Nurse-midwives are registered nurses with advanced training who assist in family planning, pregnancy, and childbirth. They also provide routine health care for women. Nurse-midwives work in hospitals, with physicians in private practice, in freestanding birth centers or well-woman care centers, in women’s clinics, and even in the homes of clients.
Nurse-Midwife Career History
Women have been giving birth by “natural” methods for thousands of years, since pain medication, hospitals, and medical intervention were largely unavailable until recent years. Women gave birth at home, guided by other women who were designated assistants, or midwives. Midwife means “with woman,” and early midwives, like today’s professional nurse-midwives, coached mothers-to-be through their pregnancy and labor. They helped women deliver their babies and taught new mothers how to care for their infants.
In the early 1900s, however, birth was transformed from a natural event into a technological marvel. New pain medications and medical procedures took birth into the 20th century, and childbearing moved from home to hospital. Back then, midwives practiced mainly in rural areas where doctors were unavailable, or where poorer women could not afford to deliver in a hospital.
Ironically, as these medically assisted births became more prevalent in America, professional midwifery became more regulated than it had been in the past. In the early 1920s, nurse Mary Breckenridge founded the Frontier Nursing Service in eastern Kentucky to bring medical services to people in areas too poor for hospitals, as well as to women who could not afford to have their babies delivered by a high-priced doctor. After completing her midwifery training in England, Breckenridge made prenatal care an additional focus of her service.
Midwife care around the world was proving itself to be both low in cost and high in quality. The Maternity Association and the Lobenstine Clinic (both in New York) established the first U.S. midwifery school and graduated its first class in 1933. In the mid-1930s, the Frontier Nursing Service opened its own nurse-midwifery school, and it remains today the oldest continuing U.S. midwifery program.
During the next few decades, most women who were able to deliver in a hospital preferred the lull of pain medication and the perceived safety of the medical establishment, and midwifery remained a tool of poor and rural women. Pregnancy and childbirth were considered medical procedures best left in the hands of obstetricians and gynecologists. Both the medical community and the public have generally frowned upon midwifery in favor of doctors and hospitals.
Since the 1960s, however, this attitude has been changing as more women insist on more natural methods of giving birth. In 1968, the American College of Nurse-Mid-wives (ACNM), the premier midwife organization in the United States, was established. This creation of a nationally standardized entity to regulate midwife training and practice introduced midwifery as a positive, healthy, and safe alternative to hospital births. The nurse-midwife, officially known as a certified nurse-midwife (CNM), has gradually become accepted as a respected member of the health care teams involved with family planning, pregnancy, and labor.
A number of studies have indicated that babies delivered by nurse-midwives are less likely to experience low birth weights and other health complications than babies delivered by physicians. In fact, a recent study from the National Center for Health Statistics, Centers for Disease Control and Prevention, indicates that the risk of death for the baby during birth was 19 percent lower for CNM-assisted deliveries than for physician-attended births.
The proven safety standards of births attended by nurse-midwives, the cost-effectiveness of a CNM-assisted pregnancy and labor, and the personal touch that many women get from their nurse-midwives will ensure that CNMs become vital links between traditional birthing practices and the high-tech worlds of today and tomorrow.
Nurse-Midwife Job Description
Nurse-midwives examine pregnant women and monitor the growth and development of fetuses. Typically a nurse-midwife is responsible for all phases of a normal pregnancy, including prenatal care, assisting during labor, and providing follow-up care. A nurse-midwife always works in consultation with a physician, who can be called upon should complications arise during pregnancy or childbirth. Nurse-midwives can provide emergency assistance to their patients while physicians are called. In most states, nurse-midwives are authorized to prescribe and administer medications. Many nurse-midwives provide the full spectrum of women’s health care, including regular gynecological exams and well-woman care.
Not all midwives are certified nurse-midwives. Most states recognize other categories of midwives, including direct-entry (or licensed) midwives, certified professional midwives, and lay (or empirical) midwives.
