The Delivery Debate

Certified Nurse-Midwives: Midwives with this credential from the American College of Nurse-Midwives ( the certification process is administered by the American Midwifery Certification Board) are licensed in all 50 states. The vast majority (about 98 percent) deliver babies in hospitals, where many studies show they have good outcomes. The ACNM says that of the small percentage of their patients who deliver at home or in free-standing birth centers, only about 9.1 percent were transferred to the hospital during labor or just after delivery. In 2005 certified nurse-midwives attended more than 306,377 births in the United States, which represented 7.4 percent of all births and 11.2 percent of vaginal births, according to the National Center for Health Statistics. That number has been rising steadily since 1975. CNMs generally have traditional nurses' training along with special training in midwifery; more than two-thirds also have a master's degree, the ACNM says. (In a press release issued earlier this month, ACOG says it doesn't support the provision of care by midwives who are not certified by the American College of Nurse Midwives or the American Midwifery Certification Board.)

Lorrie Kaplan, ACNM's executive director, advises consumers to be just as careful in selecting a midwife as they would any other health-care provider. Some questions: can the midwife prescribe medications if needed? What type of degree does she have? Is she certified? By whom? If the birth is at home, what's the backup hospital? Does the midwife have privileges at that hospital or will she have to leave you at the door? Who is the backup doctor? Also, Kaplan advises asking for client references.

A good candidate for this kind of midwifery care would be a healthy woman having a normal pregnancy, says Mairi Breen Rothman, a certified nurse-midwife in Maryland. A woman with a more complicated medical history would probably choose a doctor's practice. Rothman says CNMs often work with physicians. "We understand that we are a team," she says. "It's important for all of us to work together."

Certified Professional Midwives: About 1,300 midwives have received this credential from the North American Registry of Midwives. They specialize in out-of-hospital deliveries, either at home or in a birth center, and their training emphasizes experience—especially in out-of-hospital settings—over a traditional hospital-based medical education. They have three to five years of clinical training under another CPM and must also pass a written exam. For more details of their qualifications, check out the registry's Web site. CPMs are licensed and regulated in 24 states, says Katie Prown, campaign manager of The Big Push for Midwives 2008, which aims to extend that licensing to the entire country. Prown rejects ACOG's claims that CPMs are less qualified than CNMs. "If those accusations were true, then we would see a different trend than what we are looking at right now," she says. "In the last five years Utah, Wisconsin, Virginia and Minnesota have licensed certified professional midwives … These states are seeing good results. If they were seeing bad results, states would be outlawing CPMs." Prown says that trying to make CPMs illegal could potentially create a more dangerous situation. "When CPMs are forced to go underground," she says, "they get shut out of the health-care system, and that doesn't serve babies or mothers well at all." Prown also says it is a myth that when women are transferred to the hospital it is an emergency. "Often," she says, " we see women who want to go to the hospital for pain relief or because they are exhausted."

CPMs are a primary resource for women who want to deliver at home, since the majority of CNMs practice in hospitals. If you choose this option, you would want to understand the midwife's qualifications as well as the laws in your state governing this kind of practice. You should also check whether your insurance covers out-of-hospital care. Finally, it is important to find out what would happen in case of emergency. Again, as Kaplan advises, you want to know what connection the midwife has to doctors and hospitals so that the transfer can be seamless. If there is a backup doctor, you could ask to meet that person.

We think it's important that women understand the risks and benefits of all health-care decisions, including the choice of a childbirth provider. Your conclusion should be based on the best scientific evidence as well as your own personal preferences and beliefs. "As a woman and a mom and an obstetrician, I feel strongly that patients should have choices," says Dr. Anne Foster-Rosales, former chair of ACOG's international committee. "But I think making it as safe as possible is very important." Foster-Rosales has worked with mothers around the world, including in countries where most women give birth at home with untrained attendants. Because of what she has seen, she feels that it is important that home-birth providers not feel ostracized so that they can come to the hospital if necessary. Emergencies may be rare, but the course of an individual pregnancy is unpredictable no matter where you choose to give birth. Protect yourself and your baby by learning as much as you can.

© 2008