroines keeping the ancient torch of traditional midwifery going and giving support to families that want to have twins at home or just some basic support for an unassisted birth. If this kind of practice resonates with you, check out the Indie Birth Association for more information.

….we do not offer “midwifery services” but that of birth consultants, birthkeepers, birth attendants..or whatever else you want to call it. Women guides have also been available to other women during birth and we are honored to carry on this ancient tradition.

Indie Birth Association

Traditional Midwives Lisa Suffrage and Denise Hibben using two manual fetoscopes in order to confirm twins in their client. Most other midwives wouldn’t attend twin deliveries at home either by regulation or by choice and rely on ultrasound scans for diagnosis.

Traditional Midwives Lisa Suffrage and Denise Hibben using two manual fetoscopes in order to confirm twins in their client. Most other midwives wouldn’t attend twin deliveries at home either by regulation or by choice and rely on ultrasound scans for diagnosis.

In a nutshell…

Someone who wants to be a CNM or CM:

  • Needs a steady income to support a family or pay back debts.

  • Prepared for heavy academic work, writing lengthy care plans and years of college classes not directly related to midwifery. Does not mind spending a lot of time in the books.

  • Enjoys the protection and respect of being part of an institution and a well supported profession.

  • Does not mind taking orders and doesn’t mind being part of a hierarchy.

  • Is okay with following protocol, institutional policies and doctors’ preferences over a patient choice, patient autonomy and personal conviction.

  • Desires to be able to provide a full scope of care for women of childbearing age including prescriptive authority.

  • Needs flexibility for travel or relocation.

  • Wants to be able to work in hospital, or have continuity of care and follow your patients if they transfer to the hospital.

  • Desires access to high tech medical training and tools, and do procedures like placing IUDs, minor surgeries and assisting in C-sections.

someone who wants to be CPM:

  • Independent, enjoys autonomy and can handle high levels of responsibility and stress.

  • Doesn’t mind working insane hours. May be “on call” 24/7 for weeks or months at a time.

  • Can run their own business or enjoy working for very small business without benefits or the stability of a large corporation. Has an entrepreneurial spirit.

  • Doesn’t mind doing marketing, public education and self promotion.

  • Likely to be disrespected, persecuted by mainstream and establishment.

  • Values holistic and “alternative” medicine.

  • A hands on learner. Desires to start working now and not willing to wait years to begin clinical work

  • Willing or able to travel distances and be extremely resourceful in finding training.

Someone who wants to be a TM:

  • I think you know who you are!