Direct-entry midwives are not required to be nurses in order to practice as midwives. They typically assist in home births or at birthing centers and are trained through a combination of formal education, apprenticeship, and self-education. Direct-entry midwives are legally recognized in 29 states that offer licensing, certification, or registration programs, and they perform most of the services of CNMs. Although they generally have professional relationships with physicians, hospitals, and laboratories to provide support and emergency services, few direct-entry midwives actually practice in medical centers. Direct-entry midwives can receive the certified midwife designation from the American College of Nurse-Midwives as a recognition of their professional abilities.
Certified professional midwives (CPMs) must meet the basic requirements of the North American Registry of Midwives (NARM). Potential CPMs must pass a written examination and an assessment of their skills, and they must have proven training assisting in out-of-hospital births. The NARM accepts various midwifery programs and practical apprenticeship as a basis for certification. For more information, visit http://narm.org/.
Lay midwives usually train by apprenticing with established midwives, although some may acquire formal education as well. Lay midwives are not certified or licensed, either because they lack the necessary experience and education or because they pursue nontraditional childbirth techniques. Many lay midwives practice only as part of religious communities or specific ethnic groups, and they typically assist only in home birth situations. Some states have made it illegal for lay midwives to charge for their services.
Since the education and certification standards for direct-entry midwives, certified professional midwives, and lay midwives vary from state to state, the rest of this article will deal only with certified nurse-midwives, who must complete a core nursing curriculum—as well as midwifery training—to become midwives. When the terms “nurse-midwife” and “midwife” are used in this article, certified nurse-midwife is implied.
Deborah Woolley has been a registered nurse since 1975 and has been practicing as a nurse-midwife since 1983. For Woolley, midwifery offered her the opportunity to have a positive impact on women’s health care and childbirth experiences. “I started out as a nurse assigned to the labor and delivery unit. But I became frustrated with the type of care the women were getting,” Woolley says. “You’ll find that a lot among midwives. Most of the midwives I talk to can point to an event that was the straw that broke the camel’s back, as it were—when they realized that they wanted to have more influence over the experience the woman is having. Midwifery’s focus is on improving conditions for women and their families. In a way, midwifery is a radical departure from the old way of looking at pregnancy.”
Woolley typically arrives at the hospital at 7:00 a.m. and spends the first hour or more seeing patients in post-partum—that is, women who have given birth the day or night before. At about 8:30 a.m., Woolley goes down to the clinic to begin seeing other patients. “I work a combination of full days and half-days during the week. On a half-day, I’ll see patients for four hours and work on paperwork for one hour. On a full day, I’ll see patients for eight hours and work on paperwork for two hours,” she says. “But that doesn’t mean I always leave exactly at five o’clock. At the clinic, we see everyone who shows up.”
After Woolley meets a new patient, she’ll spend an hour or so taking the patient’s medical history, examining her, and getting her scheduled into the prenatal care system. “I also ask about a patient’s life. I spend time with the patient and try to get to know her and what’s going on in her life. It makes a big difference in the care she’s provided. I think one of the things that makes midwives so effective is that they really get to know their patients.”
An important part of a nurse-midwife’s work is the education of patients. Nurse-midwives teach their patients about proper nutrition and fitness for healthy pregnancies and about different techniques for labor and delivery. Nurse-midwives also counsel their patients in the postpartum period about breast-feeding, parenting, and other areas concerning the health of mother and child. Nurse-midwives provide counseling on several other issues, including sexually transmitted diseases, spousal and child abuse, and social support networks. In some cases, this counseling may extend to family members of the soon-to-be or new mother, or even to older siblings of the family’s newest addition. Woolley believes that this education is one of a midwife’s key responsibilities. “I spend a lot of time teaching things like nutrition, the process of fetal development, and basic parenting skills. I’ll refer patients to Lamaze classes. I’ll also screen patients for family problems, such as violence in the home, and teach them how to get out of abusive situations,” Woolley says. “In other words, I’ll teach a patient anything she needs to know if she’s pregnant. I try to empower women to take charge of their own health care and their own lives.”
