Where does the word “midwife” originate?

Middle English, meaning “with women,” or someone who assists in childbirth.

What is the historical context of midwives?

The practice of midwifery can be traced back to the Paleolithic era (40,000 BC). Traditionally, midwives were community members with experience caring for people during pregnancy, birth, and postpartum. The role was often viewed as a calling and a powerful role in indigenous communities.

In the nineteenth century, obstetrics and midwifery as professions evolved in Europe, with midwives focusing on normal birth and physicians on complications. In the United States, medicine began to incorporate childbirth by the early 20th century, and physicians actively opposed midwives who were prohibited from practicing without a means for formal licensure.

The United States saw a shift from most births occurring at home to most occurring in the hospital by the 1950s. Midwifery was rebranded as a nursing profession in the United States between the 1920s and 1950s. The American College of Nurse-Midwives (ACNM) was incorporated in 1955 as the professional organization for certified nurse-midwives (CNMs). CNMs first became licensed in Rhode Island in 1978.

How prevalent are modern-day midwives?

Midwives have slowly reintegrated into maternity care in the United States, attending about 12% of births in 2021. Worldwide, birth-related outcomes are best in regions where midwives greatly outnumber OB/GYNs. For example, there are about 4 midwives and 11 OB/GYNs per 1,000 live births in the U.S. compared to 66 midwives and 12 OB/GYNs per 1,000 live births in Sweden.

At Women & Infants Hospital, approximately 30 nurse-midwives work within several different practices, attending births for private groups and training residents in OB/GYN, Family Medicine, and Emergency Medicine, and medical students.

What is the education for certified nurse-midwives?

Most CNMs earn a bachelor’s degree followed by a master’s degree in nursing (MSN), specializing in nurse-midwifery. At a minimum, the pathway requires 2 to 3 years of graduate-level education. Some midwives go on to obtain a Doctor of Nursing Practice (DNP) or a PhD.

What types of care do nurse-midwives provide?

CNMs can independently provide care during pregnancy, childbirth, and postpartum; sexual and reproductive health; gynecologic health; family planning services; primary care from adolescence throughout the lifespan; and newborn care up to 28 days of life. Most CNMs choose to work within collaborative settings where they can readily consult or refer to physicians when medically indicated to offer the most comprehensive care. CNMs and OB/GYNs base their practices on the same scientific research, however, there may be a difference in philosophy and approach.

What are some benefits of seeking care with a midwife?

Midwifery is founded on person-centered care and empowerment of individuals; advocacy and shared decision-making; cultural safety; and promotion of pregnancy and birth as physiologic processes that benefit from non-intervention in the absence of complications. Midwives strive to provide a cocoon of safety and comfort surrounding what can be very intense and life-changing events. People sharing this perspective of normalcy surrounding pregnancy and birth may find their values align best with midwifery care. Others seek midwives for continuity of care, the power to make choices and participate in their own healthcare, and to feel heard. 

Midwives may care for people with certain medical complications, those undergoing induction of labor, and those opting for an epidural. However, midwives are specialists in supporting physiologic birth, or the naturally unfolding process of labor and birth without medical interventions. As such, people seeking a low-intervention birth benefit from midwifery care. For example, at Women & Infants, those admitted to the Alternative Birthing Center (ABC) experience an average vaginal birth rate of 96%, compared to a national spontaneous vaginal birth rate of about sixty-five percent. People choosing the ABC meet the criteria for medically low-risk pregnancies and plan labor and birth without anesthesia/epidural. 

Are there different types of midwives?

Certified nurse-midwives (CNMs) are the most prevalent among midwives in the U.S. Since the 1990s there exist other pathways to midwifery that do not require a nursing background; certified midwives (CMs) are credentialed through the same organization as CNMs, while certified professional midwives (CPMs) achieve credentialing and training through different professional organizations.

Where do midwives attend births?

Midwives can attend births in the hospital, at freestanding birth centers, or at home. In 2021, about 90% of births attended by midwives in the U.S. were attended by CNMs or CMs, and of these, 94% occurred in hospitals, 3% occurred in freestanding birth centers and 3% at home. Amongst CPM-attended births, which account for 10% of midwife-attended births in the U.S., a majority occur at home. In 2017, about 0.5% of births in RI occurred at home. As of 2023, RI does not have any freestanding birth centers, however, Women & Infants has the Alternative Birthing Center and is working toward an in-hospital accredited midwifery-led unit that follows birth center regulations, otherwise known as an Alongside Midwifery Unit (AMU).

When do midwives consult with or refer to obstetricians?

Most states allow independent midwifery practice. Facilities that employ midwives have practice guidelines that specify when providers should collaborate or refer care. A successful midwife and OB/GYN professional relationship is based on collaboration and trust and can provide supportive care, care access, and positive outcomes in inpatient settings. Within team-based care settings such as the academic practice at Women and Infants, a group of providers includes a CNM, an experienced OB/GYN, and first- through fourth-year resident OB/GYNs in training care for patients together. Within community practices, a midwife or physician may provide care for a person expecting a vaginal birth, and the midwife will consult with the physician if problems arise such as a need for a forceps-assisted birth or a cesarean section. Midwives are not surgeons; however, they may receive additional training to assist during cesarean births.

Where can I learn more?

This report by the National Partnership for Women and Families provides additional context for the state of midwifery in the United States and ways to support access to midwifery care. For more information, visit www.midwife.org.