How to Become a Midwife in the United States

May 6, 2019 Sarah Braun

In many countries, there is only one path to midwifery. In fact, in most western countries it’s a standard bachelor's-level degree and a straight shot toward becoming a midwife. You can go to college, choose midwifery, graduate, and get to work.

In the US, however, the path is far more confusing. There are many entry routes toward midwifery and the most obvious route requires you to become a nurse first. In countries like Canada and the UK, nursing and midwifery are separate paths. Closely related, but separate career tracks. In the US, it’s become all mixed together over the past century.

In many of my gatherings, classes, and friend groups, I’ve encountered people who really wanted to become a midwife. They often get hung up on the options for actually becoming one, though. It’s far too confusing and requires dedicated research to untangle and understand.

Some people become nurses, work a while, then realize they want to become a midwife. In that case, it is a relatively easy choice: just go get a master’s degree in nurse midwifery! For everyone else, the choice isn’t as simple.

After spending time explaining midwifery routes to several friends and struggling with the choice myself, I realized that there just isn’t enough information out there on specific pathways to midwifery. While I’d love to grab some tea with every person that wants me to explain the options available, it’s far more useful to just write it all out for any and every person who finds the path super confusing.

You’re not alone! It really is quite overwhelming.

If you’re scratching your head over why the US has such a weird path and other countries don’t, there’s a whole history lesson there that includes medical institutional suppression of midwifery. I plan to write another post entirely dedicated to the recent history of midwifery in general and specifically in the US. It’s quite the story! We’re still working hard to recover the profession in its complete manifestation in the US.

For those who are here to get right to the heart of becoming a midwife… let’s dive in, shall we?

Midwifery Practice Options in the US

There are four types of practicing midwives in the US. Understanding what those types are will help you better understand the pathways. They include:

Certified Nurse Midwife (CNM): A person who has first gone through nursing school and then gotten a master’s-level degree in midwifery and advanced practice nursing. This type of midwife can practice in the hospital and that is where the majority of CNMs work. Depending on state laws, they can also practice in birth centers and sometimes have their own home birth practices. CNMs have the legal authority to prescribe, giving them autonomy comparable to a nurse practitioner. They have legal status in all 50 states, plus US territories and Washington D.C.

Certified Midwife (CM): A person who has a bachelor’s degree in another field and then enters a master’s-level program that is a similar type of education to the CNM program. While CMs aren’t nursing-prepared, they end up with a comparable nursing-based education to CNMs. They are only licensed to practice in the states of Delaware, Missouri, New Jersey, New York, and Rhode Island, with the ability to prescribe only available in New York and Rhode Island.

Certified Professional Midwife (CPM): A person who goes through an apprenticeship-style training to become a midwife. Legislation varies from state to state for CPMs. Some states don’t allow these types of midwives to practice and other states are very welcoming. CPMs can only practice in home birth and birth center settings. Educational routes vary, from apprenticeship-only to MEAC-accredited schools that grant degrees in midwifery. CPMs must pass a comprehensive test administered by the North American Registry of Midwives (NARM) in order to claim to the CPM status.

Direct-Entry Midwife (DEM): A person who goes through a similar process as the CPM (typically apprenticeship-style) and chooses to not become certified through NARM. There are a number of reasons why someone would choose this path. From moral obligations, religious preferences, personal philosophies, or lack of access to resources and education options. Previous to regulatory bodies and institutional acceptance of midwifery, all midwives would have taken this route and could be classified this way today. DEMs only practice in home birth and some birth center settings.

Now that I’ve broken down the types of midwives, let’s deep dive into the educational routes that each of these pathways follow.

Educational Pathways: CNM

A CNM is a nurse-prepared midwife. This means that in order to become a CNM you’ll first need to become a nurse. This can be a challenge for some, as they might not have a nursing program available in their area. Nursing programs have become quite rigorous, as well, typically forcing students to stop or drastically reduce employment. This hurdle becomes very challenging for those with families or for those who can’t relocate to an area with a nursing school.

If you do have time and access to a quality nursing program, then this pathway might be a good choice for you. In nursing school, you’ll acquire a variety of medical and bedside nursing skills that will make you a well-rounded healthcare provider. That said, you’ll be studying all areas of medicine, not just maternal and child health care. This can be frustrating for some, even with the understanding that the knowledge is beneficial.