Apart from seeing patients, Woolley is also responsible for maintaining patient records. “I have to review lab results and ultrasounds and fill out birth certificates—things like that,” she says. “There’s a lot of writing involved, too. I have to document everything that I do with patients, including what I’ve done and how and why I’ve done it.” This may include recording patient information, filing documents and patient charts, doing research to find out why a woman is having a particular problem, and consulting with physicians and other medical personnel. Many midwives build close relationships with their patients and try to be available for their patients at any time of the day or night.
Nurse-Midwife Career Requirements
In high school, you should begin preparing for a career as a nurse-midwife by taking a broad range of college preparatory courses, with a focus on science classes. Anatomy, biology, and chemistry will give you solid background information for what you will be studying in college.
Additional classes in sociology and psychology will help you learn how to deal with a variety of patients from different ethnic and economic groups. English and business classes will teach you how to deal with the paperwork involved in any profession. Finally, you should consider learning foreign languages if you want to serve as a midwife to immigrant communities.
All CNMs begin their careers as registered nurses. The two most common ways to become a registered nurse are to get a bachelor’s degree in nursing from an accredited four-year program or to get an associate’s degree in nursing from an accredited two-year program. When you are choosing an undergraduate school to attend, however, keep in mind that a bachelor’s degree in nursing is required for entry into most certificate or graduate degree programs in nurse-midwifery. Bachelor’s degrees are also usually required for those who want to advance into supervisory or administrative positions or hold jobs in public health agencies.
After you have completed your undergraduate education and passed the licensing exam to become a registered nurse, you can apply to nurse-midwifery programs. There are 43 nurse-midwifery education programs in the United States that are accredited by the American College of Nurse-Midwives. Four of these are post-baccalaureate certificate programs. Thirty-nine are graduate programs. A certificate program typically requires nine to 12 months of study. Graduate programs that result in master’s degrees usually take 16 to 24 months to complete, and some also require one year of clinical experience in order to earn a nurse-midwife degree. In these programs, the prospective nurse-midwife is trained to provide primary care services, gynecological care, preconception and prenatal care, labor delivery and management, and postpartum and infant care. Doctorate degrees are typically required for those who want to work in top levels of administration, in research, or in education. These degrees normally take four to five years to complete.
Procedures that nurse-midwives are trained to perform include physical examinations, pap smears, and episiotomies. They may also repair incisions from cesarean sections, administer anesthesia, and prescribe medications. Nurse-midwives are trained to provide counseling on subjects such as nutrition, breastfeeding, and infant care. Nurse-midwives learn to provide both physical and emotional support to pregnant women and their families.
Certification or Licensing
After earning either a midwifery certificate from a nationally accredited nurse-midwifery program or a master’s degree in midwifery, midwives are required to take a national examination administered by the ACNM Certification Council. Upon passing the exam, the new midwife achieves full endorsement as a medical professional, as well as the title certified nurse-midwife. Those who have passed this examination are licensed to practice nurse-midwifery in all 50 states. Each state, however, has its own laws and regulations governing the activities and responsibilities of nurse-midwives.
All states and the District of Columbia require a license to practice nursing. To obtain a license, graduates of approved nursing schools must pass a national examination. Nurses may be licensed by more than one state. In some states, continuing education is a condition for license renewal. Different titles require different education and training levels.
