Certified Nurse Midwives who do home births???

**LibraSunCNM, BSN, MSN, CNM** · May 9, 2013

The outlook/work environment for CNMs doing homebirths varies vastly depending on the state. Where I am, in NY, midwives fought for legislation that says they do not have to have a written practice agreement with a physician in order to work, so homebirth midwives are "legal," in the sense that not having a relationship with an OB who agrees to back up your whole practice (which would be nearly impossible to find, in any state, although I feel like many people's perceptions of HB midwives is that they have 1 "backup" to whom they refer--not so) does not mean you are practicing outside the law. Other states, such as AL or MS, there are hardly any midwives at all, let alone HB midwives, because the laws are so strict about having agreements with a physician, and all of the physicians blackball them. So you can definitely find more HB-friendly areas of the country. With current MD attitudes about HB, it's definitely not a profession that is welcomed with totally open arms anywhere. But yes, I would say the NYC area, and the Pacific Northwest are 2 places that come to mind as being more HB-friendly.

In terms of salary and insurance, my experience with the HB midwives in NYC (there are about 20 or so midwives doing HB here, all with VERY busy practices), is that they make a lot of money, so having to pay a little more for their own health insurance (usually through Freelancer's or other companies like that) doesn't put them out in the least. They are all making 6 figures, which is more than a lot of midwives in the hospital.

Then there is the CPM route, which I am less familiar with, but which is really centered around HB. Only about half the states in the U.S. recognize CPMs as "legal," but again each state has their own definition of that.

Hope that helped a little.

queenanneslace, ADN, MSN, APRN, CNM · May 9, 2013

First - familiarize yourself with the American College of Nurse-Midwives ACNM www.midwife.org

Become an associate member, this will get you a subscription to the Journal of Midwifery and Women's Health - and their newsletter- you will learn a lot about CNM scope of practice from these resources

I love the idea of steady salary and health insurance for being a nurse midwife.

This will be challenging as an OOH/HB midwife. Most OOH practices are midwife-owned, and therefore they are not paid through salary like they would be in a hospital setting. It is a trade-off, steady pay but working in a hospital-based practice - some of which are quite large (20+CNMs), or not-so-steady pay, but having your own practice. The other part to consider is how much time off you would want. Many homebirth midwives are on call every day of their lives. Or have very limited time off call (some take a month off when they take no clients who are due.... some have very sporadic 'vacations' when they can get another midwife to cover their practices.

what is the outlook for CNM's who do home births??

It depends on the state. Some states make it effectively illegal - or extremely difficult - for CNMs to provide OOH/HB services. Other states it is widely practiced and authorized. It is related to the amount of autonomy the CNM has by the licensing requirements. Some licensing requirements for CNMs require physician supervision, and CNMs cannot prescribe medications without a physician overseeing "a delegated medical act". In my opinion, the outlook for CNMs is the best in the states that allow them to practice to the full scope of their training and expertise - regardless of whether CNMs are practicing in or outside of hospitals.

I found that CNM's most are in aid of the doctor which i am in no way shape or form interested in.

Not necessarily. Even in states where physician supervision is required by licensure, that usually does not mean that the physician is physically present and supervising the midwife's practice. Most often, CNMs work in group practices with MDs, CNMs, OBs - the midwives manage their own patients independently, and refer and consult as appropriate. I would guess that most CNMs would not say they work under a doctor - or 'in aid of a doctor' - but that they have a defined scope of practice, and can independently manage pregnancies, births and postpartum care for their patients. There are some challenges, though, and this all depends on the state where the CNM works.

michellelizabeth · May 9, 2013

thanks guys, this helps alot! I'm excited for traveling in the future, and I know that midwifery is more accepted in pacific northwest. Everything about that area interests me. I just hope as i further my schooling, everything will fall into place. I would even love to work at a birth center. Just working in a hospital doesn't appeal to me. I don't personally agree with alot of the things the medical field does. Who knows maybe that'll change. And the worst part is, I have a grandmother whos a nurse and highly advocates birth intervention (which I do not) and she is my only source of a mentor. I have no other opinions besides hers. And all your insight is helping!

midwifetobe85 · May 9, 2013

I am just wrapping up my first semester in college, so i have a longggg way to go. But my goal is to become a midwife. Home births is where my heart is at, but I love the idea of steady salary and health insurance for being a nurse midwife. I have no responsiblites that would tie me down to a certain state, I would feel more than honered to study somewhere else. I'm going to school in Missouri, which is too conservative for my liking anyway :)
So my ultamite question is, what is the outlook for CNM's who do home births?? From my research, I found that CNM's most are in aid of the doctor which i am in no way shape or form interested in. Any advice or tips would be most appreciated!!!

Hi Michellelizabeth!

I completely agree with LilyRoseRN and queenanneslace. It really depends on the state. I'm a newly admitted student midwife at Frontier Nursing U (I start in July). It's a highly esteemed distance program, definitely worth looking into. Frontier.edu

I'm originally from NY where I know many holistically minded home birth CNMs who are totally independent. They write prescriptions, legally carry o2 and all the necessary meds to births, and only consult with physicians as they see fit. I'm now located in the MA though, and there are no home birth CNMs as far as I can tell. Apparently, for a long time CNMs were required to have a 'written collaborative agreement' with backup MD, which basically meant they needed a physician to sign a form stating that they would be their backup. Unfortunately, good luck finding an MD who wants to tied to a home birth midwife (with a legally binding contract). I also think that many of the MD's malpractice insurance companies specifically stated that they could not work with a home birth midwife. Recently, the law was changed to a verbal collaborative agreement, which is the way it works in NY. If I understand the situation correctly, CNMs could start to do home birth in MA now, but the law is quite new and I don't think there are any yet. There are however two great birth centers in the area that I'm hoping to do part of my training at. I also know for a fact that there are CNM home birth practices in Maine, New Hampshire, Maryland, New Jersey, Rhode Island, and New York as I said. I'm also pretty sure there's at least one in Vermont.