There are a few options for becoming an RN and then CNM. Here is a brief overview of the pathway choices.

1) ASSOCIATE’S DEGREE --> BRIDGE PROGRAM --> MSN

Become an associate degree-prepared RN, then apply for a master’s program that leads to a CNM and includes a “bridge” portion. These programs accept RNs without bachelor’s degrees and have them do a middle year to get them caught up to a bachelor degree level. Then students go on to do the 2+ year master’s program that will lead to becoming a CNM.

Two downsides of this pathway: It might be tricky to get a job as an RN with only an associate’s degree, as most hospitals have begun to require BSNs for new nurses. You might have to work at a job that doesn’t have anything to do with your future as a midwife. This has pros and cons - you’ll learn good bedside skills but won’t have direct experience in maternal/child health. The other downside is that only having an associate’s degree makes you less competitive when you apply to a graduate program. If your GPA is less than awesome, you might have to go ahead and get a bachelor’s degree to help you get accepted into a master’s program.

2) BSN AND THEN MSN (CNM)

Become a bachelor’s degree-prepared RN, then apply for a master’s program to become a CNM. There are three ways to get that BSN degree.

First do the associate’s RN program, then complete an RN-to-BSN program. (Typically the cheapest option.)
Complete a traditional 4-year BSN program at a college or university. (Average cost option - completely depends on the school you go to.)
If you already have another bachelor’s degree in something other than nursing, you can go to an accelerated BSN program that lasts anywhere from 9 months to 2 years. (Typically the most expensive option ranging in cost from $30K to $100K+.)

Once you have a bachelor’s degree and the RN credential, you’ll be free to apply to just about any graduate school in the country to get your Master of Science in Nursing (MSN) degree (which is the requirement in order to qualify as a CNM).

3) ACCELERATED RN-TO-CNM

Attend an accelerated “direct-entry” program that combines an RN or BSN program with a graduate program to become a CNM. This option is only available for those who have a bachelor’s degree in something other than nursing (i.e. art, psychology, basket weaving). It also tends to be the most expensive option. It’s not available in every state, so you would most likely need to move in order to attend this type of program.

That said, it’s the fastest way to become an advanced practice nurse (grad-level nurse). You’ll go from where you’re at now, to an RN, to a CNM in only 3 (intense!) years. Some programs even offer dual specialization, such as CNM plus FNP (family nurse practitioner). Students who have humanitarian interests or plan to work in remote/rural areas might find this combo intriguing.

Example Programs for These Options

Here are a few examples of how to build these pathways with some existing programs out there.

First, you’ll need to take all prerequisite classes that are required by the majority of programs. These classes tend to cover subjects like human anatomy and physiology, chemistry, statistics, microbiology, English, general biology, nutrition, lifespan development, general psychology. These classes can take a while to complete, so plan accordingly.

All times for program completion indicated below are for the program only. You’ll have to also factor in the years beforehand when you’ll be taking the necessary prerequisite classes.

Thoughts about Nursing and CNM Programs

As you can see, there are a ton of ways to become a CNM! Things are changing all the time, especially as more people are choosing midwifery and other advanced practice nursing specialties as a career change. Traditional nursing programs don’t work as well for people with other degrees and families to support. So nursing schools are getting creative and offering new entry points for non-nurses to get to practicing midwifery in a more streamlined way.

Things to consider about nursing school in general. It’s super intense! Many years ago, it was possible to take a nursing class here and there, eventually leading to an RN. These days, nursing programs have become cohort style. This means that the program is planned out from start to finish and you do the program with one group of people. Part-time programs are pretty rare, so if you want to become a nurse you’ll have to consider the intensity of it. You’ll be in nursing school full-time from day one until you’re finished.

The master’s level programs are far more flexible, however. Many of them are mostly online, with yearly week-long residencies where you travel to the school to practice skills. In general, graduate-level nursing programs are super flexible. This is because once someone becomes a nurse, they really need to practice their skills to keep them going. So grad programs want you to keep working during their program. They’re understanding of the needs of a working nurse.

