No one knows when midwifery became an official profession, but there's no doubt that midwives have been around for about as long as people have been around. Despite the lengthy history, the profession experienced a long drought in North America, and only relatively recently has reemerged.

Professional midwifery was reintroduced to the United States in 1925 by Mary Breckinridge, an American nurse who trained as a midwife in the United Kingdom. Today, the American Midwifery Certification Board (AMCB) certifies nurse-midwives (CNMs) and midwives (CMs). Nurse-midwifery practice is legal in all 50 states and in the District of Columbia, with Medicaid reimbursement mandatory in all states, and with 33 states mandating private insurance reimbursement for nurse-midwifery services. CNMs also have prescriptive authority in all 50 states and in the District of Columbia. However, the CM credential is relatively new and currently only three states (New York, New Jersey, and Rhode Island) recognize it. A CNM and a CM cannot legally practice unless they are certified by AMCB and licensed to practice in the state in which they practice.

The main difference between CNMs and CMs is that CNMs are educated in both the disciplines of nursing and midwifery, whereas CMs have only been educated in the discipline of midwifery. In 2004, there were 39 nurse-midwifery and midwifery education programs accredited by the American College of Nurse-Midwives (ACNM) in the United States. Eighty percent of CNMs have a Master's degree. The ACNM reports that in the last 10 to 15 years, the number of CNMs and CMs in the United States has more than doubled, and there are now 11,320 CNMs and CMs, who (in 2005) attended 7.4% of the nation's 4.14 million births. Of these, 96.7% of deliveries occurred in hospitals, 2% were in freestanding birth centers, and 1.3% were home births.

In Canada, midwifery was only reintroduced as a regulated profession in the 1990s, with Ontario taking the lead in 1994. The profession is now also regulated in British Columbia, Alberta, Manitoba, Quebec, Nova Scotia, Saskatchewan (2008), and the Northwest Territories. It is anticipated that midwifery will be regulated in New Brunswick in 2009. Unlike all other provinces and territories in which midwifery is regulated, Alberta does not publicly fund midwifery care. In regulated provinces and territories, midwives must be registered with the regulatory authority to legally call themselves a midwife and practice. The official title in Canada is "Registered Midwife."

In Canada, midwifery education is offered at the baccalaureate level. Education programs are direct entry, meaning no nursing or other credential is required for entry.

According to the Canadian Association of Midwives' 2007 Annual Report, as of September 2007, the association's membership included 624 midwives, 67 student midwives, and 56 associate or non-practicing members. Midwives may practice in any setting, including the home, community, hospitals, clinics, or health units. As in the United States, midwives attend births in hospitals, birth centers, and at home.

Midwives are teachers and advocates for women and their families, and they are experts in normal pregnancy, normal childbirth and postpartum care, and normal well-woman care. Leslie Ludka, a CNM and Senior Technical Advisor with the ACNM points out that "normal childbirth" does not mean that a woman cannot have anesthesia or an epidural; instead, it refers more to the midwives' philosophy that birth is a normal process, not a disease.

Midwives care for low-risk women independently, and if a pregnancy becomes high risk, the midwife consults with a physician. "In fact," Ludka says, "the bulk of midwifery training is aimed at recognizing the red flags that signal high risk. We are able to order all the same standard testing that physicians order during a pregnancy. We use the same quality labs and technicians. CNMs always work in consultation and collaboration with a physician who is available to care for those women who have a pregnancy that becomes high risk." In the United States, a midwife and physician may become a team and formulate a care plan for a high-risk mother, which may involve both professionals caring for the woman, but if the high-risk care is beyond the midwife's scope of practice, the actual care may be transferred to the doctor, while the midwife usually remains available for support and teaching.

In Canada, the situation is slightly different. An Association of Ontario Midwives (AOM) FAQ says, "You can have either a midwife or a doctor for your pregnancy, birth and newborn care. Midwives, obstetricians and family physicians are all considered primary caregivers. A primary caregiver takes sole responsibility for your care. Having two caregivers is viewed as a duplication of health care services." However, if a woman's care must be transferred to a physician, her midwife remains with her in a supportive role.

For in all cases, as Ludka explains, "Midwives are educators. We will spend the time that you need to teach you everything we possibly can about your body and your pregnancy. Midwives want to empower you with information so that you are able to make the decisions that are right for you along the way. As you make your own informed decisions about your body, your pregnancy, and your baby's birth, we will walk beside you."

There are many reasons for a woman to choose to work with a midwife, of which just two reasons are excellent outcomes and high quality care. A May 1998 American study published in the Journal of Epidemiology and Community Health, which looked at birth certificate data for all singleton vaginal deliveries between 35 and 43 weeks, found that after adjusting for sociodemographic and medical risk factors, the outcomes for physicians and CNM showed: 33% lower risk of neonatal mortality with CNM-attended births, 31% lower risk of low birth weight babies with CNM-attended births, and 19% lower infant mortality rate for CNM-attended births.

An article in the September-October 1995 issue of the Journal of Nurse-Midwifery, which looked at processes of care comparisons of CNMs and obstetricians found that women cared for by CNMs were much more likelyto experience prenatal education focusing on health promotion and risk reduction activities; women in the CNM group experienced, in general, a more hands-on approach that relied less on technological interventions and a closer supportive relationship with their provider during labor and delivery; and women in the physician group were much more likely to have care based on expensive medical interventions such as invasive tests during intrapartum care.

As the last point above indicated, another notable benefit of choosing a midwife is that midwives are less expensive than doctors. Ludka explains in the American context: "The charge for a birth or an office visit is the same whether a midwife does it or a physician does it. It's the same service. However, a midwife is trained to use skills which are less expensive. For example, a midwife is trained to feel the belly to assess fetal position (Leopold's maneuvers), rather than automatically sending a woman for an ultrasound. Another example: A midwife is taught skills to protect the perineum rather than cutting an episiotomy at every birth. Skills such as these save money without sacrificing quality. A midwife's salary is much less than a physician. Overall, we save the healthcare system lots of money." Joanna Zuk, the Senior Communications Officer with the AOM says that in Canada, cost savings result in part from the fact that midwives have a different system of billing than obstetricians and family physicians, and in part from the fact that women cared for by midwives typically leave the hospital earlier and have fewer interventions (e.g., no anesthesia or C-section costs), which result in savings.

The good news for prospective midwives and those who want to work with midwives during their pregnancies is that both Ludka and Zuk feel that the demand for midwives in North America will continue to grow.

Ludka says that while there isn't a template personality that constitutes the ideal midwife, a good midwife is "someone who is called to the profession," and whose qualities include high intelligence, superior communication skills, patience, caring, and the ability to keep a level head and think clearly in every situation. Zuk believes a good midwife is a person who is smart, caring, and collaborative, and has a feminist mindset.

Ludka suggests that those considering a career in midwifery shadow a midwife for a day or two. That way, the person "will either fall in love with the profession or know to move on to something else." Zuk recommends that those considering the profession do a lot of reading, and talk to some midwives and to women who have been cared for by midwives. "Make sure they know what the lifestyle is about. It's draining to be in healthcare. You're on call 24/7, so it's a big demand, especially for those who have young children. But at the same time, it's tremendously rewarding work." Ludka, a CNM with 18 years of experience agrees with the sentiment: "I am thrilled to be a midwife. I can't imagine anything more rewarding. Clinical practice, teaching, advocating, being invited to care for women – it's all such an honor."