Many times, when someone hears the word “midwife,” they have one preconceived notion of what that means, based upon either their past experiences or things they’ve heard about midwife care. There may be regional differences as well, as midwives are regulated differently in each state. Here is a brief overview of the main types of midwives.
Direct Entry Midwife (or DEM):
This is someone who has studied specifically to become a midwife. Becoming a DEM may involve several years of education through a special school for midwives, as well as an apprenticeship under an experienced midwife (often called a “preceptor”). This kind of midwife training includes extensive knowledge of anatomy and birth physiology, handling variations of normal birth experiences (or emergencies), evaluating newborn health and maternal postpartum health, well-woman care, and natural/herbal treatments for improving pregnancy and postpartum health, as well as addressing many of the common complaints of pregnancy, birth, and postpartum. DEMs practice primarily in birthing centers or at homebirths. Their regulation differs from state to state– In some states, DEMs are covered by insurance, allowed to practice freely, and respected as trained birth professionals; in other states, they are “alegal,” or not covered under regulations at all. In most states where DEMs are legal, they are required to have a backup obstetrician to assist in evaluating and determining the risk status of their patients. In some states where they are regulated, they are prevented from attending anything other than an extremely low-risk birth, even though their training and experience may support them having more freedom. Since their is no national standard for licensing and regulation of midwives yet (although the Midwives Alliance of North America is working on standardization), state titles vary, and may include Certified Professional Midwife (CPM) or Licensed Midwife (LM).
DEMs, because they generally do not practice with an operating room and NICU in the same building, tend to have more training and experience with natural methods of preventing and handling common obstetrical challenges, such as vaginal breech birth, shoulder dystocia, avoiding tearing and episiotomies, and avoiding unnecessary cesareans. Midwives carry emergency equipment with them to all births, including oxygen and resuscitation equipment for moms and babies, treatments for postpartum hemorrhage, and more. They are readily able to handle most minor birth emergencies in the home. If, at any point during the labor, birth, or postpartum period, the midwife or mother feels that the hospital is a more appropriate or safe place for the birth to progress, the midwife can call ahead to the hospital to prepare them, and the mother is able to be worked right in after being transported to the hospital.
Certified Nurse Midwife (or CNM):
CNMs are midwives whose training is within the medical profession. A CNM must first be a Registered Nurse (RN) who possesses a bachelors degree (some states also require a masters degree to become a CNM), who then attends a year or two of additional college courses specific to pregnancy, birth, postpartum care, and obstetrics. CNMs-in-training do an internship in a hospital, whereas a DEM’s apprenticeship is usually out-of-hospital. After completion of the course and internship, a CNM-in-training must pass an exam to be certified. For more on how one becomes a CNM, check out this web site. CNMs are trained in standard medical procedures related to birth and delivery, although because of the nursing background and the emphasis in nursing on patient care and relationships, most CNMs are also experienced with less-interventive and more individualized approaches to care of the birthing woman. After certification, most CNMs work either in hospitals or clinics, although a few CNMs also work with freestanding birth centers or have a homebirth practice (either in addition to their hospital practice, or instead of it). Like Nurse Practitioners, in most states CNMs can prescribe medicine and have privileges much more like those of doctors than those of DEMs.
Because CNMs have more medical training that most DEMs, in many of the states where DEMs are over-regulated (and often unnecessarily so), CNMs are allowed more freedom. Most CNMs are required to have an OB as their backup; in most states, as long as the OB will sign off on the patient CNMs are allowed great freedom in patient selection. In many of the states in which DEMs are only allowed to attend homebirths of extremely low risk patients, CNMs are legally allowed to attend in-hospital or out-of-hospital VBAC, twin, and breech births. In many of those states, however, CNMs do not do homebirths because of pressures from local OBs (who they are required to maintain as backups) or hospitals.
The Mystery of “Medwives”:
Many women who are drawn to midwife care for their pregnancies because of the natural, less-interventive approach to pregnancy and birth as a normal, natural life event (rather than an obstetrical emergency) tend to be more supportive of care from DEMs, and leary of care from CNMs, who they may fear would be too medicalized in their approach. It is important to remember, though, that while most CNMs’ training has been based on the medical model, many CNMs (including those working in hospitals) are philosophically similar to DEMs in their approach to birth. Many CNMs working in hospitals or clinics make every effort to allow their patients the freedom to individualize their pregnancy and birth care, within the guidelines of the practice or hospital. Often, CNMs become frustrated with many of the malpractice-fear-based guidelines in hospitals and clinics that do not promote healthy pregnancy and birth, and start their own out-of-hospital practices that are philosophically similar to DEM practices. And don’t forget, even DEMs can be medicalized in their approach, based on the individual midwife’s background, training, experiences, and philosophy! So, approach each midwife as a unique individual, ask questions to find out if her birth philosophy matches well with yours, and ask for referrals from friends whose birth approaches may mirror your own.
For More Information:
Midwives Alliance of North America