Costs for nursing school can be a huge shock for some. It is expensive! I’ve heard from many, though, that it’s not something to worry too much about. Why? Because it’s pretty easy to find a full-time gig as a nurse and most areas pay their nurses pretty well. Hospitals also sometimes offer tuition reimbursement/repayment as a benefit perk, so you might get help in paying off those loans. If you’re also an advanced practice nurse, you’ll make a decent salary each year and will pay off those loans in no time.

You can also look into the Nurse Corps Scholarship Program. This unique program is government-funded and helps you to pay off your loans entirely. After you graduate from your nursing program, you will be selected to work at a Critical Shortage Facility for a set number of years. You’ll get a competitive salary plus a set amount of loans paid off or forgiven for each year you work. This is a great way to give back to a needy community while also setting yourself up financially strong.

One more thing to give consideration to when choosing a nursing program is to ensure that they are nationally and regionally accredited. Both types of accreditation are super important, especially as you begin to apply to graduate programs. Schools look to accreditation to ensure that you’ve been trained by a school that meets minimum standards of practice for nurses. Don’t waste your hard-earned money on a school that won’t serve you in the future.

You can sort through all the many nurse midwifery programs available in the United States. They’re available on the ACNM website here.

Educational Pathways: CM

The Certified Midwife is a relatively new midwifery entry pathway. While the idea of it is admirable and would make a full scope midwife credential available to more people, it’s unfortunately not taken off like some hoped. It’s limited to just Delaware, Missouri, New Jersey, New York, and Rhode Island, which means it’s a useless program for anyone who lives outside of these states or who might move out of these states at some point in their lives.

For those who live in those states and don’t plan to ever leave, it can be a great option for entry into midwifery. CMs are held to the same standards as CNMs and generally receive the same training. They are overseen by the same governing body as CNMs: the American College of Nurse-Midwives. That said, other states are beginning to recognize CMs, so stay tuned as they grow in popularity.

Generally, everything mentioned above regarding CNMs also applies to CMs. Minus all the nursing school stuff. The nursing worldview is still very much a part of the CM program, however. You’ll still be expected to be able to “do” nursing after completing a CM program.

I’m not going to go into too much depth on this option since it’s really not that accessible to most Americans. It seems that the general perception for this pathway is that it needs to be expanded throughout the country. But until it’s reached that level of acceptance, it’s probably better job security to choose the CNM route.

Here’s a sample program at the Thomas Jefferson University that can lead to either a CNM or a CM credential. Check it out here.

Educational Pathways: CPM

The CPM is a newer credential that’s been added to a very old midwifery tradition. CPMs are direct-entry midwives who have done the extra work to be nationally recognized as having completed certain benchmarks and as having in-depth midwifery knowledge. Being a CPM doesn’t necessarily mean that this type of midwife is “better” than a direct-entry midwife without the credential. It just offers a recognition of achievement and standardized knowledge that is considered respectable in our modern world.

The path of the midwife has been a path of apprenticeship for thousands of years, as is the case with many professions that have since become regulated and standardized. Midwifery was pushed out of American society during the turn of the century and we almost lost this ancient knowledge entirely. Thanks to nurse midwives, midwifery was able to slowly become established in hospitals alongside OB/GYNs. There’s still a long way to go in normalizing midwifery in hospitals (especially when compared with our UK and Canadian friends), but thankfully it’s gaining traction.

The CPM-style of midwifery came about as a way to reclaim and revive the traditional ways of caring for those who are pregnant and giving birth. As the hospital became more medicalized and interventions leading to traumatic outcomes became more common, a group of wannabe midwives decided to change things. So the apprenticeship style of midwifery was reestablished once again.

** Just a quick anti-racist note to say that in many Black communities, midwifery hung on into the 1970s when the medical establishment finally shut it down entirely. “Granny midwives” cared for pregnant women and their babies for centuries with incredible skill. This community has some amazing activists and midwives who are reviving their traditions and working to help end high maternal death rates in their communities. Read a brief piece of their history here. Learn more about several inspiring Black midwives here. **

CPMs are legal in some states, looked down on in many states, and welcomed in other states. (You can see how your state shapes up here.)They don’t have prescriptive authority in any state, so they’re restricted to holistic health practices. However, in many states they are allowed to carry and administer a small amount of drugs used to stop hemorrhages (such as Pitocin). Many states allow them to also do well-women/person care, meaning pap smears and breast exams. Some states also allow CPMs to bill insurance and get reimbursed through Medicaid, but not all (and sometimes the types of insurance allowed is pretty restricted).

