A steady presence: Certified nurse midwives

Giving birth is one of the most memorable experiences of a woman's life. Many women and their partners will spend a great deal of time exploring a wide variety of options and often devote time to considering the kind of labor and delivery process they want and who should be there to help. As one option, some women choose a certified nurse midwife to help bring their child into the world.

The basics: what does a Certified Nurse Midwife do?

A certified nurse midwife is an advanced practice nurse who provides primary care for women. A midwife can oversee a woman's labor and delivery either as part of her own practice or under the supervision of a physician. The midwife provides primary health care to women of childbearing age. This care can include gynecological exams, prenatal care, family planning, counseling in health maintenance and disease prevention, preconception care, menopausal management and newborn care. Midwives are best known for their care during labor and delivery.

Certified Nurse Midwife? Certified Midwife? Doula? OB/GYN? What's the difference?

The differences between the various titles can be confusing to patients who are just starting research into the kind of assistance they want. According to the ACNM, a variety of helpers exist:

• The certified nurse midwife is a healthcare professional who has been trained in the disciplines of midwifery and nursing. The CNM holds certification through the American Midwifery Certification Board. According to the American College of Nurse Midwives, all certified nurse midwives or certified midwives have at least a bachelor's degree, while 80 percent hold a master's degree. Certified nurse midwives are considered advanced practice nurses, and these must have a master's degree or higher, according to the Bureau of Labor Statistics. The certified nurse midwife or the certified midwife must pass the national certification exam. CNMs are legally authorized to practice in every state, as well as the District of Columbia.
• A certified midwife has been trained in the discipline of midwifery, but is not a nurse. The CM has been certified by the American Midwifery Certification Board. Currently, CMs are legally authorized to practice only in New Jersey, New York and Rhode Island.
• Doulas provide emotional and physical support to laboring mothers and their partners. A doula is not a midwife and does not perform clinical duties, such as heart rate monitoring or vaginal exams. Doulas often work closely with midwives to help provide a woman with the best birthing experience possible.
• An obstetrician is a physician who has completed medical school, earned a medical license, and is trained to help in the pregnancy and delivery process.
• Sometimes a person will call themselves a midwife even if they are not licensed by their state. The ACNM cautions that an unlicensed midwife might not hold the proper education or background to help facilitate a safe labor or delivery.

Regulations for certified nurse midwives vary from state to state. Some states require that midwives be under the supervision of physicians, while others allow the midwives to work in their own practice. Some states allow midwives to prescribe medication, while others do not.

How much does it cost to become a CNM?

Though the cost of education for a certified nurse midwife can vary from one college to another, there is little doubt that it will cost a pretty penny to move into the profession.

"Most nurse midwifery programs are located in private universities, so the costs are going to be higher than at state universities," said Gretchen Mettler, Ph.D., a certified nurse midwife and Director of the Nurse Midwifery Program at Case Western Reserve University. "Most students finance their graduate education with loans. But there is no doubt that the master's degree will pay for itself many times over."

For those who are worried about paying back their student loans, the National Health Service Corps offers a loan repayment program for midwives who agree to work for a period of time in underserved areas. The NHSC will repay $50,000 in loans in exchange for a two-year commitment.

What is the expected salary for a Certified Nurse Midwife?

According to Salary.com, the median salary of a nurse midwife in the United States was $90,904. The lowest 10 percent in the profession made $77,052, while the highest 10 percent made $106,564. However, the income of a CNM can vary.

"The salaries are very location-dependent and also depend on how busy the practice is," Mettler said. "If it is a smaller practice with few patients, the salary will be lower than a busier practice. There are nurse midwives in solo practice who are making over $120,000, as there are some in large group practices. This includes salary and productivity bonuses. However, the general salary rage is really about $85,000 for a new graduate to around $100,000 for an experienced nurse midwife."

What about job prospects?

Nurse midwives can find work in a wide variety of places, though most choose to work in a hospital setting. The results of a 2007 ACNM Compensation and Benefits Survey showed that more than 32 percent of respondents worked in a hospital and another 30 percent worked in a physician's practice. Just more than 8 percent worked in community health, while another 8 percent worked in academic institutions. Less than 4 percent of nurse midwives had their own practice.

Only 10 percent of all respondents said they were not currently working as a midwife. Most of them stated that there were no available positions in their area, or that they chose not to work as a midwife due to the long hours required.

Let's get real: The pros and cons of becoming a midwife

Just as with any profession, there are a few negatives associated with becoming a midwife. Public perception is one of the largest.

Most people think that midwives only do home births. However, while CNMs do attend home births, there are very few that do. Additionally, many midwives hold and advocate for ideas, such as water births, that fall outside of the mainstream and can result in a reputation of being "eccentric." Additionally, sometimes midwives are seen as "lesser"-than physicians.

"We are constantly needing to show our value and our worth," Mettler said. "Insurance companies do not want to pay us at the same rates that they pay physicians. We have to constantly educate legislators about what we do so that state laws can be crafted to support our practice. I work in a state where we are not supervised, but the physicians, nevertheless, still think they do supervise my practice."

But the joy a CNM often finds from the job is unparalleled by money or recognition, says Mettler. "For me, the most fulfilling part of my career has been working with women," she says. "Working with them to help them have healthy pregnancies and the birth experiences they were hoping for, and to help guide them to make healthy choices for the other parts of their lives, too."