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Midwifery in the United States

Midwives in the United States provide medical assistance to childbearing women during pregnancy, labor and birth, and the postpartum period. Before the turn of the 20th Century, traditional midwives were informally trained and helped deliver almost all births. In the first several decades of the 1900s, midwifery experienced two changes: 1) first efforts of professionalization and 2) gradual decrease. In 2009, midwives attended 7.6% of all U.S. births and 11.8% of all vaginal births. Today, midwives are professionals who must undergo several formal training routes.

Colonial
Childbirth in the United States has traditionally been attended by midwives. During the seventeenth century, the English colonies strictly had women midwives to attend childbirths. Town records indicate some well-known midwives including Bridget Fuller (d. 1664) who practiced in the Massachusetts Bay colony and Mrs. Wiat of Dorchester (d. 1705) who attended over 1,000 births. Others such as Ruth Barnaby (1664-1765) and Elizabeth Phillips (1685-1761) practiced for over forty years. While Elizabeth Phillips was trained in London before continuing her practice in Boston, other midwives such as Ann Eliot may have acquired medical skills through her husband.

Similarly, in the Dutch colony of New Netherland, women were also established in midwifery practices. In 1633 in New Amsterdam, the colonist constructed a building for the official midwife. This postion was held by Mrs. Trynje in 1644 and Hellegond Joris in 1655. Later in 1658, the Dutch councillors of New Amsterdam appointed midwife Hilletje Wilbruch to oversee a new hospital. Although the English took over New Amsterdam and renamed it New York, women continued to be prominent in midwifery.

Pre-Professionalization
Beginning in the late eighteenth century, a significant number of physicians started to attend births. Their prominence in childbirth increased drastically into the turn of the twentieth century, almost rendering midwives obsolete. However, the increase of physician-attended births coincided with an increase demand of newly arrived European immigrants who have been accustomed to midwifery from their cultures. Moreover, poor women and African Americans, particularly those living in the South, traditionally employed midwives as well. In fact, in the early twentieth century, midwives attended as many as 90 percent of all black births in the southern states. For reasons of culture, language, and cost, midwives did not completely disappear despite the rise in physician-attended births at the turn of the twentieth century.

In the early 1900s, traditional midwives came under fire in what has been called the “midwife problem” when they became scapegoats for American’s high infant mortality rate. Despite findings from the White House Conference on Child Health and Protection, the committee on the Costs of Medical Care, and the New York Academy of Medicine that point to physicians rather than midwives as the cause of these high mortality rates, many still blamed midwives for their “ignorant” and “dirty” ways. Scholars believe these traditional midwives became an easy target because of their status as African Americans or immigrants. Additionally, these early midwives lacked formal training, which made physicians even more suspicious of their practice.

The poor stereotypes of midwives, coupled with a declining birth rate and a shift of birth from the home to the hospital, decreased a demand of midwives. Moreover, national immigration policy in the 1920s temporarily ended immigrations from many parts of Europe, effectively stopping the flow of European midwives. In the ensuing decades, midwifery declined in major cities. Between 1903 and 1912 in Washington D.C., midwife-attended births dropped from 50 percent to 15 percent. Similarly, in New York City, midwives attended 30 percent of all births in 1919 and only 12 percent in 1929. These trends spread from the northeast across the United States such that midwives no longer attended the majority of births in the country by the 1930s.

While some public health officials, pediatricians, and social workers wanted to eliminate midwifery, others did not think this would solve the problem. In the 1910s and 1920s, S. Josephine Baker, director of the New York City Bureau of Child Hygiene, advocated to keep midwives because many immigrants and African-Americans whom midwives have traditionally served could not afford the care of physicians. As such, the solution of the “midwife problem” was to train, license, and regulate them.

Professionalization
Early regulation and training of midwives had begun in the early 1900s. In 1911, New York City opened the first municipally sponsored American midwifery school called the Bellevue Hospital School for Midwives. Josephine Baker played a prominent role in establishing the school. The school mostly enrolled Italian, German, Polish, and Hungarian immigrants and provided them with eight months of training in prenatal care, postnatal care, and deliveries. Additionally, the deliveries attended by midwives trained by Bellevue had lower maternal and infant mortality rates than city-wide statistics.

Around the same time, some advocated for the creation of nurse-midwifery, extending the role of a nurse to specialize in midwifery practices. In a paper presented to the National Organization for Public Health Nursing in 1914, Dr. Frederick J. Taussing wrote that “the nurse-midwife will […] prove to be the most sympathetic, the most economical, and the most efficient agent in the case of normal confinement.” In the next couple of decades, there were several short-lived attempts to create nurse-midwifery training, including the Maternity Center Association (MCA) in New York City in 1923 and the Manhattan Midwifery School in 1925.