You’ll want to do some research to find out what kinds of opportunities and restrictions exist in your state.

There are three specific ways to become a CPM in the US. Here are your options for this pathway.

1) APPRENTICESHIP

You’ll find a CPM in your area to apprentice with over a period of years. It doesn’t have to be just one person, either. In fact, while it’s nice to have an “anchor” preceptor to learn from, it’s also important to have a well-rounded educational experience. That means learning from several different midwives so you can ensure to fill in any “gaps” you might have in your education. It’s also just generally nice to see the various ways that different midwives do things so you can figure out how you want to do things once you’re a midwife.

Throughout this process, you’ll want to keep on top of your paperwork. By doing 100% apprenticeship as your path to learning, you’ll qualify for the Portfolio Evaluation Process (PEP). This means that as you complete specific skills and your required birth attendance, you’ll have your preceptor (midwifery mentor) sign off on your paperwork. This guarantees that you get credit for what you’ve completed so you can complete the process in a timely manner.

Once you have completed all the requirements in order to qualify for the NARM exam, you’ll be able to send in your paperwork to prove that you’re ready to become a CPM. After passing the test, you’ll earn the credential.

2) APPRENTICESHIP + NON MEAC-ACCREDITED MIDWIFERY SCHOOL

This is the same process as the option above, but with the addition of education from a school. In this pathway, you’ll complete education either in-person or via distance/online classes. For this option, the school will not be accredited by Midwifery Education Accreditation Council (MEAC - the national accreditation body that regulates CPM-oriented midwifery schools).

By graduating from a midwifery school and completing the apprenticeship, you will again qualify for the PEP process mentioned above. Between your preceptor(s) and school, you’ll be able to be signed off on skills and birth as needed in order to take the NARM exam to become a CPM.

One example school for this pathway is the Indie Birth Midwifery School.

3) APPRENTICESHIP + MEAC-ACCREDITED MIDWIFERY SCHOOL

This option is the same as the one above, except that you will attend a school accredited by MEAC. The difference is that after graduation, you wouldn’t be required to go through the PEP paperwork process. You’d immediately qualify to take the NARM exam.

Just like non-accredited schools, MEAC-accredited schools can be in-person (such as Birthingway School of Midwifery), low residency (such as the community option at Birthwise Midwifery School), or entirely online (such as the National Midwifery Institute). All educational pathways must include apprenticeship so that you can experience enough births to qualify as a midwife. The choice comes down to preference, accessibility, and good fit with the school.

You can find a full list of MEAC-accredited schools on their website here.

Also a quick note to mention that California has extra requirements for CPM-pathway students. Make sure to check that out here if you plan to practice there.

Thoughts About the CPM Pathway

Becoming a homebirth midwife isn’t for everyone. But it’s a really special tradition that has been reclaimed and preserved because of tireless work on the part of activists and rogue midwives. Not everyone feels comfortable giving birth or receiving well-person care in hospital/clinical environments. Home and home-like environments are where many feel the most safe and cared for.

As a homebirth midwife, you’ll live a life of being almost constantly on call. If you have a solo practice, you might not have others to spell you off during a long birth or a series of long births. (Though having a backup or partner midwife is the ideal scenario.) This type of work is exhausting and disruptive to daily life. But you also get to spend uninterrupted, unhurried time with each client. You get to stay through each birth and get to know your clients very well. You aren’t subject to hospital shift changes or protocols that aren’t evidence based.

Of course, CPMs are limited by state laws and in some states they’re still even illegal. You’ll need to do thorough research on the place where you live and how your practice will be regulated. Having a good peer review group, deep bonds with other midwives, and a team to back you up can be good measures to help avoid burnout.

OTHER CONSIDERATIONS

Not all apprenticeship models are the same and if you can be choosy, go for it. Some midwives will charge you for the apprenticeship and others will see you as a birth assistant they don’t have to pay in exchange for your training. Others still might have entirely different arrangements. If you attend a school, part of your tuition might go to the midwives you apprentice with, helping to manage that on your behalf. You’ll be responsible for figuring out how to make it all happen, however.

Also, not all schools will be of excellent quality. Do your research and search out student reviews before signing up. Some schools operate under a specific philosophy or moral worldview. Make sure it fits the kind of training you’re after.

