significant proportion work independently, providing total care for their clients within a community setting. however, recent government proposals to require insurance for all health professionals is threatening independent midwifery in england. midwives are at all times responsible for the women they are caring for. they must know when to refer complications to medical staff, act as the women's advocate, and ensure that mothers retain choice and control over childbirth. most practising midwives in the united kingdom are female: men account for less than 0.5 per cent of midwives on the register of the nursing and midwifery council. professional associations/colleges royal college of midwives (rcm). independent midwives uk (imuk). association of radical midwives (arm). united states us navy midwife checks on a woman education, training and regulation accredited midwifery programs can lead to different professional midwifery credentials: midwifery programs, accredited by the midwifery education accreditation council (meac), leading to the certified professional midwife (cpm) credential, certified by the north american registry of midwives (narm), that is at the level of a degree in midwifery (as midwifery, bsc midwifery, msc midwifery). completion of a portfolio evaluation process (pep) or a state licensure program are considered. cpms have to apply for recertification every three years. midwifery programs (for graduates with a relevant degree who wish to become midwives), accredited by the accreditation commission for midwifery education (acme), leading to the certified nurse midwife (cnm) and certified midwife (cm) credentials, certified by the american midwifery certification board (amcb), that are at the level of a masters degree or equivalent qualification in midwifery (msn in midwifery). cnms and cms must apply for recertification every five years. according to each us state, a midwife must be licensed and/or authorized to practice midwifery. practice midwives work with women and their families in many settings. they generally support and encourage natural childbirth in all practice settings. laws regarding who can practice midwifery and in what circumstances vary from state to state. many states have birthing centers where a midwife may work individually or as a group, which provides additional clinical opportunities for student midwives. cpms provide on-going care throughout pregnancy and continuous, hands-on care during labor, birth, and the immediate postpartum period. they practice as autonomous health professionals working in a network of relationships with other maternity-care professionals who can provide consultation and collaboration, when needed. although qualified to practice in any setting, they have particular expertise in providing care in homes and free-standing birth centers, and own or work in over half of the birth centers in the u.s. today. cnms and cms work in a variety of settings including private practices, hospitals, birth centers, health clinics, and home birth services. they supervise not only pregnancy, delivery, and postpartum period care for those who were pregnant and their newborns, but also provide gynecological care for all women who need it and have autonomy and prescriptive authority in most states. they manage biological females' healthcare from puberty through post-menopause. with appropriate training, they can also first-assist in cesarean (operative) deliveries and perform limited ultrasound examinations. it is possible for cnms/cms to practice independently of physicians, establishing themselves as health care providers in the community of their choice. professional associations/colleges midwives alliance of north america (mana). national association of certified professional midwives (nacpm). american college of nurse-midwives (acnm). men in midwifery a male midwife in oslo, norway men rarely practice midwifery for cultural and historical reasons. in ancient greece, midwives were required by law to have given birth themselves, which prevented men from joining their ranks. julian clement is often attributed to being the first male midwife, after he attended to madame de la valerie in france in 1663. in 17th century europe, some barber surgeons, all of whom were male, specialized in births, especially births requiring the use of surgical instruments. this eventually developed into a professional split, with women serving as midwives and men becoming obstetricians. men who work as midwives are called midwives (or male midwives, if it is necessary to identify them further) or accoucheurs; the term midhusband (based on a misunderstanding of the etymology of midwife) is occasionally encountered, mostly as a joke. in previous centuries, they were called man-midwives in english. william smellie is credited with innovations on the shape of forceps. this invention corresponds with the development towards obstetrics. he advised male midwives to wear dresses to reduce controversy over having a man present at birth. as of the 21st century, most developed countries allow men to train as midwives. however, it remains very rare. in the united kingdom, even after the passing of the sex discrimination act 1975, the royal college of midwives barred men from the profession until 1983. as of march 2016, there were between 113 and 137 registered male midwives, representing 0.6% of all practising midwives in the uk. in the us, there remain a small, stable or minimally declining number of male midwives with full scope training (cnms/cms), comprising approximately 1% of the membership of the american