Note: This is a first post by doula extraordinaire, midwife-in-training and legislative advocate, Rachel Dolan Wickersham. Amy and Rachel are thrilled to begin our work as a team to bring ChicagoDoula to you in its new format as a collaborative birth blog. Enjoy!
I’ve had a lot of requests for a basic primer on the different types of midwives available to home and hospital birth mothers and families. Generally, everyone understands that midwives have a more holistic approach than MDs, spend more time with their clients, and get better outcomes for both mother and baby. However when it comes to figuring out which type of midwife is best for a given situation, the devil is in the details. Here is my best shot at sorting out who’s who.
CNMs and CMs (Certified Nurse-Midwives and Certified Midwives)
CNMs receive a degree in nursing and then go on to get a master’s degree in midwifery in most cases. There are a number of CNMs who have a bachelor’s in nursing and a certificate in midwifery, rather than a master’s, but basically, it’s nursing plus midwifery training. Starting in 2010, a graduate degree will be required for all CNMs and CMs.
CMs receive midwifery training alongside CNMs. They are part of the same program, however before the midwifery training they do not receive an RN. They do however, have to receive a bachelor’s before the midwifery training because they will be receiving a master’s in midwifery. Those who already have a master’s degree in a related field, may earn a certificate.
Both CNMs and CMs sit the same midwifery exam to receive their credential. The exam is administered by the AMCB – American Midwifery Certification Board. One is not required to prove out-of-hospital experience in order to sit the exam or receive a CNM or CM credential.
CNMs can practice in all 50 states. CMs can practice in 3 states – New York, New Jersey and Rhode Island. The vast majority of CNMs- or CMs-attended births occur in hospital settings. Less than 5% are outside of the hospital in homes or free-standing birth centers.
DEMs and CPMs
DEMs are direct-entry midwives – midwives who do not enter the profession through nursing. They learn through a variety of pathways. Possibilities include but are not limited to formal midwifery schools such as Seattle School of Midwifery, exclusive apprenticeship, or a combination of the two. These midwives may or may not use the same textbooks as CNMs and CMs. They may or may not be legal within their state. They do not carry a national certification unless they choose to become a CPM (see below). They may or may not have education equivalent to that of a CNM/CM. Whereas the CNM/CM proves her entry-level competence by passing the AMCB exam and earning her CNM/CM credential, the DEM who does not become a CPM has no such designation.
It is up to the consumer to discern their DEM’s level of education and expertise through asking questions, contacting references, and examining any evidence their DEM provides (such as certificates of training in neonatal resuscitation, etc). In some states, licensure is offered to DEMs who meet certain requirements. Often, but not always, the requirement is to earn a CPM (certified professional midwife) credential.
Some DEMs wish to prove their competence by meeting certain criteria and then sitting a national exam. These DEMs become CPMs (certified professional midwives). They may still receive their education through a variety of routes, (see DEMs above) but it is almost guaranteed that they will learn from the same textbooks as CNMs and CMs because the national certification exam draws questions from materials in these textbooks.
The national certification exam for CPMs is administered by NARM (North American Registry of Midwives). NARM’s exam tests for the same body of midwifery knowledge as the AMCB‘s exam. It does not test for advance practice nursing skills and knowledge (such as knowing how to calculate and prescribe narcotics doses for pain relief in a hospital birth) because CPMs are not nurses and are intentionally, out-of-hospital providers. In addition to passing the exam, in order to receive a CPM credential, the applicant must prove documented out-of-hospital experience (something CNMs and CMs do not need to do).
CPMs are legally allowed in 26 states and are selectively ignored in other states. Only 11 states actively ban them. In some states they even get Medicaid reimbursement, as can CNMs.
CNMs, CMs and CPMs have all earned certificates demonstrating competence in midwifery. Consumers should be able to verify proof of their certification. In the case of CNMs in all 50 states and CPMs in some of the 26 legal states, one can verify their state licensure. Where licensure is not available, it is up to the consumer to ascertain proof of education. To see a list of legal states for DEMs and CPMs, go to www.mana.org and click on the resources tab.
Since I live in Illinois, I can comment on our situation here.
In Illinois we have no CMs. We have many CNMs. Most practice in hospitals. At this writing, there are no free-standing birth centers for them to practice in, though a law establishing a pilot project of such centers passed in 2007.
Five nurse-midwifery practices offer homebirth services in the Chicago area. Two practices offer homebirth services downstate. Altogether, these practices are based in only 5 out of 102 Illinois counties.
Currently in Illinois, DEMs of all kinds, including CPMs, are illegal but there is a bill before the Illinois House for licensure of DEMs requiring the CPM credential as proof of competence. Licensure would also require an associate’s degree with specific science-based coursework in addition to the CPM.
There are DEMs all over the state of Illinois. Some are in the open. Some are underground. Here in the Chicago area, we have only a few CPMs.
CPMs are legal in some neighboring states (Wisconsin and Missouri). They are generally allowed/ignored in Michigan. Iowa and Indiana are working on licensure for CPMs, as is Illinois.