It’s also important to understand that the majority of midwifery schools (even the MEAC accredited schools) aren’t typically regionally accredited. This means that it’s highly unlikely that your credits from these schools would transfer to your local college or university. You can think of these schools as trade schools similar to stand alone massage therapy schools and other holistic health institutions. They do a great job at training you to do what they were created for, but they operate outside the accepted realms of “academia” as we know it in the US.

Educational Pathways: Traditional Midwifery

A Traditional Midwife is similar to a CPM, but these midwives choose not to pursue national certification through NARM. This was once the only option for midwifery practice in the US (and the world).

Traditional midwives typically take the traditional route of apprenticeship-style training, often devoting themselves to lots of hands-on work with a midwife or many midwives over several years. Some also do supplementary education, either through an in-person educational program, online/distance schooling, or several intensive trainings. They complete similar education to choices 1 and 2 in the above description for CPM pathways. The difference is that they don’t complete the NARM requirements.

Those who choose this path have a variety of reasons for doing so. Being licensed in any field comes with legal restrictions. Some midwives don’t want to be restricted from supporting their clients in ways that aren’t necessarily evidence-based. Others want to integrate other practices into their service offerings that might conflict with state regulations, such as spiritual or religious practices. Others might simply just not appreciate the appearance of government meddling or the paperwork and fees required to get and stay licensed.

It’s important to understand that there are amazing traditional midwives, CPMs, and CNMs out there and there are some that cause trauma or stray into unethical territory. The qualification type doesn’t say what kind of person that midwife is. It’s crucial to decide what kind of person you want to be in the role as midwife and then work to become that person, regardless of your training and certification path.

How to Decide Which Midwifery Path to Take

There are a number of things to consider when deciding which midwifery path is for you. Some people might read through the options above and immediately know which one works best for them. Others might see the virtues of each path and struggle to figure out which one to choose. Others still might choose one path to begin their training and then continue on to also train in the other path. All types of midwives bring different skills, perspective, traditions, and innovations to the table. All are needed and important.

For those who can’t seem to figure it out, take heart. Midwifery is a calling, not just a job. Since it’s heart work, it’s supposed to take time to figure out. There’s no race to the finish line and the process can be just as beautiful as the destination. Be as ambitious as you need to be, or allow things to unfold organically. Do what works for you.

Here are a few things to consider as you’re making your decision.

1) MAKE SURE YOU ACTUALLY ENJOY BIRTH AND REPRODUCTIVE HEALTH.

While the idea of birth is alluring, the reality can be far more overwhelming. The stress of responsibility for a mother and baby’s life can be intense. Staying up on necessary emergency skills takes time and investment. Births can last several days and you might get very little sleep during that time. You might have to miss your child’s birthday party or pay fees for missing a dental appointment. Your ability to commit to things won’t be as firm as it was in the past.

Do some low-cost direct-entry trainings first. Become a doula and get some experience with birth and being on call. Try out a CNA training to get a taste of the nursing world and develop some basic medical skills that will be useful in both home and hospital.

You might find that you’d rather support birth in a non on-call way (such as becoming an herbalist or perinatal-focused massage therapist). Or you might discover that you really love being a doula and would rather give emotional and physical support to a laboring person and avoid the stress of medical responsibility. You might also realize that midwifery is really where you belong, and this conviction will help you make it through all the intense training.

2) DECIDE IF YOU ENJOY OR CAN TOLERATE THE HOSPITAL ENVIRONMENT.

Lots of birth activists are joining the CNM ranks so they can create better conditions for people in hospitals. CNMs are creating a ton of change in the hospital environment, which is where the overwhelming majority of people give birth. They’re able to offer full medical insurance coverage and subsidies, giving compassionate midwifery care to people in need. They’re able to meet people where they’re at and bring all the good qualities of care to these people.

That said, hospitals can be challenging places to work. They often have strict policies that aren’t always based on evidence. Hospitals are hierarchical systems and CNMs don’t have as much power in some states as they do in others. Outside of the hospital, clinic environments can be more relaxed and provide more patient-provider time. But most CNMs that work in clinics aren’t catching babies, but are instead focused on reproductive health.