college of nurse-midwives. in the myth of some cultures that "men lost their ability to give birth and subsequently became midwives". in some southeast asian cultures, e.g. with the semelai people (also e.g. in some sudan cultures), some or even most of the midwives are men; and the women no longer consider themselves "brave enough" (historically men and women worked as midwifes, and there are no formal prohibitions, for either gender). history medieval europe in medieval europe, it wasn't necessary for midwives to be literate. several women were midwives in medieval england. often they could be married to male medical practitioners. pierrette de bouvile the sworn midwife in the 1460s in the village of arpajon south of paris, she was married to a churchwarden. asseline alexandre, a woman who attended the births of the duchess of burgundy in the 1370s, was not married to a physician, but she was married to a bourgeois of paris. ming china a midwife in ming china had to be female, and had to be familiar with the female body and the process of childbirth. the sexual limitation in midwifery was strict due to strict sex segregation, which was common in the ming dynasty. males were not allowed to see or touch a female's body directly. in this situation, male physicians played only a minor role in childbirth. they were usually responsible for only antenatal examinations and body check-ups before and after the baby was born, but never participated in the delivery room. the skill set in midwifery was also different from medicine. women who wanted to be a midwife could only learn the skill from experts because there was no literature about midwifery. to serve in the forbidden city as a midwife, applicants had to apply through the lodge of ritual and ceremony ("lodge") (li-i fang), which was also called the bureau of nursing children (nai-tzu fu). pregnant women outside the palace were likely to pay more to hire "palace midwifes" than "folk midwifes". responsibility a midwife's responsibilities could include criminal investigations, especially those that involved women. they consulted in investigations of rape cases and determination on a female's virginity because they were the society's top specialists in sexual medicine. midwives were sometimes assigned to inspect female healers selected by the lodge, to make sure they were healthy. during the process of childbirth, they cleaned the byproducts from abortions, miscarriages and stillbirths. such work was considered "pollution" during the ming dynasty. infanticide, particularly of newborn baby girls, was part of family planning in ming times. midwives and their knowledge of infanticide played important roles in this custom. when a baby was born, the midwife inspected the baby and determined its gender. if it was a female infant, the midwife asked the mother if she wanted to keep it or not. if not, the midwife used her professional knowledge to kill the baby in the simplest and most silent way and then ask for payment. even if the decision was not made by the midwife, she had to kill the baby because she was the only one who had ability to do so in the delivery room. moreover, they were also considered as "merchants" of body parts. they were also responsible for disposing waste from the process of childbirth, which consisted of body parts from the placenta. therefore, they could easily sell them to others secretly to earn additional income. public perception the dirty work and knowledge mentioned above had a negative impact on the public attitude toward midwives. some writers then described the midwife as a second or vicious character in their stories due to a midwife's guilty knowledge. midwives were also labeled as one of "six grannies". this term was originally established by scholars and officials. over time, male physicians also blamed midwives for the same reason. although midwives dominated the field and had extensive experience in childbirth, they did not have equivalent participation on elite medical literature. oppositely, elite medical literature are dominated by male physicians, although who contributed much less in childbirth process. elders and male physicians also disparaged midwives' knowledge about the female body and the process of childbirth. male physicians even established a boundary between their learned pharmaceutical knowledge as opposite to the midwife's manual manipulations. they did not consider midwives as professionals that required expertise because their skill was not learned from scholarly literature. they believed the midwife's existence was due to gender segregation, and it limited the male physician's role in childbirth. notable midwives marie-rosalie cadron-jetté yvonne cryns charlotte führer barbara kwast emmi mäkelin zeinebou mint taleb moussa elizabeth nihell justine siegemund ronnie lichtman ina may gaskin juana miranda jennifer worth midwives in culture pharaoh and the midwives, james tissot c. 1900 shiphrah and puah are two midwives in the book of genesis (6th-5th century bc). they are noted for disobeying the pharaoh's command to kill all new-born hebrew boys. midwives is a 1997 novel by chris bohjalian. a midwife is arrested and tried when a woman in her care dies. it was selected for oprah's book club and became a new york times best seller. the tv film midwives (2001) was based on it. call the midwife (2012) is a drama series based on novels by jennifer worth. it features midwives working in the east end of london 1950–1960. the midwife (sage femme, 2017) is a film drama about claire, a midwife, and her late father's eccentric former mistress.