If you are interested in becoming a nurse-midwife, you will need skills that aren’t necessarily taught in midwifery programs. Nurse-midwives need to enjoy working with people, learning about their patients’ needs, and helping them through a very important life change. They should be sympathetic to the needs of their patients. They need to be independent and able to accept responsibility for their actions and decisions. Strong observation skills are key, as nurse-midwives must be tuned into their patients’ needs during pregnancy and labor. Nurse-midwives also need to listen well and respond appropriately. They must communicate effectively with patients, family members, physicians, and other hospital staff, as well as insurance company personnel. Finally, nurse-midwives should be confident and composed, responding well in an emergency and keeping their patients calm.
Exploring Nurse-Midwife Career
Volunteer work at your local hospital or clinic may put you in contact with nurse-midwives who can help you learn more about midwifery. You might also volunteer to visit and offer emotional support to laboring mothers-to-be at a hospital or free-standing birth center.
You may wish to contact a professional midwifery organization for more information about the field. These associations often publish journals or newsletters to keep members informed of new issues in midwifery. The better-known organizations may have Web sites that can give you more information about midwifery in your area. A list of some organizations is at the end of this article.
Finally, young women may wish to see a nurse-midwife in lieu of a physician for their well-woman care. Although nurse-midwives are usually thought of in conjunction with pregnancy, many women use nursemidwives as their primary medical contact from their teenage years through menopause.
The American College of Nurse-Midwives reports it has about 7,000 members, of which approximately 6,200 are in clinical practice. More than half work primarily in an office or clinic environment, and physician practices and hospitals are the places where most CNMs are employed. At hospitals, CNMs see patients and attend deliveries on hospital grounds and use hospital-owned equipment for examinations and other procedures. Additional medical personnel are always available for emergency situations. Other nurse-midwives work in family planning clinics and other health care clinics and privately funded agencies. These nurse-midwives usually have relationships with specific hospitals and physicians in case of an emergency. Finally, some nurse-midwives operate their own clinics and birthing centers, while others work independently and specialize in home birth deliveries.
Deborah Woolley earned a bachelor’s degree in nursing and then began her career as a nurse at a labor and delivery unit in a Texas hospital. While working, she attended graduate school and earned a master’s degree in maternal child nursing. She then went to Chicago, where she began training as a nurse-midwife. “After earning my nurse-midwifery degree,” Woolley says, “I heard there were openings at Cook County Hospital [now called John Stroger Hospital] here in Chicago. So I applied for a job there. What I liked about Cook County was that they continued to train me while I was working. They gave me assertiveness training and training in urban health issues.”
Like Woolley, most nurse-midwives finish their formal education in nursing and midwifery before beginning work. They usually have some opportunities to work with patients as a student. Beginning midwives may also intern at a hospital or clinic to fulfill class requirements.
Nurse-midwives can begin their careers in various ways. Some may move from an internship to a full-time job when they complete their education requirements at a certain facility. Others may seek out a position through a professional midwifery organization or try for a job at a specific location that interests them. Finally, some nurse-midwives begin by working as nurses in other areas of health care and then move into midwifery as opportunities become available.
With experience, a nurse-midwife can advance into a supervisory role or into an administrative capacity at a hospital, family planning clinic, birthing center, or other facility. Many nurse-midwives, like Deborah Woolley, choose to continue their education and complete Ph.D. programs. With a doctorate, a nurse-midwife can do research or teaching. “I spent four-and-a-half years at Cook County while I was working on my Ph.D.,” Woolley says. “From there I was recruited to Colorado to head up the midwifery unit at a hospital there. After six years as a director in Colorado, I learned that the director’s position here at the University of Illinois-Chicago was open, and I jumped at the chance to come back to Chicago.”
Nurse-midwives with advanced degrees may choose to move away from the day-to-day patient care and write for journals or magazines. They may also lean more toward the research aspects of prenatal care and obstetrics. Finally, nurse-midwives may prefer to apply their experience and education as a midwife toward other areas of medicine or hospital administration.
