CNM or direct-entry midwife

jer_sd · Nov 5, 2007

I looked into both routes about 3 years ago before I found out as a male I would have a very difficult time finding preceptors....CNM can be licensed in all states, rx authority, more flexability in job options. They can do gyn, ob, both, home birth, hospital or birth center. CPM state license and certification more expensive, no rx in most states, limited to birthcenter or home births less option for career growth but can do gyn or ob. As a nurse CNM makes sense but being educated in another focus could be fun. If you are a CNM you can challenge the CPM relativly easily but it does not work the other way.....Jeremy

NeuroNP · Nov 5, 2007

Hello. I am trying to decide between a career as a CNM or a direct-entry midwife. I know there are some differences between the two and I was wondering if anyone can expand on this. I read that CNM spend a lot of time doing other things like GYN and often don't have time to spend w/ a laboring woman, (which I want to do). She basically just comes in to catch the baby. Also, I would like work in a birth center, but is it hard for a CNM to find work in a birth center? How often would CNM get to participate in labor and delivery if she has to also tend to non-pregnant women? I live in MD where direct-entry isn't legal, so based on your answers, I might have to consider moving. Thanks.

I don't really know much about this, but I know that a friend of mine recently had a baby and used a CNM and she spent a LOT of time with her during labor as well as doing the office visits. I was really impressed at the amount of time and attention my friend got from her CNM. She was in and out of the room all day in between seeing patients in her office and then after the office closed, she came and sat at the bedside until 10:00pm when she told my friend that labor wasn't progressing well enough and they needed to do a C-section. Even then, when her responsibilities were gone (the MD came in to do the section), the CNM went into the OR and took pictures for my friend and her husband. So, I'd say that as a CNM, you could probably do as much labor and delivery as you wanted.

beckinben, CNM · Nov 5, 2007

Hello. I am trying to decide between a career as a CNM or a direct-entry midwife. I know there are some differences between the two and I was wondering if anyone can expand on this. I read that CNM spend a lot of time doing other things like GYN and often don't have time to spend w/ a laboring woman, (which I want to do). She basically just comes in to catch the baby. Also, I would like work in a birth center, but is it hard for a CNM to find work in a birth center? How often would CNM get to participate in labor and delivery if she has to also tend to non-pregnant women? I live in MD where direct-entry isn't legal, so based on your answers, I might have to consider moving. Thanks.

Some CNMs do gyn care, some do not. There are CNM practices that do emphasize "labor sitting" where you really can be with the laboring woman during her labor instead of in clinic. There are other practices that are more OB-model where you are expected to see your people in clinic even if you have a laboring patient. It's on you to figure out what type of practice it is before you start working for them.

You also have to decide for yourself that you will go in to labor and delivery and do labor support when someone is in labor in the middle of the night instead of staying home in bed (which is what many OBs choose to do). I personally will labor sit for women who choose not to have an epidural, which is sadly not common in my practice. If they have an epidural, I won't go in until they are closer to delivery - if she's going to sleep through her labor, so am I. I still go in much sooner than the OBs.

There are CNMs who work in birth centers. Not as many as in hospitals, but it is possible. You might have to move to get a birth center job.

If you have questions about direct entry midwifery - I would suggest either the midwifery today forum or the mothering dot com forums. There are more direct entry midwives around on those forums to answer questions about their practices.

smallwonders07 · Nov 5, 2007

Thanks for the replies everyone. So you can choose whether or not you want to do gyn? Does it just depend on the hospital you work for? Why is it hard to find a job in a birth center as a CNM? Is it because the demand for them is low?

beckinben, CNM · Nov 6, 2007

Thanks for the replies everyone. So you can choose whether or not you want to do gyn? Does it just depend on the hospital you work for? Why is it hard to find a job in a birth center as a CNM? Is it because the demand for them is low?

You can choose to find a job where you only see OB patients. If the clinic does gyn care, you might have a harder time not seeing gyn patients. I honestly find the gyn patients I see to be very interesting and challenging and a nice change from hearing the aches and pains of pregnant women all day long. Not that I don't love my pregnant patients.

