May 5 is International Day of the Midwife. May 6 begins National Nurses Week. This Friday, May 7th, 2021, our governor will sign a law allowing full practice authority for Certified Nurse Midwives in Arkansas.
This is a pretty exciting week for us midwives, nurses, and nurse-midwives!
It's also the perfect time to explain the different kinds of midwives and how to go about becoming a midwife.
How Do I Become a Midwife?
This is a question I am frequently asked. I begin my answer with a question: "What kind of midwife do you want to be?"
What kind of setting do you prefer--hospital, home, birth center? Do you want to be independent or part of a group? Do you want to prescribe medications or do you lean toward herbalism? Here's a quick rundown of the different kinds of midwives...
A Certified Nurse Midwife (CNM) has a degree in nursing and has completed a master's level program in nurse-midwifery. CNM training is hospital-based, and the majority of CNMs practice in a hospital setting, though they may also practice in a birth center or attend home births, depending on the laws of their state. They are licensed in all 50 states. Some states require a consulting agreement with an OB to provide intrapartum care and a collaborative agreement to prescribe medications, but Arkansas is finally joining the states allowing CNMs to practice independently. Of course, they will still collaborate with and refer out to OBs when needed.
Direct-entry midwives (DEM) are not required to be nurses before becoming midwives. Each state has its own legal requirement for educating and licensing these midwives, if any.
In some states, direct-entry midwives are unregulated. But most states require licensure to practice midwifery, many states require certification to become licensed, and a few prohibit midwives from attending home births. DEM may include any of the following:
A Certified Midwife (CM) has a degree in a health-related field other than nursing and then completes a master's level midwifery program. The hospital-based training is similar to a CNM, but they are not nurses.
A Certified Professional Midwife (CPM) is a certification issued by the North American Registry of Midwives (NARM). CPMs are trained and work primarily in out-of-hospital settings, either home births or birth centers. Certification is awarded after completing education requirements, experience providing prenatal/postpartum/newborn care and attending births under the supervision of an approved preceptor, and passing the national exam. Here is a map of states where CPMs are licensed to practice.
Licensed Midwives (LM or LLM) are granted a license to practice midwifery by their state after completing the education and experience requirements of their state. Some states require a certification (CPM) to become licensed, others do not.
Lay midwife or traditional midwife refers to an uncertified or unlicensed midwife who often has an informal education, such as apprenticeship under an experienced midwife or self-study, rather than a formal education.
Listen to the podcast by Evidence Based Birth “Evidence on Midwives.”
How does it work in Arkansas?
Arkansas allows both CNMs and DEMs with the CPM credential and licensure (LLM.) Currently, two hospitals--UAMS in Little Rock and Willow Creek Womens Hospital in Johnson--utilize CNMs for intrapartum care (catching babies.)
Update: as of March 2022, there is a CNM in Northwest Arkansas who attends home births: Eden Birth & Wellness.
There are approximately 30 LLM/CPMs attending home births.
Currently, there are no birth centers are open in the state.
As mentioned, Arkansas will now allow CNMs full practice authority, and CNMs will hopefully become more widely utilized by hospitals. It a CNM wants to attend home births, a transfer agreement with a hospital will be required.
You can start this path by getting a traditional 4-year Bachelor's Degree in Nursing. Or you can get an Associate's Degree in Nursing (about 2 years if you have some prerequisites) and work as a Registered Nurse and gain Labor & Delivery experience while working toward your BSN.
After that, you will apply to a nurse-midwifery program. Once you've graduated, you'll pass an exam to become licensed as an APRN and pass a certification exam to become a CNM.
Arkansas requires a license for DEMs to practice midwifery and requires the CPM credential to obtain licensure.
Here's more information about the requirements to become a CPM. Although many states are requiring education through a MEAC-accredited school for the educational component of the CPM, Arkansas currently does not require this. But you will have to obtain the eighteen referenced textbooks and study on your own for the NARM exam (see the requirements link above for the reading list.) This takes self-motivation and discipline.
I suggest starting by obtaining and reading the textbooks while you are waiting to be accepted by a preceptor. Finding a preceptor for the clinical part is challenging and often will take time and persistence. Of the approximately 30 licensed lay midwives in Arkansas, a handful are not attending births although licensed, and less than half currently train apprentices. Your preceptor must be registered with NARM for your clinical experiences to count.
The length of your apprenticeship will depend on the time it takes to complete the required number of births. The clinical component requires a minimum of two years, but most apprenticeships last much longer. My own apprenticeship lasted 4 1/2 years, and it felt pretty dang busy. I've known several apprentices who've taken 5-6 years to become licensed. But trust me, it's not something you'd want to rush through. You need time to become comfortable handling whatever you may be faced with at an out-of-hospital birth.
As far as I know, Arkansas is the only state to use the term "Licensed Lay Midwife" (LLM.) This is confusing to families who are looking for a lay/traditional midwife who is not licensed. Some families seek a midwife who is not bound by state rules and regulations to attend their births for a variety of reasons, often religious or philosophical. But in Arkansas it's illegal to practice midwifery without a license, and licensed midwives have rules we are required to follow, even though we are called licensed "lay" midwives.
There is a loophole in the law--"friends and family" who attend births without compensation are not counted as "practicing midwifery." So there are a few unlicensed traditional midwives attending births.
LLM/CPMs must also learn how to build and run a business. With no birth centers or hospitals hiring CPMs here, we are all self-employed. Being my own boss and having control over my caseload was a factor I considered in deciding whether to become a CPM rather than CNM. If running a business isn’t for you, if you want steady hours and a job you can clock in and out of, CNM may be the path for you.
Basically, there's no quick or easy or inexpensive way to become a midwife. Count on investing a chunk of time and money. Count on making plans including the phrase "unless I'm at a birth." Count on the stress from being on call 24/7 and the heavy responsibility wearing on your soul. Count on becoming reborn as a midwife. As with every birth, there is a transition phase, where you will think to yourself "I can't do this anymore." You will get through this with the same mindset as you would getting through an unmedicated birth. The midwifery practice that is born will become your baby and will require continuous nurturing until it matures.
My preceptor, Deb Phillips, says "you don't choose midwifery; midwifery chooses you." Many of us feel a persistent calling, and when we answer that call, it won't let us quit.
As Arkansas is recently making changes, I will be updating this post as I become aware of those changes. Do you know of more hospitals using CNMs or any CNMs practicing independently? Is there talk of another birth center opening? Leave a comment or shoot me a message!