Brief history

The history of Midwifery in the United States is filled with health care politics and conflicting interpretations of statistics and events. What is not in question is the fact that despite100 years of evidence showing the European model of midwifery care to be at least as safe as - and often safer than - the physician/hospital model for both pregnant women and their infants, there have been extreme efforts to eliminate the profession from the nation's health care choices. Although reports vary, it appears that between 1910 and 1935 the percentage of midwife-attended births in this country fell from around 35-40% to around 10%, and continued to fall over the next 20 years to a low of about 3% in the early 1950s.

The struggle for control of birthing began in the late 1800s, when the American Association of Obstetricians and Gynecologists was formed (1888). Not all members opposed midwifery, but the goal of the group was certainly to declare childbirth a medical specialty requiring physician intervention and care. They were very successful. Although the Sheppard-Towner Maternity and Infancy Protection Act was passed in 1921, providing funds for the training and regulation of midwives (an important step toward improving and standardizing midwifery training), continued opposition from the American Medical Association and obstetricians resulted in the act's expiration by 1929, followed by 50 years of a significant struggle for the profession's very survival.

As with many alternative health care approaches, renewed interest in midwifery began to build in the mid-to-late 1970s and has grown slowly but steadily since then. The population expansion of the last quarter century has been so significant that today’s percentage of midwife-attended births is still very low (less than 5%), but the number of such births has grown to around 200,000 annually. More important, a growing body of research has demonstrated that midwife-delivered care continues to be a safe, effective and highly cost-effective alternative.

The World Health Organization, a staunch supporter of midwife-delivered care, has pointed out that midwives deliver over 70% of the babies born in Western Europe, with lower infant and maternal mortality, lower cesarean rates and lower overall costs. Such statistics have led the WHO to recommend out-of-hospital birth as the standard of care for normal birth. Estimates of the cost savings of implementing such a policy in the U.S. and making midwifery care widely available range between $13 billion and $20 billion a year. Even such incentives as these have unfortunately not yet really penetrated the American consciousness, in provider, payer or consumer communities.

In the United States today, there are two recognized branches of midwifery: direct entry midwives and nurse-midwives. Both have established standards, accreditation of schools and excellent outcomes. However, nurse-midwives have a much closer relationship with hospital-based care and are much less likely to do home births; as nurses, they are governed by medical standards and guidelines. Direct-entry midwives do not practice medicine, as the law defines it, and the vast majority practice in the out-of-hospital setting. These differences have both historical and philosophical roots.

Direct-entry midwives evolved from the ancient practice of having experienced older women assist younger women in the birth process. Over the centuries, a recognized profession emerged, with training by apprenticeship outside the context of medical or nursing schools. Herbal lore, hands-on clinical knowledge and home-based care of women (and children) by women were hallmarks of the midwifery tradition. Today’s direct-entry midwives have independent practices, acquire their education through a variety of means, and still are the primary providers of home birth services.

Nurse-midwifery was brought to the United States from Great Britain in 1929 by Mary Breckinridge. A nurse herself, she had observed midwife-delivered maternity care in France and England and was very impressed with the quality of care and the excellent outcomes for mothers and infants. The first U.S. schools were founded in the 1930s,and the profession grew slowly but steadily. Today there are more than 40 standardized programs in the U.S. and 4-5,000 CNMs (Certified Nurse-Midwives), attending more than 150,000 births annually, primarily in hospitals.

Philosophy

Both branches of midwifery see birth as a normal event in a woman’s life, but there are significant differences stemming from adherence to either the medical model or the midwifery model. The Midwives Alliance of North America has crafted the following definition:

• The Midwifery Model of Care is based on the fact that pregnancy and birth are normal life events. The Midwifery Model of Care includes: monitoring the physical, psychological and social well being of the mother throughout the childbearing cycle; providing the mother with individualized education, counseling and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support; minimizing technological interventions; and identifying and referring women who require obstetrical attention. [www.mana.org]

The American College of Nurse Midwives offers the following perspective:

• The practice of nurse-midwifery encourages continuity of care; emphasizes safe, competent clinical management; advocates non-intervention in normal processes; and promotes health education for women throughout the childbearing cycle. This practice may extend to include gynecological care of women throughout the life cycle. Such comprehensive health care is most effectively and efficiently provided by nurse-midwives in collaboration with other members of an interdependent health care team. [www.acnm.org]

Studies of midwife-delivered care have shown decreased incidence of prematurity and low birth weight, decreased neonatal death rate, increased compliance with schedules for prenatal care, and 50% fewer cesarean sections. The U.S. has among the worst maternal and infant mortality and morbidity statistics in the Westernized world, and the highest rate of cesarean section. Although midwifery has survived and is beginning to thrive here, prejudice and misinformation still guide most people’s decisions about births.

