As a student at Brown University in Providence, Rhode Island, in the 1980s, Afua Hassan dreamed of becoming an obstetrician. But her career took a sudden turn after an unexpected meeting.
“I had been seen in a clinic one day by a midwife and I said, ‘I want to be a midwife,’” the Houston-based midwife told TODAY. After graduating with a degree in African American studies, Hassan pursued midwifery and has been practicing for 35 years.
Hassan is a direct entry midwife, also know as a certified professional midwife (CPM). CPMs are not recognized in all 50 states, but Texas is one of 31 states that recognizes them, according to the American College of Nurse Midwives (ACNM). A CPM is an independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives.
Hassan attended the Houston School of Midwifery for three years, which included shadowing and assisting a midwife. For 10 years, she assisted others before finally starting her own practice in Houston.
In 2011, Hassan founded the Birthing Place, a women's health center offering well woman care, fertility consultations, prenatal, birth and postnatal services. While women can deliver at the Birthing Place, Hassan also offers home births with experienced midwives from her practice.
CPMs are one of three different kinds of midwives. The training they have, where they can practice and what services they offer varies. But most people don’t understand the difference. To them, a midwife is a midwife.
“When women are making decisions about seeking midwifery care, they don’t ask the questions about what type of midwife you are, what are your credentials and how have you been certified,” said Erin McMahon, faculty practice director and assistant professor of nurse-midwifery and women’s health at Yale University School of Nursing. “All women should be curious and ask questions about a midwife’s training and their level of experience.”
Direct entry midwife or certified professional midwife
Direct entry or certified professional midwives (CPMs) are a more community-based approach to midwifery, where people attend some classes, but learn by shadowing and apprenticing with other midwives. Most CPMs focus exclusively on prenatal and postnatal care. Hassan learned midwifery this way.
“It is like an apprenticeship model. A student would work with another midwife often in the home and sometimes in a birth center. They develop their skills with education and by working with their preceptors,” McMahon explained.
CPMs are more likely to attend home births and often do not have privileges in hospitals. While they can't prescribe medication, they frequently work closely with physicians. That's how Hassan obtains pregnancy-related medication, such as Pitocin (used to induce labor), for her patients.
While she's often allowed to stay and help the mom if she's transferred to the hospital, attending a hospital birth can feel isolating. Not all doctors welcome her or other CPMs. But she advocates for her patients even if she can’t continue helping with delivery.
“I am no longer their healthcare provider, but I am giving all the information the doctors want and I stay until the baby comes,” Hassan said.
Certified nurse midwife
A certified nurse midwife (CNM) has a bachelor's degree in nursing and master’s degree in nursing midwifery. CNMs can practice in all 50 states and they can prescribe medicine, according to ACNM. While CNMs deliver babies, they also provide care to women throughout their lives.
“We are lifetime healthcare providers. We provide contraception, gynecological services,” Shadman Habibi, director of the nurse-midwives program at UCLA Medical Center, Santa Monica, told TODAY. "We can administer routine care."
CNMs most often practice in hospitals or birth centers, though some participate in the 1 percent of home births that take place in the United States.
“The majority of births in the U.S. are in hospitals and that is where you will find the majority of CNMs,” said McMahon.
A certified midwife (CM) has a graduate degree in midwifery from a program certified by the Accreditation Commission of Midwifery Education, but does not have a bachelor's degree in nursing.
Like CMNs, CMs practice in hospitals and birth centers but can only prescribe medication in certain states. Normally, CMs have close relationships with physicians who can prescribe drugs needed for their patients.
The ACNM includes CMNs and CMs in its ranks. The American College of Obstetricians and Gynecologists (ACOG) works closely with CMNs and CMs. According to a policy statement, ACOG and ACNM recognize the importance of collaboration:
“Shortages and maldistribution of maternity care clinicians cause serious public health concerns for women, children, and families … ACOG and ACNM recommend increasing the number of OB-GYNs and CNMs/CMs, utilizing inter-professional education to promote collaboration and team-based care."
Emergency care across settings
The overwhelming majority of births in the U.S., 99 percent, occur within hospitals or birth centers. Birth centers can be affiliated with hospitals or universities or they can be community-based, like Hassan’s center.
The Commission for the Accreditation of Birth Centers provides accreditation for birth centers that adhere to their standards. Regulations on setting up a birth center vary from state to state and some states make it cost prohibitive to open a birth center, Hassan said.
While birth is normally uneventful, emergencies can occur in any setting. Hospitals use standardized practices to handle emergencies.
“We have protocols in California,” Habibi, who works at the UCLA Medical Center, said. “Everyone knows the steps. We talk about it. We have drills for obstetric emergencies.”
Birth centers and CPMs also have plans for emergencies or transfers to a hospital. Hassan has a 7 percent transfer rate and she knows exactly what to do if a mom needs to go to the hospital.
“I am five minutes away from the largest medical center,” she said. “Either we get in the car or we can take the ambulance depending on the situation. I have the patient’s records. I explain what is going on.”