BIRTH PLANNING: QUESTIONS TO ASK HOMEBIRTH MIDWIVES
While Betty Ann Daviss and Kenneth C. Johnson on planned homebirths with midwives in North America and Canada.(BMJ 2005;330:1416) study concluded that childbirth at home is safe, out-of-hospital birth is not for everyone. Mothers choosing homebirth must live a healthy lifestyle and have had a normal pregnancy. Birth at home is safe when there is skilled attendant present (midwife or doctor), the mother is in good health, the pregnancy and course of labor has been normal, and there is a plan for medical interface if necessary. Also the laboring woman and all persons attending the birth should be comfortable with the out of hospital option. Comfort with this option is essential for safe and normal birthing. We do recommend planned homebirth with skilled midwives, but we do not endorse or recommend unplanned homebirth or unassisted homebirth.
But first, some helpful terminology:
Certified Nurse Midwife – Trained in both midwifery and nursing, CNMs provide care during pregnancy and management of normal childbirth and postpartum. They also provide well-woman gynecology care throughout a woman’s lifetime, menarche to menopause. 98% of Nurse-Midwives work in hospital settings. A few provide homebirth and birth center care.
Direct Entry Midwife – refers to midwives who are not trained in nursing, who learned through apprenticeship and/or special schooling or university-based education. They may be licensed or certified. 98% offer homebirth services. A few offer birth center care. Very few have privileges at hospitals; those that do, are Certified Midwives, working in New York or New Jersey. There are three categories of Direct-Entry Midwives. They include:
1) Certified Professional Midwives (CPMs) – have met clinical and didactic requirements established by the North American Registry of Midwives (NARM) and have passed their certification exam or are graduates of midwifery programs which meet NARM standards.* They may also be licensed or registered in the jurisdiction in which they practice. The CPM credential alone is not recognized as legal for practice in California. CPMs must become licensed by the California Medical Board to practice legally in the state.
2) Certified Midwives (CMs) – have met academic and clinical requirements established by the American College of Nurse Midwives (ACNM): university-based education equivalent to that received by Certified Nurse Midwives, and have taken the certifying examination of the ACNM. Only New York and New Jersey recognize this credential and have a mechanism for licensure. Most CMs practice in hospitals in New York or New Jersey. It is not a legal credential in California.
3) Licensed Midwives (LMs) – are legally recognized in the state in which they practice and are regulated by an oversight agency. In California, LMs are licensed by the California Medical Board and practice out-of-hospital birth centers, in private homes and birth centers.
Primary Midwife – Conducts all aspects of prenatal care, births and postpartum and newborn care without supervision by a senior midwife. She is licensed and/or certified. She is has met all requirements for licensure or certification as a Licensed Midwife (LM) or Certified Nurse-Midwife (CNM), Certified Professional Midwife (CPM) or Certified Midwife (CM). Please note: in California, only the California, Florida or Washington Licensed Midwife and ACNM-Certified Nurse-Midwife credentials are legally valid.
Student Nurse-Midwife or Student Midwife– is enrolled in a Nurse-Midwifery program of study pursuing requirements to become a Certified Nurse-Midwife (CNM) who is participating in supervised clinical training with a Certified Nurse-Midwife preceptor and is a Registered Nurse enrolled in a Nurse-Midwife education program. A Student midwife pursuing the Licensed Midwife credential in California is participating in or enrolled in a California Medical Board approved midwifery training program or challenge process (which means she is already a Certified Professional Midwife). She is a “bona fide student who is enrolled in a program of supervised clinical training” approved by the California Medical Board. The supervising midwife must be a California Licensed Midwife whose license is free and clear of any restrictions and has been in practice a minimum of two years. All care of mothers and infants by students must be conducted in the physical presence of the Licensed Midwife at all times,. Furthermore, the students status must be made known to the client. The California Medical Board , who regulates the practice of Licensed Midwifery, does not consider apprenticeship a legal or viable option. Students must be officially enrolled in an approved midwifery school with a school-approved preceptor (supervising midwife).
Primary Midwife Under Supervision/Student Nurse-Midwife – Is a student midwife pursuing the CPM or LM or CNM credential who is in the final stage of her training, conducting all aspects of maternity care under supervision of a clinical preceptor. The student midwife is training under supervision of an LM, while obtaining her required experiences for licensure. She is either a student of a nurse-midwifery program (if this is the case her preceptor would be a CNM), or pursuing licensure as a Licensed Midwife in California enrolled and/or participating in a California Medical Board approved midwifery training program; enrolled in a program of supervised clinical training with a California Licensed Midwife whose license is free and clear of any restrictions. The Clinical Supervising Midwife must be physically present at all times when care is being conducted by the student, and the students status must be made known to the client. The student in this phase of her training conducts all aspects of care of mothers and newborns including prenatal and postpartum exams, newborn exams, well woman gynecology exams and labor managements under direct physical presence and supervision of a Primary Midwife (Licensed Midwife). The California Medical Board, who regulates the practice of Licensed Midwifery, does not consider apprenticeship a legal or viable option, thus students must be officially enrolled in an approved midwifery school with a school-approved preceptor (supervising midwife).
Midwife’s Assistant – Is not enrolled in a midwifery training program and is not an apprentice or student enrolled in a program of supervised clinical instruction with a Licensed Midwife or Nurse-Midwife or Certified Midwife. The Midwife Assistant assists the Primary Midwife with the care of mothers and infants under the physical supervision of the Nurse-Midwife or Licensed Midwife. The Midwife Assistant’s duties include conducting non-midwifery tasks such as set up and clean up, sterilization of instruments and changing of bed linens, etc. If she is a Registered Nurse or other licensed skilled health professional (such as a CNA, EMT, LVN), she may perform clinical tasks within the scope of practice of the license she holds. She does not provide any direct care to mothers or infants; rather her job is to assist the midwife in conducting care of her patients.