The United States still has a long way to go in undoing the harm that has been done to our nation’s women and infants through the suppression of midwifery and the medicalization of the birth process.

Scope of practice

Midwifery licensing does differ for direct-entry midwives and nurse-midwives, and the statutes regulating each branch also vary from state to state (although the variations are fewer for nurse-midwifery, which is regulated in all 50 states). The training of both branches, however, encompasses comprehensive management of prenatal, delivery and postnatal services for the healthy woman and well-baby care for the first two to six weeks of life. A comprehensive listing of the areas of competence one can expect of a Certified Professional Midwife can be found at www.mana.org/narm under “1995 Job Analysis.” The following list is not all-inclusive, but gives a good overview of the scope of practice: Comprehensive midwifery care for the mother includes a thorough physical examination and complete medical history, and appropriate follow-up exam and history throughout care. Laboratory work is ordered, and screening is done for conditions that might affect the mother or baby during pregnancy or birth. Any significant risk factors identified are thoroughly discussed.

• A review of all the birth options available to a pregnant woman should be done, including information about relative risks and, for home birth, criteria for transporting to a hospital. Mothers should be informed about the midwife’s obstetrical back-up and hospital relations in cases where transport and physician services are determined to be necessary.
• Midwives require that mothers give informed consent for any services declined, for permission to consult or transport in an emergency, for knowledge about risk factors, and for awareness of the midwife’s scope of practice and clinical responsibilities.
• During the course of care, the family environment is explored, and sensitive issues that may affect mother or baby are discussed, including abuse, addictions to alcohol, drugs or nicotine, and mental/emotional health factors.
• During labor, the midwife ensures that the birth environment is warm, clean, and comforting to the mother. Monitoring of mother and baby sufficient to detect conditions requiring referral is done, and measures to manage pain or other problems such as maternal exhaustion or variations in presentation are implemented.
• The actual birth can be assisted by many different procedures, including changing the mother’s position, changing the newborn’s position or episiotomy. It is the midwife’s responsibility to ensure that the appropriate actions are taken in a timely and competent fashion.
• After delivery, the midwife assesses the condition of the newborn, helps mother, baby and other family members to establish loving bonds, and assists the delivery of the placenta. The midwife maintains careful observation of mother and baby for at least two hours after delivery, or until both are stable.
• Follow-up care is provided for up to eight weeks for the mother and up to six weeks for the baby.

Regulatory scope

Direct-entry midwives are regulated in 15 states, according to information provided by the Midwives Alliance of North America. Eleven states issue a license - LM or LDM (AR, AZ, CA, FL, LA MN, MT, NM, OR, SC, WA); two states certify midwives - CM or CDM (AK, NH); one registers them - RM (CO); and one “documents” them - DM (TX). There are also 13 states where the practice may be permitted by statutory inference or judicial interpretation, 7 others where a statute exists but licensure itself is not available, 7 where midwifery is not expressly prohibited, and 9 where it is prohibited (Wa-DC, IN, IA, KY, MD, MO, NC, VA, WY). Regulatory bodies include advisory committees, advisory councils, independent boards, and boards which function with or under other groups. Statutes differ from state to state on such issues as prescription rights, referral and transport requirements, and the required relationship with obstetrical backup. Medicaid reimbursement is available in 7 of the licensed states.

Nurse-midwives are regulated in all states, the District of Columbia and a number of other jurisdictions such as Puerto Rico and Guam, but even with nationwide licensing, the regulating bodies vary. There are nursing or advanced nursing boards (38 states), joint oversight by nursing and medical boards (5 states), an independent CNM (UT) or midwifery board (NY), a public health or board of health board (3 states), and even two states where the practice is regulated by the medical board alone (NJ and PA). The statutes are reasonably uniform in defining scope of practice, although there are some variations, particularly for independent prescriptive authority and whether or not the CNM is defined as a primary care provider (PCP). CNM services are a federally mandated benefit for Medicaid beneficiaries, although patients may have to “work the system” to get what they want.