Finally in 1925, Mary Breckinridge, a British-trained American public health nurse, formed the Frontier Nursing Service (FNS) in Kentucky. The mission of FNS was to provide nurse-midwives care for mothers and infants who live in an isolated area without access to healthcare. Indeed, the Appalachian Mountains of eastern Kentucky where FNS was located had some of the highest maternal and infant mortality rates in the nation. Statistics on the maternal mortality rate of FNS is significantly lower compared to state- and nation-wide data. In the late 1920s, FNS fired renowned statistician Louis I. Dublin to compile their statistics. He showed that the maternal mortality rate (per 10,000) of FNS between 1925 and 1937 was 6.6 compared to 44 to 53 of Kentucky whites and 48.9 to 69.5 of the United States.

Later in 1931, Rose “Rosie” McNaught successfully implemented MCA’s nurse-midwifery program its second time, modeled after the FNS. McNaught worked at FNS as a staff nurse before Breckinridge sent her to New York City to set up MCA. MCA pioneered midwifery in two ways. First, in February 1932, MCA opened the nation’s second nurse-midwifery school called the Lobenstine School of Midwifery, named after Ralph W. Lobenstine, an obstetrician and one of the founders of the school. The two goals of the Lobenstein School were to “1) supervise and teach untrained midwives and 2) bring skilled maternity care […] to women in remote rural areas.” The MCA modeled its midwifery curriculum after European, particularly British examples. It required registered nurses to complete a ten-month midwifery program. Secondly, around the same time in 1931, MCA established the Lobenstine Midwifery Clinic, which served predominately poor African Americans or Puerto Ricans in Harlem who needed the services. The Midwifery Clinic encouraged prenatal care for its patients, who averaged 7.7 prenatal visits from 1933 to 1952. In incidents of complications, midwives at the Clinic would also refer patients to the care of a physician. These efforts certainly contributed to the low maternal mortality rate at the MCA. Between 1932 and 1936, MCA births had a maternal mortality rate of 10 (per 10,000) compared to 104 for New York City and 56.8 to 63.3 for the nation.

Despite the success of these early efforts to establish professional status of midwives, midwifery failed to make a significant comeback. In the following decades, childbirths almost completely moved to the hospital where they were managed by physicians. At the onset of World War II, more than half of births were in hospitals. In the early 1950s, that number rose to 90 percent and finally over 99 percent by the early 1970s.

During this time, nurse-midwives have been described to struggle to find their place. In the 1954 annual convention of the American Nurses’ Association, nurse-midwives paved the way for the creation of the American College of Nurse-Midwifery (ACNM) in 1955. ACNM was later renamed to the American College of Nurse-Midwives in 1969 and continues to establish legal status and to set standards for the training and regulation of midwives.

Types and Qualifications
In the United States, people can gain midwifery certification primarily through two paths: Certified Nurse-Midwives (CNMs) or Direct-Entry Midwives. The main difference between the two is that CNMs require nursing training and licensure while Direct-Entry candidates can enter midwifery without nursing background.

Certified Nurse-Midwives
A Certified Nurse-Midwife (CNM) is an Advanced Practice Nurse who has specialized education and training in both the disciplines of nursing and midwifery. The CNM certification process includes first completing the required education and then passing a national exam. CNM candidates must complete a nursing degree as well as a nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME). The midwifery education program is a post-baccalaureate program that requires a bachelor’s degree and may sometimes also require a registered nurse (RN) license. Since 2010, all CNMs are required to possess a minimum of a graduate degree such as a Master of Science in Nursing (MSN) or a new doctoral degree in nursing, the Doctor of Nursing Practice (DNP). Thus, recent graduates from an accredited CNM education program are awarded at least a Masters degree. After completing the required education in nursing and midwifery, CNM candidates are eligible to take the national certifying exam administered by the American Midwifery Certification Board (AMCB). Recertification take place is every five years.

Direct-Entry Midwives
A direct-entry midwife is educated in the discipline of midwifery in a program or path that does not require prior education as a nurse. Direct-entry midwives learn midwifery through self-study, apprenticeship, a private midwifery school, or a college- or university-based program distinct from the discipline of nursing.

Direct-entry midwives in the United States includes the following forms:

The American College of Nurse-Midwives (ACNM) also provides accreditation for direct entry to midwifery practice as a Certified Midwife (CM). The CM route was created more recently in 1997 in order to provide an alterative entry in midwifery that did not involve nursing requirements. Like the CNM program, the CM program is also at the post-baccalaureate level. Candidates can apply for admissions to an ACME-accredited midwifery program with a bachelor’s degree and completion of relevant courses in the sciences. After completion of the education component, CM candidates earn a master’s degree and are eligible to take the national exam toward certification. All CMs must pass the same national certification exam administered by the American Midwifery Certification Board (AMCB) for CNMs. CMs also have to go through a recertification process every five years.