Certified nurse-midwives who work for large hospitals tend to earn more than those working for small hospitals, clinics, and birthing centers. The most experienced nurse-midwives, including those in supervisory, director, and administrative positions, have the highest earnings. Salaries also vary according to the region of the country and whether the employing facility is private or public. Because of their special training, CNMs are among the higher-paying nursing professions. According to the U.S. Department of Labor, the median yearly income for all registered nurses was $53,640 in 2004. This median, however, may actually be closer to the starting salary for a certified nurse-midwife. http://nursemidwifejobs.com/, a division of the company Health Care Job Store that offers job placements to medical professionals, reports the average salary for a nurse-midwife was approximately $79,720 in 2005. For an example of what a nurse-midwife may earn working for the government, consider a May 2006 job posting from the Indian Health Service for a nurse-midwife to work in Aberdeen, South Dakota. The salary was listed in the GS-11 category, with the starting pay ranging from $61,589 to $75,499, depending on experience. Experienced CNMs in the private sector may earn $87,342 a year or more, according to Salary.com.
Nurse-midwives generally enjoy a good benefits package, although these too can vary widely depending on employer. Those working in hospitals or well-established clinics or birthing centers usually receive a full complement of benefits, including medical coverage, paid sick time, and holiday and vacation pay. They may also be able to work a more flexible schedule to accommodate family or personal obligations.
Nurse-midwives who work in hospitals or as part of a physician’s practice work indoors in clean, professional surroundings. Although most nurse-midwives perform checkups and routine visits alone with their patients, a number of other health care professionals are on hand in case the midwife has a question or needs assistance in an emergency. Nurse-midwives often consult with doctors, medical insurance representatives, and family members of their patients, as well as other midwives in order to determine the best care routine for the women they serve.
In a hospital, nurse-midwives usually wear professional clothing, a lab coat, and comfortable shoes to allow for plenty of running around during the day. They often wear hospital scrubs during delivery. In a free-standing birth center, the nurse-midwives may have a more casual dress code but still maintain a professional demeanor.
Midwives try to make their offices and birthing areas as calm and as reassuring as possible so their patients feel comfortable during checkups and delivery. Soft music may play in the background, or the waiting area may be decorated like a nursery and filled with parenting magazines.
Although most nurse-midwives work a 40-hour week, these hours may not reflect the typical nine-to-five day, since babies are delivered at all hours of the day and night. Many hospitals or clinics offer nurse-midwives a more flexible schedule in exchange for having them “on-call” for births.
Finally, although there are no gender requirements in the profession, nurse-midwifery is a field dominated by women. Approximately 98 percent of nurse-midwives in the United States are female. Women have traditionally helped each other through pregnancy and delivery. Just as women who became doctors 100 years ago had to overcome many barriers, men considering entering midwifery should be prepared for hurdles of their own.
Nurse-Midwife Career Outlook
The U.S. Department of Labor predicts employment for all registered nurses to grow faster than the average through 2014, and this should be especially true for specialists. As certified nurse-midwives gain a reputation as highly trained and compassionate professionals, they will become an integral part of the health care community. According to the National Center for Health Statistics, the number of births in the United States attended by midwives was more than 310,000 or 7 percent of all births in 2003. Currently, there are more positions than there are nurse-midwives to fill them.
There are two factors driving the demand for nurse-midwives. The first element is the growth of interest in natural childbearing techniques among women. The number of midwife-assisted births has risen dramatically since the 1970s. Some women have been attracted to midwifery because of studies that indicate natural childbirth is more healthful for mother and child than doctor-assisted childbirth. Other women have been attracted to midwifery because it emphasizes the participation of the entire family in prenatal care and labor.
The second factor in the growing demand for nurse-midwives is economic. As society moves toward managed care programs and the health care community emphasizes cost-effectiveness, midwifery should increase in popularity. This is because the care provided by nurse-midwives costs substantially less than the care provided by obstetricians and gynecologists. If the cost advantage of midwifery continues, more insurers and health maintenance organizations will probably direct patients to nurse-midwives for care.