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2023 State of Midwifery: The 10,000 Foot View of the Profession

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Welcome to the state of midwifery 2023! Get excited. I’ve got 5 posts for the series that are outstanding.

https://nashp.org/midwife-medicaid-reimbursement-policies-by-state/

If you’re new to the blog, I started a state of midwifery series back in 2020, then repeated the series in 2021. (I missed 2022 because of a lot of things: mom of 3 littles, working spouse, international travel, 1st trimester of pregnancy – you pick which excuse seems best to you.)

If you missed those posts, check them out…

2021

2020

Moving onto 2023, here’s what in store.

This post is a 10,000 foot view of midwifery. What is a midwife? What are the types of midwives? How many midwives are there? Where do you find a midwife? How do you become a midwife?

It’s important for everyone to go back to most basic facts to know how far we have come and how far we have to go.

Next up in the series is a post on teaching people how to be midwives, also known as precepting. Yes, it might be boring to some, but precepting is the only way to make more midwives. After that, there are posts on becoming postpartum warriors, promoting physiologic birth , and how to promote midwifery.

You may be asking, why so much promotion for midwifery?

It’s your choice again, but all of the above is the right choice too.

  • Because maternal mortality and morbidity will not change in the United States until midwifery becomes the standard of care for low risk pregnancies.
  • Because the majority of people still don’t know what a midwife is or what midwifery care is.
  • Because birth moved into the hospitals in the 1950s and physicians have been managing birth for the past 70 years and our outcomes are only getting worse. (Briefly, I’ll mention that physicians are integral to obstetric care and high risk management; my opinion has always been that obstetric care should be multi-disciplinary. However, for low risk, uncomplicated pregnancy or birth, autonomous midwifery care should be the standard.)

The problem is the United States hasn’t hit the positive tipping point to incite change across the nation.

What’s a tipping point?

A tipping point is when the slow evolution of change starts to move at a faster past resulting in a transformation of care, culture or “the way things have always been done.”

For midwifery, the tipping point is estimated to happen when midwives are attending 18% of births. If you’re curious where the 18% comes from, listen to Ginger Breedlove explain it in this podcast with Midwifery Wisdom collective.

As of 2020, midwives are attending 15.9% of vaginal births and 10.3% of all births in the United States (American College of Nurse-Midwives, 2022). To put the trend in perspective for you, I’ve included the table where those statistics come from below:

Source

From the top, let’s start with the most basic thing – the definition of a midwife.

What is a midwife?

A midwife is a professionally trained expert in normal pregnancy, birth and postpartum care.

Midwives also provide primary care (treating strep throat), birth control counseling, gynecologic care (like your pap smear or management of your heavy periods or irregular bleeding), vaccinations, well woman care, fertility and infertility care, and pregnancy loss care (miscarriage care) – to name a few!

Midwives work in the hospital, clinic, birth center and the home settings.

Midwives are like nurse practitioners or advanced practice nurses but they attend births as well manage patients in clinic. Not all midwives have nursing degrees, so these terms aren’t the best descriptors.

You can read the whole list of skills a midwife receives during training here.

What are the different types of midwives?

Three different types of midwives are recognized in the United States:

  • Certified nurse-midwives (CNMs)
  • Certified midwives (CMs)
  • Certified professional midwives (CPMs)

For more information or to compare the different types of midwives, check out this chart.

What are the core tenants of midwifery?

Midwifery practice adheres to a list of hallmarks, or standards, that midwives put into practice for every patient and their family.

The hallmarks include:

  • Pregnancy and birth are normal life events for women.
  • Watchful waiting and withholding interventions during pregnancy and birth are the standard in normal circumstances; advocacy in support of normalcy is of the upmost importance
  • Consultation, collaboration and referral to other health care team members when care is outside the midwifery scope of practice
  • Continuous, compassionate care with the goal of partnership between the midwife and the clients they serve
  • Acknowledgement of a client’s experiences, opinions, preferences and knowledge
  • Individualizing care to the client with a focus on evidence-based interventions
  • Therapeutic presence, touch and communication
  • Health promotion, disease prevention and health education are the pillars of care
  • Informed choice and shared decision-making in every decision (American College of Nurse-Midwives [ACNMa], 2020)

The North American Registry of Midwives (NARM) also maintains a list of practice guidelines here.

How do I find a midwife?

