All About Midwives

In the State of Michigan, consumers have great freedom of choice regarding midwifery care. If you are just beginning on a path of looking into your choices regarding birth attendants and place/setting for the birth of your baby, then these choices may be a little confusing. We will attempt to clarify here.

Certified Nurse Midwives (CNMs)

mary-gd_opt.jpgCNMs are credentialed through the American College of Nurse Midwives (ACNM). They are RNs with additional Masters-level training in midwifery. Nurse midwives can attend births in hospitals, free-standing birth centers, and homes, though they are primarily found working in hospitals. You may find nurse midwives in solo practice, small group practices of two or three midwives, or large practices of ten or more who rotate being “on call.” Large practices may assign one midwife who you see for prenatal care, but it is potluck at your birth. Most insurance companies will reimburse for their services. They work with doctor back-up and abide by medical protocols that may mandate consultation with, or transferral of care to, the back-up doctor in some circumstances. CNMs, for example, cannot be the primary care provider for women expecting breech or twin deliveries. Ask your prospective nurse midwifery service about their protocols regarding transferral of care and insurance coverage.

Direct-Entry Midwives

018_182.jpgDirect-entry midwives — also known as “lay,” homebirth, or traditional midwives — are an eclectic group in Michigan. There is no government oversight regarding licensure or certification of direct-entry midwives in this state. The practice is considered “a-legal” in that it is neither prohibited by law nor sanctioned by the state. Compared to some states in the country where direct-entry midwifery is against the law, or other states where it is licensed and regulated, the status of Michigan direct-entry midwives allows for maximum consumer choice regarding birth attendants.

Direct-entry midwives may attend homebirths or out-of-hospital birth center births. Typically they work with low-risk, healthy women who desire a normal, non-medicated birth. A complete homebirth or birth center service package should include prenatal care, attendance at your labor and birth, and postpartum care, with phone consultations as needed.

Direct-entry midwives may participate in a national certification process through the North American Registry of Midwives (NARM). A midwife who has completed experiential skills training and passed the NARM exam earns the Certified Professional Midwife (CPM) credential. This credential is used as the requirement for licensure in 22 of the 24 US states which license direct-entry midwifery. Some direct-entry midwives may have a nursing background and RN credential, but practicing midwifery is outside the scope of nursing licensure. Direct-entry midwives who lack credentials may nevertheless be highly experienced and qualified, and have sound reasons why they have chosen not to pursue the CPM credential. Most direct-entry midwives are apprenticeship trained and self taught. Some have attended midwifery schools or undertaken a home study course. “Lay” midwife technically means a person with no experience or training who attends births.

Theoretically, there are no complications that a birth center midwife can handle without medical backup that could not also be handled at home. While a birth center may convey a greater sense of safety, this, in and of itself, is an illusion. However, if the birth center attendant is more skilled, that is not an illusion. When emergencies happen at a homebirth or in an out-of-hospital birth center, 911 is called and the woman and/or baby is transported to the nearest hospital. In Michigan, physicans do not back up direct-entry midwives in the same sense that they back up nurse midwives. However, ERs cannot refuse care and many direct-entry midwives have friendly doctor “back up” to the extent that a physician may order necessary tests for the midwife or be willing to consult with her if needed.

Insurance & Fees

As a rule, insurance companies do not cover out-of-hospital birth attended by direct-entry midwives, but there are some exceptions. Women on Medicaid or covered under HMOs will not be able to get reimbursement for direct-entry midwifery services. Check with your insurance provider regarding the feasibility of homebirth coverage. Midwives should also be able to tell you the providers with whom their clients have had success in gaining reimbursement or partial reimbursement. You should expect to pay the midwife’s fee up front, out of pocket, and then gain her help in generating a proper receipt suitable to submit to your insurance provider for reimbursement. Midwifery fees in Michigan currently range from $1,000 (very low-end for midwives attending rural, religious, or Amish communities) up to $4,00 or more. If you have a high-deductible insurance plan, it is quite possible that the midwife’s fee would equal the amount of your co-pay for a hospital birth. Healthcare Spending Accounts (HSAs) or “Flex” accounts can be used as well.

Choosing a Midwife

The practice of midwifery is not the practice of medicine, and medical procedures such as pitocin induction, epidurals, and surgical procedures should take place only in hospitals. Some homebirth midwives may be skilled in working with herbs, homeopathics, and nutrition. Prevention is a hallmark of good midwifery care, and supporting, rather than interfering with normal processes often prevents complications. Midwives can vary in their approaches to midwifery care. For example, some midwives may choose to use dopplers to listen to fetal heart tones, while others may use the low-tech fetoscope. Just because a midwife attends births in a birth center or at home does not guarantee her practice of midwifery is non-interventive.

Clients should interview midwives carefully to find the approach to care that is a good match for their needs. How many births has she attended as the primary midwife? (This should be distinguished from “years in practice” which is essentially meaningless; i.e., someone can claim 25 years’ experience, but have very limited experience as a primary midwife. Hint: Most midwives worth their salt will have a ready and precise answer to this question and it should not be rounded off to the nearest hundred. Do you trust the claim she is making?) Which potential complications can the midwife handle? How is she prepared to handle them? What percentage of her clients give birth with their perineums intact? What are her practice protocols for pre-term or post-term babies? Under what circumstances will she transfer care to medical backup? What percentage of her clients end up with a hospital transport? Is water birth an option? The answer to these questions will vary, depending upon the individual midwife and the practice setting. By asking the right questions, you should be able to find the midwifery practice that is most closely in alignment with your beliefs and preferences.

Careful interviewing of prospective midwives is in order! Ask around. Good word of mouth about a birth center or homebirth practice is important. Midwives who are dishonest, irresponsible, or unskilled get weeded out pretty quickly, but there may be a few out there who are mis-representing their level of training and experience. Create your own list of questions prior to interviewing midwives, a list that reflects your values and priorities, and hire someone who has her act together. Trust your instincts AND check her references/credentials.

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