Types of Care Providers
What is a midwife?
- Are well-suited to care for healthy women who expect to have low-risk, uncomplicated births.
- Provide prenatal care, care during labor and birth, and care after the birth.
- Prioritize providing good information to women, involving women in decision-making and providing flexible, responsive care.
- Try to avoid unnecessary tests and treatments. In fact, women under the care of midwives are less likely to have a cesarean, an episiotomy and other interventions than women receiving care from doctors.
- May provide continuous support throughout labor and birth.
- Often encourage and provide a lot of information and support for breastfeeding.
- May have additional training and credentials for childbirth education, breastfeeding support and/or doula care.
Where do midwives practice?
Midwives attend births in many hospitals throughout the United States, and they attend most of the births that take place in out-of-hospital birth centers and homes.
Midwives attend about nine percent of births in the United States, or more than 360,000 every year. In 1975, midwives attended about one percent of U.S. births. The trend shows a steady increase in use of midwifery services over time. In contrast to the United States, midwives are the most common maternity care providers in many countries.
What types of training and education do midwives have?
The National Commission for Certifying Agencies accredits three national midwifery credentials:
Certified nurse-midwives (CNMs)
CNMs have training in both nursing and midwifery. They are registered nurses who have graduated from a nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education. They get “certified” when they pass an exam overseen by the American Midwifery Certification Board, and are licensed by their state to practice nurse-midwifery. All 50 states license CNMs, and most midwives who practice in the United States are CNMs.
CNMs are trained to provide prenatal care, care during labor and birth, and follow-up care to the mother and newborn after the birth. Most CNMs attend births in hospitals, but they also attend births in out-of-hospital birth centers and in women's homes. CNMs may also provide “well-woman” care, such as gynecological checkups, pelvic and breast exams, and pap smears, as well as family planning care.
CNMs may work within a midwifery-owned and led practice; in a practice with physicians; or as employees of hospitals, health plans or public agencies. In all cases, they have relationships with local physicians in case they need to work together to best support a woman or newborn.
Certified professional midwives (CPMs)
CPMs have passed the certification examination of the North American Registry of Midwives (NARM). They are educated in core content areas, have clinical experience working with childbearing women and newborns, demonstrate core skills, and have practice plans (including care guidelines and an emergency care plan). The NARM certification doesn’t require a midwife to be a nurse first. Most states in the United States license CPMs or legally recognize them in other ways. Efforts to regulate those holding this relatively new midwifery credential (since 1995) are under way in the remaining states.
CPMs provide prenatal care, care during labor and birth, and care of the new mother and her baby in the early weeks after birth. The CPM credential requires knowledge of and experience in out-of-hospital settings. CPMs attend births in women's homes or in out-of-hospital birth centers.
Certified midwives (CMs)
CMs are also relatively new maternity care professionals. Since 1997, the American Midwifery Certification Board has certified midwives who don’t have nursing training. Although not registered nurses, CMs are educated in both midwifery and other health-related skills and knowledge so that their education is similar to that of CNMs.
CMs graduate from an education program accredited by the Accreditation Council for Midwifery Education. CMs are "certified" when they pass the same exam that the American Midwifery Certification Board gives to certified nurse-midwives. The settings in which they practice and the care they provide are comparable to CNMs. CMs are licensed in New Jersey, New York and Rhode Island, and authorized to practice in Delaware and Missouri.
Other midwives offering home birth services do not have any of the above nationally recognized and standardized credentials, so it’s important to ask carefully about qualifications, experience and existing relationships with physicians before working with a midwife who is not a CNM, CPM or CM.
Where do physicians practice?
Nearly all physician-attended births in the United States are in hospitals. A small number of physicians attend births in out-of-hospital birth centers or in homes. They provide prenatal care and care after birth in office settings.
Physicians attend about nine in 10 of the births in the United States at this time. This proportion has been declining with the growth of midwifery care during the last quarter century.
What types of physicians provide maternity care?
Medical training for maternity care emphasizes expertise in identifying and managing risks and complications. For this reason, doctors who provide maternity care, and especially obstetric specialists, are optimal care providers for women with serious health problems or risks for such problems.
Because of this focus on problems, medical maternity care may emphasize physical concerns and give less attention to emotional matters or normal childbearing processes.
Because this is their perspective, doctors may recommend many tests and treatments for a healthy woman to be sure nothing is wrong, or in case a problem may arise. The role of the doctor may be to take charge by managing care and delivering the baby. Rules, restrictions and routines appropriate for women with serious health problems (or risks for such problems) may be applied to most women.
OB-GYNs are doctors who have special training in prenatal care, labor, birth, high-risk pregnancy and surgery. Most obstetricians also provide gynecological care and other health services to women. Many obstetrician-gynecologists retire from providing maternity in the middle of their career.
Obstetricians are well-suited to care for women with serious medical problems or who are at high risk for developing such problems. Many obstetricians approach birth as a medical event best managed by highly trained specialists. Obstetricians tend to have higher rates of interventions (such as cesareans and episiotomy) than family physicians and midwives, even when the health status and risk level of women is similar.
Providers who are “board-certified” in obstetrics and gynecology have received a medical degree (MD or DO) from an accredited school, completed at least four years of training and practice in an accredited obstetrics and gynecology residency program and passed an examination given by the American Board of Obstetrics and Gynecology. All 50 states license obstetricians.
A type of obstetrician known as a “maternal-fetal medicine specialist” is educated and trained to care for women with the most complex pregnancies.
Family physicians (FPs)
FPs are doctors who provide cradle-to-grave care to the whole family and approach care from a family-oriented perspective. They address needs and concerns relating to the whole body. This means that they can provide ongoing care for mothers, babies and other family members. FPs may combine both an obstetric style of maternity practice and a view of childbirth as an important family event and normal life process.
Roughly 15 percent of FPs attend births and some FPs provide prenatal and postpartum care but do not attend births They may work together with an obstetrician or refer to an obstetrician if a complication arises. Some FPs are trained in surgery and perform cesarean sections. A “board-certified” family physician has received a medical degree (MD or DO) from an accredited school, completed three years of training, practiced in an accredited family practice residency program and passed an examination given by the American Board of Family Medicine. All 50 states license family physicians. In some areas of the United States, FPs are crucial in providing access to maternity care.
Studies comparing practice styles of FPs to other maternity care providers have generally found that women using FPs are more likely than those using midwives, and less likely than those using obstetricians, to have common maternity interventions like a cesarean section, episiotomy and induced labor. However, practice style varies from person to person within each of these types of providers.