It depends which kind of midwife you are looking for and where you live in the United States. Often times, you’ll find a midwife by word of mouth or recommendation from someone you know.

  • Community Resources – Do an internet search with your city, county or state plus the word midwife and see what services are near you.
  • ACNM Find A Midwife – Use this search tool to find a midwife near you.
  • The State Resource Page – Maintained by me for no cost, I offer links or information about birth workers in each state. If you have a resource to add, please email me at amidwifenation@gmail.com!

How many midwives work in the United States?

As of February 2022, there were 13,524 CNMs and CMs in the US (ACNM, 2022).

As for CPMs, they are a little harder to track and it’s not known how many CPMs are actively practicing in the US. I emailed the North American Registry of Midwives to get an update on their issued certificates in February 2023 but got no response from the organization.

In 2020, this was the response I got from NARM’s Debbie Pulley:

“[NARM has] ….issued a total of 3,693 certifications since the credential was certified in 1994″ (personal communication, 2020).

On NARM’s website in 2020, they listed that 3,850 certificates have been administered since 1994 and they look to reach 4,000 in the year 2021.

Regardless of training path, it’s difficult to know how many midwives are actively practicing even though about 17,000 midwives have achieved certification.

What does the current workforce look like?

The current workforce is a constant area of study among researchers. Data on the workforce is collected a number of ways: surveys completed with new or re-certification, surveys completed through independent research teams, and surveys completed informally.

Here are some facts about the CNM/CM workforce:

  • The majority of midwives are ages 30 to 69. Almost half of midwives are less than age 50 and the other half are over age 50. 4.9% of midwives are over age 70 and continue to re-certify each year.
  • 85% of midwives are White, 6.8% are Black, and 5% identify as other minorities.
  • 96% of midwives speak English as their priamry language but 30% also speak Spanish; 8% of midwives speak other languages other than Spanish.
  • 98.8% of midwives are female; 0.75% are male; the remaining choose not to report sex.
  • 57% of midwives work full time – more than 35 hours per week.
  • 18% of midwives work part time – less than 34 hours a week.
  • 10% of midwives are employed but not performing midwifery work.
  • The majority of full time midwives make between $100,000-$149,000 a year while the majority of part time midwives make $75,000-99,000 a year (see salary table below) (American Midwifery Certification Board, 2020).
Source

Facts about the CPM/LM workforce:

  • The median annual salary for a CPM is estimated at $54,201. The salaries range from $25,650 to $100,390 (Comparably, 2023).

As far as data on the CPM workforce, I can’t find any that’s freely published. In 2018, a study in Texas surveyed approximately 200 licensed midwives and certified nurse-midwives in an attempt to describe the workforce in Texas. The NARRM surveys their members every 7-8 years; 2023 is a survey year and I expect the organization will release data later this year after the survey is completed.

Additional information about the CNM/CM workforce (number of midwives by state, independent practice, etc.) is reported here.

Does the United States need more midwives?

YES.

There is a shortage of maternal health workers and midwives are included in these shortage predictions.

Currently, there are only 4 midwives per 1,000 births in the United States; estimates predict that 25 midwives are needed per 1,000 births.

The U.S. has 3.7 million births a year

To meet the goal of 25 midwives per 1,000 births, the country needs 93,000 midwives.

That seems like a really high number, especially when you see that no other country in the world has that many midwives per 1,000 births.

It’s good to have goals though. Even doubling the number of midwives in the United States would have significant beneficial ripples through the entire health care system.

Source

Why can’t we just make more midwives?

There are two main reasons it’s hard to make more midwives.

One is the number of midwives leaving practice:

30% of midwives leave clinical practice before their 5 year certification cycle and HALF of all midwives report leaving clinical practice within 10 years after their initial certification (ACNM, 2022b).

That’s some big attrition in the profession. The current force can’t even replenish the midwives leaving with new graduates.

The second reason is that the pipeline into midwifery is a bit of a bumpy road. What does that mean? To start, midwifery schools are not easily accessible and many states don’t even offer a midwifery program.

Source

A 2019 report summarizes the main idea: “Despite the compelling need for more midwives to enter the workforce, there has been no growth in the number of ACME accredited midwifery education programs between 2009 and 2018″ (ACNM & ACME, p. 5). For my own training, I moved from Texas to Colorado to attend my midwifery program.

