There are two types of midwives available where I live in California. Direct entry midwives and certified nurse midwives, or CNMs. You may think that any midwife will offer care consistent with the midwifery model of care. Which is more conducive to a natural and enjoyable pregnancy and birth. Midwives are not all equal! Depending on the certification and title of the midwife, and their personal philosophy about birth, your experience could end up being quite similar to seeing an OBGYN, and not in a good way. Choosing a midwife who isn’t well-trained or qualified wouldn’t be best for you or baby either. So, how to choose?
Certified Nurse Midwives
CNMs are certified as nurses, as their title may suggest. They work in hospitals and birthing centers, and very rarely attend home-births.
Direct Entry Midwives
Direct entry midwives are trained through midwifery schools and apprenticeships. They are certified by a governing board such as the North American Registry of Midwives or the American Midwifery Certification Board. They may have the title of LM (licensed midwife), CPM (certified professional midwife), or CM (certified midwife). These types of midwives most commonly attend home-births or births in a birthing center.
There are also midwives who are trained through various means, but who choose not to become certified. This is often midwifery schools and apprenticeships. These midwives have the ability to operate outside the legal parameters placed on midwives. Which are considered by many to be unnecessarily limiting and not in the best interest of mothers and babies. For example, women who are considered “high-risk” by the medical community are unable to receive prenatal care or plan a home birth with a certified midwife. However, many reasons for classifying women as high risk are unwarranted, including having a higher-than-average BMI, carrying twins, or planning a vaginal birth after cesarean (VBAC). Traditional midwives may choose to serve these women, and/or may have other personal reasons for choosing to remain uncertified.
Many people who are wary of home-birth or midwives in general may gravitate towards CNMs, and midwife-assisted hospital births. Even a birthing center with CNMs may seem safer from this perspective. They have more formal medical training, as opposed to “normal birth” training. Because of their medical perspective, CNMs are more likely to medicalize birth instead of respecting the natural process.
LMs and traditional midwives are experienced in normal birth, so they expect birth to proceed safely and normally without the need for medical interventions. That being said, they are also well-trained in knowing when a birth moves outside the realm of “normal” and needs to be treated in a medical way. They are trained to refer care to an OBGYN or transfer to the hospital in cases where there is a need for medical interventions. Of course, there is always a level of subjectivity in these decisions, and that’s where individual style, philosophy, personality, training, and experience all become very important when choosing the right midwife for you.
With CNMs, care is often less personal than typical midwifery care, because patients will be assigned whichever midwife is on duty at the hospital or birthing center. In contrast, hiring a direct-entry or traditional midwife ensures that you will see that specific midwife for each and every prenatal visit, as well as during your birthing time. (In rare cases, a backup midwife will attend a birth when the midwife you hired isn’t available, but this is usually prevented by not over-booking clients).
Prenatal care can also be more strictly managed when working with CNMs. In hospitals and birth centers, there are protocols, procedures, and rules that patients are expected to follow. Care is not as personalized, and the family’s preferences and unique needs are not always considered.
Working with a LM, women are more likely to receive personalized care and feel in control of their own prenatal care. Midwives should accept care choices without judgement, and this has been my experience when working with LMs. That being said, there is still a lot of variety when it comes to individual midwives’ approaches to care. You should always ensure that your particular midwife is one who respects your choices.
In general, Certified Nurse Midwives are trained to “offer” specific tests and procedures during prenatal care. I say “offer” because in my experience, declining these procedures has not been met with acceptance or understanding. Blood panels and pelvic exams are expected, at pre-specified intervals. On the other hand, Licensed Midwives are much less likely to offer any pelvic exams during pregnancy. These exams are not evidence-based or beneficial, and may in fact be harmful (not to mention uncomfortable). They are also more likely to let you decline certain blood panels, or even all of them depending on your situation. Care is determined collaboratively, based on what each individual client wants and needs.
Home Birth Option
LMs also attend home-births, whereas CNMs rarely do so. Midwives bring all the same equipment to a home birth as would be available at a birth center, so it is equally safe. Home birth allows the family to be in a familiar and comfortable environment. It also eliminates the need to do anything after the birth other than settle in with the new baby.
If you are looking for a midwife who will treat your pregnancy and birth similarly to an OBGYN, I recommend choosing a CNM. But if you are looking for a midwife who will offer a more personalized, natural, and comfortable approach to your prenatal and birth care, then a direct-entry midwife or even a traditional midwife might be a better fit.
That being said, even within these distinct types, all midwives are individuals and offer their own unique approach to care. There are even rare OBGYNs who act more like midwives, discouraging unnecessary interventions and encouraging a natural birth process. That is why it is of the utmost importance to interview potential caregivers.
Ask questions about the issues that concern you. Ask about the midwife’s training, certification, and experience. If you might want to decline certain procedures, ask about that. Ask in what situations the midwife will transfer care to a hospital. Get to know their personality and care style, and take time to consider if it is a good fit for you. Interview several midwives before choosing one. Ultimately, the type of care you choose should feel right for you, whatever that may be. So choose wisely!
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