What is a certified professional midwife? And why are so many doctors “anti-midwife”?

Image courtesy of wikimedia

For those who are new to the blog, this post was written by an OB/GYN resident whose own child was delivered by a midwife.

image courtesy of wikimedia, and has been cropped to remove anatomy which some might find objectionable

A German midwife in a birth center checking on an infant after delivery

It’s a bit of a departure from our usual fare, but today I wanted to address an issue that has been hotly debated recently: that of midwifery. There has been a lot of fuss lately about an increase in midwife-attended births (see here, here, and here) and out-of-hospital births (Reutersresearch), and some states are even changing their laws about midwifery practice. 

This is a sensitive issue for many obstetricians, and for good reason. In order to understand why, we need to define some terms. The term “midwife” actually encompasses two separate and very different groups: certified nurse-midwives (CNMs) and certified professional midwives (CPMs). The terms sound similar, but the two are very different.

Certified Nurse-Midwives

Let’s start with certified nurse-midwives, or CNMs. CNMs are highly trained, licensed healthcare professionals. They typically start out with a Bachelor’s degree in nursing (BSN), and receive additional classroom and clinical training focused on prenatal care, labor and delivery care, and postpartum care. CNM training typically takes 3 years after obtaining a BSN, and some programs require clinical nursing experience before applying for CNM training. So a CNM has a total of 7 years of formal education after high school.

CNMs typically follow the same clinical practice recommendations as physicians when it comes to questions like what medications and vaccines are safe in pregnancy, prevention of unnecessary cesarean sections, and recommended testing during pregnancy. CNM training emphasizes normal childbirth, and CNMs do not perform operative vaginal deliveries (forceps/vacuum), or cesarean sections. Because of this emphasis, some patients feel that CNMs have a more “normal” view of childbirth and may be more skilled at helping patients navigate an unmedicated birth, for example. CNMs operate under the indirect supervision of a physician, who is available in case they are needed for an emergency procedure. CNMs can prescribe medications under the supervision of that physician.

Most CNMs are also trained to repair perineal lacerations which occur during delivery. Your vagina will thank you.

A US Navy CNM (certified nurse-midwife) at work

A US Navy CNM (certified nurse-midwife) at work

If you are interested in more information about CNMs, check out the American College of Nurse-Midwives. 

Certified Professional Midwives

Certified professional midwives, or CPMs, however, are a whole different group. CPM training, like CNM training, requires both classroom and clinical experience, but with some key differences. First, CPMs are not required to have any nursing or healthcare experience or education. In fact, while some CPMs do attend a formal CPM school which lasts anywhere from one to three years, a CPM may have no formal education beyond a high school diploma. CPMs can gain certification, according to their certifying body, the North American Registry of Midwives, either through completion of a formal program (1-3 years of school, requiring a high school diploma) plus performing 10 deliveries, or through an apprenticeship pathway (observe 10 deliveries, assist with 20 deliveries, perform 25 deliveries). Both pathways also require a written certification exam. Let me say that again: you can become a certified professional midwife after performing only 10 deliveries. (Don’t believe me? Here it is in their applicant’s guide, page 12.) To put that in perspective, I performed 10 vaginal deliveries under supervision as a medical student. Does that mean that, once I graduated medical school, I should have been performing deliveries unsupervised and without backup? Absolutely not!

Image courtesy of wikimedia

A midwife doing a home prenatal care visit

Another difference between CNMs and CPMs is that CPMs do not require physician supervision or backup. In fact, CPMs do not have any supervision whatsoever. They typically do not adhere to the current standards of care with regard to recommended prenatal testing, vaccinations, etc. Because they have no physician backup, if something goes wrong, instead of picking up the phone and calling their on-call physician backup, CPMs have to call 911 and bring their patients to the Emergency Room.

CNMs also typically do not perform any sort of repair of vaginal or perineal lacerations after delivery. They do not have access to local anesthetics and are not trained in surgical repair techniques. If a woman experiences a severe laceration and the CPM recognizes it, the patient is brought to the Emergency Department. If a women experiences severe bleeding, the CPM does not have access to the medications or tools that are typically used to treat this, and again must bring the patient to the Emergency Department.

My midwife just says she is a “certified midwife” – what does that mean?

A “certified midwife” can be either a CPM or a CNM, so it is important to ask your midwife who she is certified by. Keep in mind that there are also other bodies that grant various certifications beyond the ones that I have mentioned here. It is important to know who supervises your midwife, if anyone, and what her emergency plan is in case something unexpected happens and you need to go to the hospital.

So why don’t doctors like midwives?

Most OB/GYN physicians are uncomfortable with CPMs. Why? As physicians, we unfortunately tend to see “unplanned hospital transfers” after things have gone badly wrong. when mother or baby may be in danger. We remember how good (or, rather, bad) we were at delivering infants after we had done only 10 deliveries. An OB/GYN physician must perform 200 vaginal deliveries during residency, not including forceps and vacuum deliveries. I performed over 200 deliveries in my first year of residency alone. I would not want someone who had only delivered ten infants to be responsible for the health and well-being of my infant.

After delivering that many infants, OB/GYN physicians have also, inevitably, seen a few cases where what looked like a totally normal labor became an emergency in seconds.

Army and Navy healthcare personnel practice obstetric emergency management, here they are doing a simulated emergency breech vaginal delivery

We have seen shoulder dystocias, where the infant’s shoulders get stuck during delivery. If not rapidly resolved using specialized maneuvers, this can lead to permanent neurologic injury or death of the infant. It happens in about 1% of births. OB/GYNs do simulation drills where we practice these maneuvers over and over, and we will take care of several patients with this problem during our training.

It’s true that the vast majority of vaginal deliveries are uncomplicated, but when that changes in an instant, we want someone with the knowledge, experience, and resources to intervene. 

CNMs, incidentally, do the same shoulder dystocia drills that physicians do, often with us, and have physician backup available in an emergency.

Ok, so why won’t CNM do my home birth?

Most CNMs, like most physicians, are not comfortable doing home births. Some CNMs do out-of-hospital births in birth centers with transport available to a hospital in case of emergency. The reason why most CNMs and most physicians won’t do a home birth is simple: we have delivered enough babies to know that sometimes you need an operating room, or a medication, or an ultrasound, and you can’t afford to wait. 

What if I still want a midwife?

I’ll say it again: I’m not anti-midwife. I am a firm believer in CNMs, especially in hospitals. CNMs allow patients to have the unmedicated, low-intervention birth that they want while having the safety of a hospital and physician backup. My own child was delivered by a CNM, in a hospital, without medications of any kind.

I am NOT anti-CNM.

I AM anti-CPM, because I don’t think that a high school diploma, a one-year course, and ten deliveries is enough for your to be responsible for my child’s life in a situation where there may not be any time to call for help.

So if you want a midwife and a low-intervention birth, go for it! Just be safe about it – choose a CNM with reliable physician backup, and a solid emergency plan in case something goes wrong. 

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