Third party reimbursement for midwifery is also highly variable. Some payers may reimburse CNMs but not LMs; others will reimburse both. Some policies cover a clinic setting for midwife births but not home births. Obstetricians may find their malpractice insurance rates going up if they provide regular backup for direct-entry midwives (despite their good safety record), so MD backup can be difficult to find for LMs doing home birth.

It’s very important for a woman considering a midwife-assisted birth to determine the precise regulatory environment in her state, to clarify any insurance coverage well ahead of time, and to understand and be comfortable with the midwife’s scope of practice and legal requirements for medical consultation and transfer.

Education and credentialing

Direct-entry midwives can and do obtain their education from a variety of sources, including independent midwifery schools, programs in college or university settings, apprenticeship and self-study. In order to bring credibility and accountability to the diversity of educational backgrounds, the Midwives Alliance of North America established the North American Registry of Midwives (NARM) to develop and administer a certification process that includes verification of knowledge and skills through examination of credentials and completion of a written examination and skills assessment. This credential requires training in out-of-hospital births. The process results in the CPM-Certified Professional Midwife credential, which is recognized by many of the licensed states. As a reasonable precaution, if an LM does not have a degree from a midwifery school or program recognized by the Midwifery Education Accreditation Council, then she should have the CPM credential. Best protection for the consumer is to select a midwife with both.

Nurse-midwives go through a similar certification process administered by the American College of Nurse-Midwives, which sets the standards by which nurse-midwifery is practiced and accredits nurse-midwifery educational programs. CNMs obtain their nursing degree first and then pursue additional training to become a CNM. The credential is recognized in all 50 states.

Typical first office call or visit
The first visit to a midwife will usually be information-oriented. You need to know what the midwife offers, how she practices, what the risk/benefit assessment for using midwifery is for you personally, what her services will cost, and what her personal approach to the birthing experience is like. The midwife needs to know your medical history, any significant risk factors, and your priorities and preferences for the birth experience. If the two of you decide to work together on your pregnancy and birth, then a complete physical exam and laboratory work will be scheduled. Medical records from other providers will likely be requested as well. Expect to spend 45 minutes to an hour for your first visit, and 30-45 minutes for subsequent visits. Good midwives understand that pregnant women have many, many questions and concerns about the prenatal and birth process, and will be very accustomed to doing a lot of talking to convey information, facilitate decision making, and provide comfort and support. Midwifery is a family-centered approach to pregnancy and delivery; husbands/partners and other children are welcomed into the process, and their participation will be discussed and planned for.

Limitations
Midwifery is intended for the normal pregnancy and birth. Serious chronic diseases such as diabetes, heart disease and cancer generally make a home birth inadvisable and may require that an obstetrician provide maternity care. Use of drugs (legal or illegal) which can affect the health of mother or baby, excessive use of alcohol, or a history of significant mental illness are considered contraindications for home birth and may also preclude a midwife-assisted birth even in the hospital setting. In addition, there are many potential conditions and symptoms that can arise during the pregnancy, or even after the onset of labor, that require the attendance of a physician. Your midwife should explain these circumstances to you clearly in advance, so that if such a situation arises, the decision to transfer care will not be a surprise. If you find that you do not qualify for midwifery care, ask the midwife for a referral to an obstetrician whose approach is as compatible with your preferences as possible.

Resources
To find a practitioner near you
For more information and additional referral options:
American College of Nurse-Midwives www.acnm.org and www.midwife.org
Citizens for Midwifery www.cfmidwifery.org
HealthGrades Birth Center Profiles
Midwifery Education Accreditation Council www.mana.org/meac/
Midwives Alliance of North American www.mana.org
Motherstuff www.motherstuff.com (a good resource for finding other resources)
North American Registry of Midwives www.mana.org/narm/

Publications

Monograph reviewed by:
·Cathy Rogers, ND, former Licensed Midwife in the State of Washington; past Academic Dean, Bastyr University; past President, American Association of Naturopathic Physicians.
·Nan Dunne-Boggs, ND, RN, former nurse-midwife; President, Federation of Naturopathic Licensing authorities; Board Member, American Association of Naturopathic Physicians and Naturopathic Physicians Licensing Examination.
·Victoria M. Taylor, LM, CPM, President, Quality Midwifery Associates. Quality Midwifery Associates is an expression of every midwife’s heartfelt desire to give healthy childbearing women the best care and the profession’s commitment to assuring its own standards of service.

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