I'm still trying to find a source that breaks down each state but, in general, it seems the conservative states tend to be more conservative about midwifery practice and home birth. This list offers some basics on each state - ACNM Library

You can also go here to look up nearby home birth CNM practices or birth centers: Find a midwife

Hopefully that helps! Are you planning on studying nursing for undergrad or going back for a nursing degree afterwards? If you're already a home birth minded aspiring midwife, nursing school may be psychologically tough for you, as it was for me. I originally majored in French and returned to school for an accelerated BSN a few years later when I realized that midwifery (specifically home birth/birth center midwifery) was my calling. I never had aspirations to be a nurse and in many ways nursing philosophy (which is rooted in the medical model, not the midwifery model) conflicted with a lot of my beliefs. It's meaningful work to be sure, but it felt pretty far removed from my dreams of home birth midwifery. It's also hard, rough work with plenty of issues of its own. I will say though, I made it and I'm still very glad to have chosen this pathway and am so excited to finally be starting midwifery school! If you're certain about midwifery I'd recommend that you do major in nursing if you can and just get it done with. Who knows, you may actually enjoy it too.

Let me know if you have anymore questions!

amoLucia · May 10, 2013

I'd just be curious what your malpractice insurance premiums will be?

**LibraSunCNM, BSN, MSN, CNM** · May 10, 2013

Malpractice insurance for homebirth midwives is high, and some choose not to carry it, but most of them can afford it. The HB midwife I've done clinicals with bills each pt.'s insurance an $11,000 global fee, in the hopes of getting between $7500 and $11,000, and usually gets payment. Even if a pt's insurance refuses to pay, she works out a payment plan with the patient , or sometimes forgives it all together. Still, if you're doing 6 births a month, 10 months out of the year, you can afford the $20,000 annually for malpractice (I believe that is what she told me it costs).

michellelizabeth · May 10, 2013

That insight helped alot!! I'm very young and not sure where I'm going to end up (state wise) but New York sounds exactly like what I want as far as midwifery and their privileges go. So far my plan is to go to nursing school and get my RN. Then I will get my BSN. Then start midwifery training. Those things you said about nursing school are my exact fears. I view things different than traditional nurses and would hate to hate to do things their way. But I want to have the more versatile certification which is CNM. I don't have any interest in being a nurse. I'm dreading nursing school actually.

**LibraSunCNM, BSN, MSN, CNM** · May 10, 2013

I decided I wanted to be a CNM in high school, and had the same fears you did about nursing school, not fitting in to the traditional birth models, butting heads with others, etc. My original plan was to just get through my BSN, go straight through to my master's, or work for a year at most before going back, but only in L&D. I was only going to nursing school because I had to.

However, during my nursing school experience I was exposed to so many other areas that interested me, such as psych, and med/surg, that I never expected. I ended up working as a nurse in med/surg for 2 years, before transferring to a position in Mother/Baby, all while I was working on my CNM, and am so glad I did it that way. I gained a ton of valuable experiences and skills that I wouldn't have, skills that were especially important for me since I didn't go into midwifery with any previous experience in birth.

My advice is to keep an open mind throughout your schooling. You may not hate it so much! Yes, my views and experiences with birth are still very different from most other nurses, or people in general really. But I'm actually really proud to be a nurse, and proud of my pathway to midwifery.

queenanneslace, ADN, MSN, APRN, CNM · May 10, 2013

I have to echo some comments about nursing school too - because I had the exact same fear and dread and resistance to going to nursing school (I've even started and dropped out of nursing school many times! But finally made it through.)

IT'S NOT THAT BAD. :)

Trust me, there are a lot of different types of people who go into nursing, it is not always as medically-oriented as it is portrayed - and at every clinical - and workplace - I have been at, there are always nurses acting as patient advocates - not bots mindlessly obeying medical orders.

Being a patient advocate and patient educator is incredibly rewarding - and I never imagined that I would enjoy my role as an RN - especially way back when when all I wanted to do was become a midwife.

What helped me finally get through nursing school was having some natural birth experiences under my belt - it is frustrating to be learning about kidney failure and chest tubes and nitroglycerin patches when all you want to learn about is birth --- but if you can do some things along side your nursing training: doula work, lactation counseling, childbirth education instruction, etc - it can help. There are so many things about nursing that are directly applicable to midwifery - so, so many things - it is such a valuable experience. I can totally relate to not being interested, because it is not midwifery - but it really is valuable. I never thought I would say that, nursing used to just seem like a hoop to jump through to get to CNM school. I don't feel that way at all any more.

You will meet some wonderful and holistic-minded nurses during nursing school. They will inspire you. I promise.

amoLucia · May 10, 2013

Moving outside of licensed nursing, there is the practice of being a doula. I do recognize that it is not widely accepted by many.

sunflower918 · May 10, 2013

Another route is becoming a "Direct Entry Midwife"; check out Midwives Alliance of North America (sorry don't have link).

Also you could check out MA Friends of Midwives site....

Good luck to you in whatever path you choose. It is a humbling experience to say the least to be the waiting hands that receive a new life into this world.