Commentary: Understanding Midwife Credentials

The American College of Nurse-Midwives (ACNM) read, “Birthing Collaboration Between Midwives and OB/GYNs” with great interest. The author is correct: The US is facing a shortage of OB/GYNs, and certified nurse-midwives (CNMs) can help fill this gap in the availability of maternity services. CNMs and certified midwives (CMs) provide maternity services, as well as a full range of women’s health care services, from puberty all the way through menopause.

It is important to understand the similarities and differences among midwives, their licensure, scope of practice, and supervisory and collaborative requirements.

Who, What, and Where?

Both CNMs and CMs have graduate-level midwifery degrees from education programs accredited by the Accreditation Commission for Midwifery Education (ACME). They also have passed the national certification exam of the American Midwifery Certification Board (AMCB). CNMs and CMs work in many different settings, such as hospitals, health centers, private practices, birth centers, and homes. They receive the same preparation to safely prescribe a full range of substances, medications, and treatments and to provide primary care to women.

CNMs are also registered nurses. In addition to their masters or doctoral degree granted by a nurse-midwifery education program, they receive hands-on clinical training by practicing CNMs. Most midwives in the United States are CNMs, and approximately 95% of CNM-attended births occur in hospitals. CMs have a bachelor’s degree in a field other than nursing before pursuing their graduate-level midwifery degree.

Certified professional midwives (CPMs) have no educational degree requirements. The majority of them are educated through an apprenticeship process, enabling them to take a national certification exam administered by the North American Registry of Midwives (NARM). CPMs provide pregnancy, birth, and postpartum care for women outside of the hospital-most often in birth centers and homes. CPMs are not able to prescribe most medications and do not provide the full range of services of CNMs/CMs.

CNMs are licensed to practice in all 50 states, plus Washington, DC. CMs are licensed in New Jersey, New York, and Rhode Island and are authorized to practice in Delaware and Missouri. CPMs are regulated in 26 states.

CNMs have been granted full practice authority in 25 states, and CMs have such authority in the 3 states where they are licensed, which means they are allowed to take full responsibility for services that are performed under their scope of practice and may decide when they need to consult a provider with different skills.

Only 6 states require that CNMs work under the supervision of a physician, and 14 states require that they work under a legal collaborative agreement that describes what services they may provide and when they must consult. An additional 6 states require a formal collaborative agreement for prescribing medications.   

Legal Requirements and Barriers to Practice

It’s also important to distinguish between the normal, collegial consultation that takes place on a daily basis between professionals within their scope of practice and training, and these legal requirements for supervision and collaboration. CNMs/CMs absolutely want and pursue collegial consultation and collaboration, just as obstetricians seek out the same type of interaction with other specialists. However, the legal requirements for supervision or a collaborative agreement pose significant barriers to a professional’s ability to practice.

For example, if a supervising or collaborating physician moves, no longer attends births, retires, or dies, the CNM/CM who is legally dependent on that relationship must stop practicing until a new legal supervisory or collaborative relationship can be established. For a variety of reasons, it may be a significant challenge to obtain this relationship. Unlike CNMs/CMs, an obstetrician who works with a collaborating perinatologist, for example, who moves out of state or stops practicing would not experience such an abrupt cessation in his or her ability to practice. 

ACNM and ACOG have issued a joint position statement on the relationship between the professions. It states that, “Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients.”

The professions agree that while they have differing training and scopes of practice, each should be permitted to take full responsibility for the entire range of services encompassed by those parameters. Again, while perinatologists have different training from obstetricians, obstetricians do not feel the need for a legal supervisory or collaborative agreement with perinatologists. Rather, obstetricians use their professional judgment to determine when collegial consultation and collaboration are necessary to meet patient needs.   

ACNM believes strongly that removal of fundamental barriers to practice, which both professions agree are superfluous, would significantly enhance the ability of CNMs/CMs to meet the need for obstetric care to better serve women and their families.