Second, maximizing student enrollment in the available midwifery programs continues to be a problem. Let’s take 2018 for example. In 2018, approximately 2,000 individuals applied for candidacy into a midwifery program, approximately 1,000 individuals were accepted, and 123 spots were unfilled (ACNM & ACME, 2019). The average for vacant program spots from 2014 to 2018 was 135 students annually (ACNM & ACME, 2019).

Over a ten year period, that’s almost 1,000 students that could have started midwifery school! So, why are there so many vacant spots?

“Midwifery education program directors provided ACME with reasons for not reaching capacity which included insufficient qualified applicants, limited clinical sites and preceptors, and
applicants accepting positions in other midwifery programs” (ACNM & ACME, p. 6, 2019).

The problem isn’t just vacant spots. It’s also finding someone to teach students the art of midwiery. Midwives practice in all 50 states, but that doesn’t mean finding a preceptor is easy.

“Midwifery program directors consistently indicate that they could increase graduation rates if more clinical sites and preceptors were available for midwifery students” (ACNM & ACME, p. 10, 2019).

Regardless of the barriers, the number of graduates is slowly but surely increasing each year.

How do you become a midwife?

The path to becoming a midwife depends on which midwife you aspire to be.

Certified nurse-midwives (CNMs) obtain a BSN (Bachelors of Science in Nursing), obtain their RN license, and thes go on to graduate school to obtain either a MSN or a DNP (Masters of Science in Nursing of Doctorate in Nursing Practice with an emphasis in Nurse-Midwifery).

Certified midwives (CMs) have a bachelors degree in a non-nursing field and attend nurse-midwifery graduate school.

CNMs and CMs take the same exam for a license in midwifery practice.

CPMs do not require an academic degree to practice but must have a high school diploma. CPM training includes many courses and an apprenticeship to learn the art of midwifery. CPM is a national certification while LM (licensed midwife) is a state certification; midwives can have dual LM and CPM certifications.

For more information on the training pathways to midwifery, check out this chart.

Where do you find midwifery programs?

There are 38 accredited midwifery programs for CNM/CMs across the US and four programs in pre-accreditation to initial accreditation phases. Some states don’t have a program while some states have more than one program.

There are 9 accredited programs for CPMs across the US.

I maintain a complete list of the programs and the degrees they offer on the MAKE MORE MIDWIVES page.

You can also find a list on ACNM’s website here.

What national organizations represent midwifery?

American College of Nurse Midwives (ACNM)

Midwives Alliance of North America (MANA)

National Association of Certified Professional Midwives (NACPM)

Which national organizations provide certifications to midwives?

CNM/CMs: American Midwifery Certification Board

CPMs: NARM (North American Registry of Midwives)

Where can I learn more about midwifery?

Great question! These articles or sites are ones I’ve collected over the year that answer a lot of common questions about midwifery. I maintain a list on the MAKE MORE MIDWIVES page year round.

That’s the recap! Hope you learned something. If you are a midwife and have some data to add that. I didn’t cover or know about, please send it my way: amidwifenation@amidwifenation

Forward this post to someone who needs to read it!

Make more midwives wherever you may be!

Jamie

1 year ago on the blog…What Happens At My 36 Week Visit?

2 years ago on the blog…The State of Midwifery (Part 2): How to Bolster the Force

3 years ago on the blog…Let’s Talk Epsom Salts!

References

American College of Nurse-Midwives. 2020. Core competencies for basic midwifery practice. https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000050/ACNMCoreCompetenciesMar2020_final.pdf

American College of Nurse-Midwives. 2022a. Fact sheet: Essential facts about midwives. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000008273/EssentialFactsAboutMidwives_Final_2022.pdf

American College of Nurse-Midwives. 2022b. What is the rate over time that midwives leave clinical practice? https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000008718/20221201_ACNM_WorkforceStudyBrief_No1.pdf

American College of Nurse Midwives & Accreditation for Midwifery Education. (2019). “Midwifery Education Trends Report – 2019“, 1-13.

American Midwifery Certification Board. (2020). 2020 demographic report. https://www.amcbmidwife.org/docs/default-source/reports/demographic-report-2019.pdf?sfvrsn=23f30668_4

Comparably. (2023). Licensed midwife certified professional midwife salary. https://www.comparably.com/salaries/salaries-for-licensed-midwife-certified-professional-midwife

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