Here are some questions to ask the midwife you are considering:
- How many years experience do you have as a Primary Midwife (beyond your time as a student or apprentice)?
- How many births have you conducted as a Primary Midwife after your training period? (We recommend at least 40 births beyond the supervised births she obtained to obtain licensure or certification).
- What year did you begin your training and with whom did you study (or what school did you attend for how long?). It is required that student midwives pursuing the California Licensed Midwife designation attend a 3 year approved midwifery program, participated in or were enrolled in a program of supervised clinical training with a Licensed Midwife. (If she is a Certified Professional Midwife, she is required to participate in a one year program of supervised clinical training with a CPM preceptor or preceptors).
- How many births did you conduct during your training as a midwife? (The North American Registry of Midwives standards are as active participant, the candidate for CPM status must attend 20 births (as an assistant). Functioning in the role of primary midwife under supervision, the applicant for CPM status must attend a minimum of additional 20 births which must meet the following criteria:
- Minimum of 10 of the 20 attended as primary under supervision must be in homes or out of hospital settings
- Minimum of 3 of the 20 births attended as primary under supervision must be where applicant has provided primary care during at least 4 prenatal visits, birth, newborn exam and one postpartum exam (i.e. “with continuity”)
- In role of primary under supervision, how many prenatal exams, newborn exams and postpartum exams have you conducted, including well woman gynecology exams? North American Registry of Midwives standards for entry level midwives are:
- 75 prenatal exams, including 20 newborn exams
- 20 newborn exams
- 40 postpartum exam
- Are you licensed or certified? By what agencies? (CPMs are certified by North American Registry of Midwives, CNMs and CMs are accredited by the American College of Nurse Midwives. Licensed Midwives (LMs) are regulated by the California Medical Board. Nurse-Midwives (CNMs) are regulated by the California Board of Registered Nursing).
- How and where did you receive your education?
- Did you attend midwifery school or nursing school? For how many years? Did you graduate? Do you have a degree or certificate?
- Did you complete an apprenticeship? For how many years?
- Who was your clinical preceptor? Was she certified and/or licensed? How many births had she conducted when she trained you? Where did she receive her training?
- Where and for how long did you receive your supervised clinical training?
- How did you learn your midwifery academics?
- What is the month and year you received your license and/or certification?
- Is your license free and clear of any restrictions by the California Medical Board or Board of Registered Nursing? If not, what happened?
- Has any client filed a complaint against you? For what reason? Has the issue been resolved? And if so, what was the outcome?
- Do you carry malpractice insurance? if so, who is your insurance carrier?
- What physicians do you consult with or transfer care to in an emergency?
- What emergency equipment, experience and/or training do you have? (Safety requires CPR and neonatal resuscitation certification, IV and venipuncture certification, anti-hemorrhaging medicines, oxygen, suturing skills).
- Will your students be participating in my care? What is their level of experience?
- You may also wish to ask about the midwife’s reputation (from former clients, childbirth educators and doulas, other midwives, and doctors who work with the midwife).
It is wise to check out the midwife you are considering. You may wish to find out
whether any complaints or actions have been filed against her. To do so, contact:
The Medical Board of California Division of Midwifery Licensing
2005 Evergreen Street, Ste 1200, Sacramento, CA 95815
Web: California Medical Board-Division of Midwifery Licensing
(916) 263-2382 phone
(916) 263-2687 TDD
(916) 263-2944 fax
8:00 a.m. – 5:00 p.m. PST
If checking on the status of a Certified Professional Midwife, you can contact the North American Registry of Midwives (NARM) at: www.narm.org.
For Nurse-Midwives contact California Department of Consumer Affairs Board of Registred Nursing
Parents must choose their midwife carefully and understand what makes for safe midwifery. Take responsibility for the decision you make and realize no birth, be it in-hospital, or planned out-of-hospital, is without some degree of risk. Weigh the pros and cons and make an informed choice. As an expectant mother, you and your partner have a responsibility to educate yourselves and weigh the advantages and disadvantages of homebirth. Know that there are risks involved in all birth settings–both in-hospital and out-of-hospital. In a hospital you are at greater risk for side effect complications, and in a home birth, you will have less immediate access to emergency treatment. If you plan a homebirth, do not attempt to do it without a skilled birth attendant, as unassisted birth can be risky. Be certain that the midwife you choose is trained in emergency measures, and that you have a hospital transport plan, just in case. Make sure the midwife will bring the appropriate equipment to your home to stabilize you and your baby should an emergency occur until critical care can be obtained (such as oxygen, newborn resuscitation equipment, anti-hemorrhagic drugs, etc.).
Most of all, however, be sure you choose a midwife who will bring to your birth the most important skill of all: the sound judgment gained from years of experience and solid training. In planning a homebirth, you must be prepared for all eventualities. There are no guarantees your birth or baby will be perfect. No birth is without some degree of risk. Learn all that you can, and make informed choices. Most of all, be prepared to take responsibility for the decision you make. This way you can have a joyous and safe birth!
*Please note: the credentials CPM, CM or DEM are not a legally recognized in the state of California. California midwives must either be a CNM or LM to practice legally. However by saying this we do not imply that the presence of a license, or absence of one, guarantees safety; or the absence of a license means lack of expertise.