A Certified Professional Midwife (CPM) is a professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and adheres to the Midwives Model of Care. The CPM is the only US credential that requires knowledge and experience for out-of-hospital settings. Entry-level applicants for CPMs can be certified through a two-step process: an education requirement and a written exam issued by NARM. Completion of a formal midwifery education program can be used to satisfy the education requirement. These include programs and schools accredited by the Midwifery Education Accreditation Council (MEAC), Certified Nurse-Midwifery (CNM) and Certified Midwifery (CM) programs accredited by the American Midwifery Certification Board (AMCB), or state-level legal recognition that has been evaluated by NARM for educational equivalency. It is also possible for applicants to take an alternative route that does not involve the aforementioned formal educational programs such as through apprenticeship, self-study, or foreign training (except UK). In those cases, the applicants can still satisfy the educational requirement by completing the NARM Portfolio Evaluation Process (PEP), which includes skills evaluations, references, and experiences in specific birth setting. In a survey sent to current CPMs in 2009, 45% of respondents were trained by apprenticeship, 33% through a MEAC program, 12% through a non-accredited program, and 7% were self-taught. It is only after the education component is satisfied that the CPM applicant is eligible to take the NARC written examination. Successful CPM candidates would have to apply for recertification every three years.

It is also possible to practice as a midwife without undergoing the certification or licensing process. Lay midwife refers to a (usually) traditional midwife who is not formally trained or certified. Although this term carries a negative connotation, a lay midwife does not necessarily hold a low level of education. There are many reasons for practicing without formal regulation, including spatial and temporal constraints (i.e. residing in a place or practicing at a time where certification is not a possibility).

Numbers and Scope
As of March 2009, the American College of Nurse-Midwives represents over 11,000 Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) in all 50 states and most US territories. In 2005, Certified Nurse-Midwives attended more than 10% of vaginal births in the United States. From 1996 to January 2012, NARM has issued over 2000 CPM certifications. In terms of gender, only 2% of CNMs are men.

Because Certified Nurse Midwives also hold an active Registered Nurse license in the state in which they practice, their scope of practice is often greater than that of direct-entry midwives. In addition to providing care related to low-risk pregnancy and childbirth, CNMs are also able to attend to women’s reproductive health needs from puberty through menopause as well as for the care of their newborns. Additionally, they are able to prescribe some medications, use certain medical devices, and implement therapeutic and diagnostic measures.

Occupational Profile
The occupational profile of modern professional midwives varies in terms of workload and salary. Results of a 2007 survey find that the median salary of full-time (35 or more hours a week) Certified Nurse-Midwives (CNMs) is $79,093 to $89,916. In 2007, 79.7% of CNMs report working full time. Certified Professional Midwives (CPMs) average three to six births per months so that they are able to give women more personalized care throughout their entire childbearing cycle.

Setting
Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) are able to practice in all settings, including hospitals, birth centers, and private homes. However, the majority of CNMs and CMs attend hospital births. Certified Professional Midwives (CPMs) undergo training that tailors to out-of-hospital experiences, and most CPMs work in the private home or birth centers. In a 2001 survey sent out to all current CPMs, 91.5% responded that they primarily practice in home births, 5.8% cite birth centers, and 1.1% say hospitals. In contrast, a majority of CNMs are employed by hospitals and medical centers (32.7%) or physician practice (30.5%).

Midwives attend a majority of home births in the United States. In 2009, over 62% of home births in the United states were attended by midwives, with 19.5% as certified nurse midwives (CNMs) and 42.9% as "other midwives" (i.e. direct-entry).

Legal Perspectives
Certified Nurse-Midwives (CNMs) can legally practice in all 50 states and the District of Columbia. As of 2011, direct-entry midwives are legally regulated in 26 states, though the specific type of direct-entry requirements of licensure, certification, and registration depends on the state. For instance, Certified Midwives (CMs) can only be licensed to practice in three states (New York, New Jersey, and Rhode Island) but are also “authorized” to practice in two others (Delaware and Missouri).

Current legal issues regarding midwifery are largely state-specific. On October 20, 2012, the Alabama Birth Coalition organized a "Walk 4 Midwives" in Huntsville to raise awareness of Alabama's law that prohibits midwives from attending home births. Currently, it is legal to give birth at home in Alabama, but that birth cannot be attended by anyone, including midwives. Proponents of midwives have been trying to introduce a bill to change the law for the past nine years when it was finally made it out of committee in 2011. Because the session ended right when that happened, no action has yet been taken. Recently in Texas, a group of midwives working on the U.S.-Mexican border have been found guilty of selling false birth certificates. Their verdict has caused U.S. Customs and Border Protection to question the validity of birth certificates of many people birthed by these midwives and others along the border.