It can be harder to find a job at a birth center - there are many states with no birth centers, and many more with maybe only one or two birth centers. It is not really from lack of demand, but more that state and insurance issue can make running a birth center difficult or impossible. I have seen it is more difficult to get a job in a birth center without job experience as a CNM.

shauntaebrit · Nov 15, 2007

I am also planning on pursuing a CNM degree but the problem is I cannot find and school that I can go to after I complete my masters degree. I mean I will have my Associate in Nursing my bachelor degree in health administration and I will like to know what I will need to get my master in to go further to obtain CNM certificate. If anyone know of any school perferable in florida, I will be very thankful.

beckinben, CNM · Nov 15, 2007

I am also planning on pursuing a CNM degree but the problem is I cannot find and school that I can go to after I complete my masters degree. I mean I will have my Associate in Nursing my bachelor degree in health administration and I will like to know what I will need to get my master in to go further to obtain CNM certificate. If anyone know of any school perferable in florida, I will be very thankful.

I am a little confused. You have a ASN and a bachelors degree, but not a BSN. Do you have a masters degree in something or are you working on one?

Usually what people with a ASN do is either finish their BSN in one of the many RN to BSN programs, and then get a masters degree as part of their midwifery education, which would make you eligible for the CNM examination. Or you can find a school that offers an ASN-MSN bridge program with a midwifery program. You don't need to get a master's degree and then a "CNM certificate" - although some people who are already FNPs or other types of nurse practitioners sometimes can do that.

The best thing for you to do would be to look here - http://www.midwife.org/map.cfm - and find a school close to you. Call their advisor or the midwifery program director and ask what you need to do with your educational background to become a CNM.

Good luck!

EarthboundMare · Dec 9, 2007

i've practiced as a direct-entry midwife for the past 9 years. early on in my interest in midwifery i had decided to go for my cnm, mostly for the legality and salary. while i was taking my prerequisite classes i was also apprentincing with a dem as well as working as a doula with a cnm. overtime i saw that whereas the dem had her own protocols and could make individual variations for each woman's care, the cnm could not. she had a physician and hospital protocol to answer to. ultimately, i decided against the cnm route. i chose instead to apprentice with 2 different dem/cpm's and after 6 long years, i became a midwife in my own right. i stopped practicing about a year ago when my husband and i divorced. with children in the home and no one to care for them during those 3 am calls, i had to make the sacrifice. i have thought long and hard during my time off about that choice i made when i was young and green and full of ideals. i have thought about the cnm attended births i have been to in free standing birth centers and how home-like they were, how i approved of the decisions the midwives made. so, i have come full circle with midwifery and i am once again in school working towards my cnm. i like the idea of sharing call with other midwives, of having insurance and approved protocols to protect me in cases of liability, and most of all, i now have the confidence in myself as a midwife that i will be able to find like minded cnm's to work with and hopefully a great physician to support us. i have known a handful of truly great, open-minded ob's over the years so i knwo it can be done. i like the idea of taking medicaid...helping low income moms but still getting paid myself. in the dem world, no matter how strict you try to be there will always be that birth you attended for free, or bartered some babysitting for. and while that was fine for me, for many years, as an older, wiser, single parent...i now realize the value of not only serving, but being compensated for it.

[color=#2f4f4f]i hope that gives you some insight.

[color=#2f4f4f]as far as gyn goes, i always did once a year paps on my mom's, usually for years after they had their babies, also, birth control counseling, cervical cap fitting and breast exams.

[color=#2f4f4f]good luck in your decision making!

nizhoni · Dec 12, 2007

I am a registered nurse, ANCC-certified in perinatal nursing, and a licensed midwife in California. I've been attending homebirths as a direct-entry midwife for over 31 years.

Licensing laws for direct-entry midwives vary from state to state but are generally improving with each new state that passes midwifery legislation. Here in California I work with both CNMs and LMs. In this state, there is very little difference between the two except that CNMs have prescriptive authority and LMs do not (though of course LMs work with alternative health care modalities). California CNMs who are part of "an organized health care system" (hospital, clinic, etc.) may write prescriptions but if they are working outside such a system they are not supposed to do so. Essentially the scopes of practice for either LMs or CNMs attending homebirths are the same.

