A direct-entry midwife is a midwife who has become credentialed without first becoming a nurse. There are direct-entry midwifery programs that prepare students to become Certified Nurse Midwives (CNMs) or Certified Professional Midwives (CPMs). Certified Professional Midwives are known for being "more natural and less intervention oriented." In other words, these midwives typically work outside of the hospital setting in homes and birth centers and do not employ methods for childbirth that physicians in hospitals commonly use such as caesarean section, forceps and other types of equipment and drugs.
Legality of direct-entry midwifery in the United States
While direct-entry midwifery is popular and legal in many cultures around the world, it struggles to gain legality in several states in the U.S. Nurse-midwives can practice legally in all 50 states. However, Certified Professional Midwives are regulated and licensed in 23 states.
17 states do not regulate Certified Professional Midwives or provide an avenue for licensure. Penalties for practicing as a midwife without a CNM credential range from a misdemeanor to a Class C Felony. These states include Connecticut, the District of Columbia, Georgia, Illinois, Iowa, Kansas, Massachusetts, Mississippi, Nebraska, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, and West Virginia.
North Dakota, for instance, is one of many states that have no official laws regulating or prohibiting the practice of midwives without a CNM credential. States can unintentionally encourage issues with midwifery by not providing standards or licensure opportunities to ensure the competency of midwives.
Also, practicing midwifery without having a CNM credential in these states is basically equivalent to practicing medicine without a license and has severe penalties.
Some states, while they regulate the profession, make it very difficult for midwives to obtain licenses to perform. Hawaii is one of these states. While Certified Professional Midwifery is legal in Hawaii, licensure has been deemed too expensive and is unavailable to most, according to the Midwives Alliance of North America. Delaware is another state that, while it regulates the profession, sets up obstacles that make it difficult for CPMs to practice in the state. Theoretically, Delaware CPMs are able to obtain a permit to practice, but one hasn't been issued since 2007.
The decline of midwifery in the United States
The decline of midwifery in the United States can be contributed to a number of complex factors: the rise of the American Medical Association and the growth of hospitals in the country in the late 1800s and early 1900s shifted births from the home to the hospital. The fall can also be attributed to the movement toward universities teaching gynecology and surgery as well as advancements in technology such as anesthesia and forceps. All of this led physicians to see midwives as competition instead of partners. They were also worried about what people would think about doctors if it appeared that anyone so uneducated could perform the work of a medical professional. During this time period, organized medicine launched a campaign to convince the public that hospital births were the best option, while painting midwives as unintelligent, untrustworthy and criminal. However, it wasn't just physicians who joined in the campaign against midwifery – by the late nineteenth century, wealthy, pregnant women joined in because they thought childbirth was less painful and safer if performed by physicians.