An Overview and Brief History of Midwifery in the United States
Under the perinatal umbrella, there are lots of different and essential roles. Today, I’d like to talk about out-of-hospital midwifery. As a doula, I have worked alongside midwives and learned so much from them! Midwives who are oriented toward Reproductive Justice are contributing to necessary changes in birth work.
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Types of Midwifery
First things first, midwifery is an area of healthcare that goes back generations and generations to community-based care. Today, most midwives come to this work through formal education, though practices and laws around midwifery where I live in the US vary from state to state, so take the time to learn the specific guidelines where you live. As the next section outlines, these laws have DEEP roots in racism and industrialization. It’s important to understand that Black Granny midwives deserve credit for the gifts of this work.
There are 5 types of midwives that we see most commonly in the United States. Each type has a unique scope of practice and offers different services to birthing folks and newborns. (The info below is paraphrased using GraduateNursingEDU.org.)
Certified Nurse-Midwife (CNM): CNMs have completed a graduate-level nurse-midwife program and passed a certification exam from the American Midwifery Certification Board. They can offer perinatal healthcare, as well as well-visits for adolescents through seniors. All states license CNMs for independent practice.
Certified Midwife (CM): CMs have completed a graduate-level midwifery degree program and passed a certification exam from the American Midwifery Certification Board; they are not nurses. CMs can offer the same services as CNMs (see above). Laws surrounding practice privileges vary by state.
Certified Professional Midwife (CPM): CPMs have met requirements and are certified by North American Registry of Midwives (NARM). CPMs focus on perinatal health. Laws surrounding practice privileges vary by state.
Direct-Entry Midwife: Direct-entry midwives specialize in births at home and in free-standing birth centers. There is no nationally recognized certification or licensing for direct-entry midwives, though each Direct-Entry Midwife will have gone through a training program. Each state has its own legal requirements for education and licensing (if any).
Lay Midwife: These are uncertified or unlicensed midwives who often have an informal education, such as apprenticeship or self-study, rather than a formal education. It can be argued that lay midwives shaped the profession, with certification and licensure introduced in an attempt to wipe out the Black Granny Midwives.
This chart from The American College of Nurse-Midwives compares the scope of CNMs, CMs, and CPMs.
History of Black Granny Midwives
It’s crucial that we acknowledge both the racism involved in healthcare for pregnant and birthing people, AND the beautiful, important ways Black midwives paved the way for person-centered, community-based care. This section is an excerpt from my book, Birthing Liberation: How Reproductive Justice Can Set Us Free, Chapter 2: History of Race and Gynecology.
African women with generational knowledge about reproductive health and childbirth were among the slaves transported to North America. During the centuries of slavery, these women, also known as midwives, continued to pass down the knowledge and skills of midwifery. These African enslaved women had the responsibility of caring for not only the enslaved community but also the community of non-BIPOC slaveholders. These women also assisted with lactation, birth complications, and general care, and they were valued in their enslaved community.
When slavery ended, these women became known as Granny midwives. Although slavery was outlawed, Black people were still facing racism, discrimination, abuse, denial of care, and more. Granny midwives became the matriarchs in their communities, especially in southern and rural Black communities. At the same time that Granny midwives were continuing their work in the 1800s, healthcare was becoming more industrialized. This meant that physicians were now beginning to be more present and take a bigger stake in gynecology and obstetrics, especially with white upper- and middle-class patients’ experience of childbirth…
The traditional practices of Granny midwives typically reflect those of a lay midwife, an apprentice who learns from a practicing midwife, gaining hands-on knowledge rather than receiving credentials from a formal midwifery school. These laws had a major impact on Granny midwives, who in the 1940s were attending up to 70 percent of the births in their southeastern communities.
Only a few years later, Granny midwives ceased to exist, and Black birthing people now had to interact with the medical-industrial complex to receive care.
Navigating Midwifery Today
Because of the ways white supremacy framed midwifery care as “unsafe” through false accusations and because the medical industrial complex (MIC) has harmed both BIPOC care providers and BIPOC birthing folks, the reality is that being a midwife can be quite difficult these days. From barriers to opening birth centers, and regulations preventing operating out of the hospital setting, it can be a fight to do this work!
These are just a few examples of contemporary challenges in the field of midwifery leading to an overall shortage of providers under the midwifery model of care.
My friend and colleague, Dr. Stephanie Mitchell, the founder of Birth Sanctuary Gainesville has been working for years to open Alabama’s only midwifery owned, led, and operated freestanding birth center. Regulations proposed by physician-led boards of health have kept the center from opening. Read more here.
Medicaid programs do not pay midwives the same rates they pay doctors for performing the same services. This means midwifery care is less accessible, AND midwives face burnout due to low wages.
Current legislation doesn’t provide all CNMs and CMs with full practice privilege in many states. This is a major barrier that midwifery organizations are working to shift.
Midwifery preceptors and clinical sites do not have the same federal support that OBGYNs have, making teaching in this field extremely challenging and unappealing.
Looking to the Future
Working within the various institutions in order to move towards change can be challenging, by design. The fight can sometimes feel too monstrous for us to make a difference, but it is through communal efforts, funding the people doing the work, looking at systems already in place working against these institutions, and providing your support, rather than trying to reinvent the wheel, that will impact change. So, reach out to your community. Provide support where and when you can - whether that means providing financial support, supporting with your time, volunteering your services, advocating alongside, and raising awareness.
Katie Krebs, President of the Midwifery Education Accreditation Council (MEAC) Board of Directors and Executive Director of the National Midwifery Institute, a MEAC-accredited, Direct- Entry midwifery school, wrote an important piece about continuing education and its influence on maternal and infant mortality and morbidity on the BADT blog.
Additionally, check out this Midwifery Education Trends report from 2019 from the Accreditation Commission for Midwifery Education (ACME) and American College of Nurse-Midwives for more info about how “a robust and diverse workforce of midwives, educated through ACME-accredited midwifery education programs” can contribute to the maternal health crisis. There is so much change that is necessary to make this work sustainable, accessible (to prospective midwives and their future clients), and inclusive.