In my practice I provide full scope midwifery care and well-woman care, except for birth control requiring a prescription. We have arrangements among the midwives in our community to share coverage when needed. From my perspective, I traded the "sure thing" of a regular paycheck for the autonomy and satisfaction of having an independent midwifery practice. I have so much experience now with homebirths that I would be loathe to practice in a hospital setting even if I could get privileges. I supplement our income by working twice a week doing perinatal case management for a health plan. It's all very satisfying.

I have managed to make a midwifery practice work very well for three decades in spite of the fact that I've been a single parent twice and am now the sole wage earner in our family due to my husband's ill health. When my children were young, the daughter of the vet door would come and babysit for me when I had those middle-of-the-night maternity cases. (Their family understood "on call.") Some years later, I asked a college-age girl to live with us and provide child care in exchange for room and board and a small amount of spending money.

You can do midwifery effectively either way, CNM or direct-entry. But just as homebirth and hospital birth each have their advantages and disadvantages, so do both routes of entry into midwifery. If you would like to read a wonderful book that delineates both sides beautifully, get a copy of Catherine Taylor's book, "Giving Birth: a Journey into the World of Mothers and Midwives." It will help you decide. And this doesn't have to be about having money as a CNM vs. being a happy but impoverished direct-entry midwife. I am well acquainted with a few licensed midwives in my own community who are making six figure incomes, so it can be done, depending on where you are willing to live and how many births you wish to do each month.

PM me if you want more information.

All the best to you!

Marla

EarthboundMare · Dec 12, 2007

I agree with all that Marla has just said. I am in an illegal state, meaning DEM's are completely illegal. That does throw a different slant on things, especially where money is concerned.

When you are working semi-underground, for one, you are way more picky about who you will take on ( less clients, less money), also because I practiced in a poor, rural area, my fees were very low, though competitive with the other midwives in my state..for 2, there are less midwives, at least in my state, so taking call for eachother normally only happened occasionally, for well planned vacations and such.

I certainly didn't mean to sound negative about being a DEM, homebirth is where I am in my element. The idea of nursing school and the medical model is not an easy pill for me to swallow. I finally had to decide that serving mothers in a way that allows more personal benefit for me was the path I needed to follow. I will say if I was in a legal state, where I could get state licensure, work collaborativly with other midwives and docs in an open way, could take medical insurance, etc...there would be no choice to make. I apologize for not being clear about legal issues in my previous post.

My fantasy is to find a super great physician who just loves out of hospital birth (wink) and a few like minded CNM's and open a free standing birth center. Or possibly open a homebirth practice with another CNM and that same birth loving doc.

I will admit I am terrified of the protocols that I will have to adopt, I have made my own choices, based on each individual woman for years now. There's nothing I love more than VBAC's. This is a very diffiult choice for me. My sister midwives and I have battled legality in our state for soo many years...I don't like to feel like I am selling out. But I do have to provide for my family.

WOW that was a mouthful huh? lol... I look forward to the response

nizhoni · Dec 12, 2007

EarthboundMare,

It sounds like you have really looked at (and lived through!) the options available in your state. If I were in your situation, I absolutely would go for my CNM. I lived for 17 years in Utah. During most of my time there, direct-entry midwifery was not regulated but eventually, true to form, the "powers that be" determined that non-CNM midwifery was in reality the practice of medicine. We began the lengthy legislative process to create a licensure mechanism for midwives, which was successful in 2005. In the midst of that, our family moved to California and I became licensed here.

Life as a licensed midwife is not perfect, but it's significantly easier than when I was living in a state in which midwifery had no real legal standing. I can only imagine what you had to deal with practicing in a state in which it is illegal.

All the best to you! We need more midwives, both CNMs and LMs/CPMs. We need more birth centers. And I know those physiologic birth-loving docs are out there. You just have to coax them out; often they are taking more heat than any of the rest of us. After all, everyone expects the midwives to be "off the hizzle," right?

Marla