Many states will allow CNMs to practice as homebirth midwives, but the CNM training doesn’t often include exposure to home environments, which leaves some CNMs feeling inadequately prepared. (The only exception I’ve heard mentioned often is Frontier University’s program, which encourages students to take on preceptorships at birth centers.)

As mentioned above, it would be a good idea to take a CNA training and get some experience doing clinicals in a hospital-based environment. You’ll get a taste for the hierarchical experience, medical skills, and further training. If you get certified and work your way into a hospital maternity unit, even better. The more exposure you can have to help you make the decision, the better.

3) DECIDE IF YOU’RE CUT OUT FOR RUNNING YOUR OWN BUSINESS.

When you choose to become a CPM, you’re generally choosing to run your own business. Yes, it is possible to work for birth centers with a team of midwives. But the majority of midwives work for themselves.

You might love the freedom of this. Or you might feel overwhelmed by the idea of not having a regular, guaranteed paycheck. If you just don’t feel like you’re willing to learn the skills necessary to run your own business, the CNM route might be the better choice for you.

Running your own business means paying for your own health insurance, liability and malpractice insurance, hiring a lawyer to help draft legal documents and represent you if necessary, dealing with contracts, doing bookkeeping and chasing down money, doing marketing and website maintenance, doing outreach in the community to get clients, and so much more.

The biggest benefit of running your own business is the flexibility. You’re your own boss, so you get to determine how many clients you take per month, when you want to take time off, sneak in a nap or shower whenever it works, take up a new craft during the day, and so on.

The drawback is the loneliness. When you’re not on a team, you won’t have anyone else to bounce things off of. This is why it’s super important to build a community of good midwife friends around you. Participate in peer reviews so you can improve your skills. Get coffee and break bread with other midwives. When it’s 3 in the morning and you’re worried about a client, your midwife friends will be there to help through text or in person. Build your community.

4) DETERMINE IF PRESCRIPTIVE AUTHORITY IS SOMETHING YOU WANT.

CPMs are not legally allowed to prescribe drugs. CNMs are allowed to do this. When a client has a urinary tract infection that could be easily cleared up with antibiotics, you might find yourself wishing for the ability to call that in for them.

If you’re okay with not being able to do that, it might be a good idea to make friends with a CNM, NP, DO, or MD who appreciates your work and is willing to be that person. Find ways to support your clients, even through your limitations.

If you feel called to do full spectrum work, the CNM route might be best because of the prescriptive ability. Abortion is highly politicized in our country, so everyone faces limitations in that scope of work. Do your research on what is legal in your state and decide how you can best support. Perhaps a side of doula work might be the best way to offer your midwife’s big-heart support. Stay safe, stay legal, and do what you feel called to do.

5) FIND YOUR WHY AND KNOW YOUR OWN PERSONAL NEEDS.

It’s a good idea to do a lot of reading and personal growth when deciding which path to pursue. There are a million amazing books out there about birth, reproductive health, loss, doula work, midwifery, and so on. Read as much as you can so that you understand the scope of the work and the joys and sorrows of midwifery and birth work.

It’s also a good idea to dig deep inside yourself to find what you feel you are called to support. Midwifery is a standard profession, but every midwife brings a unique perspective, specialty, gift, and worldview to their midwifery work. No two midwives do things the exact same way.

What population of people do you really want to work with? Is there a cause or issue you feel especially passionate about? Are you willing and able to relocate to another area to be able to work on that issue?

Another aspect of personal growth is healing your own trauma and wounds. Often, people are drawn to birth work because of a traumatic birth. This is a great origin story to help propel you into the work. However, it could be triggering for you to be around births and you could inadvertently project your own trauma on your clients. Take the time to work with a therapist in order to unravel your wounds and heal them. Then you might be able to make a choice on the path to midwifery with fresh eyes.

Final Thoughts

Midwifery is a very old profession, going back thousands of years. It’s been through some rough times. But it’s still here, trying to thrive and preserving the traditions of our ancestors. I think it will always exist in some form or another. Giving birth and losing a baby are transformative moments in our lives and we need someone by our sides to help guide and support us. Future midwives might have different names or the profession might transform into something new. But we all need support during those crucial moments of our lives.

Feel free to reach out with questions and I’d be happy to point you to whatever resources I can. Cheers to your midwifery path!

Rewild Mothers