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Midwifery in the U.S. is as old as the country itself. Midwife-attended childbirth was a customary practice up until the earliest part of the 20th century, when a number of medical groups, pushing obstetrical care, recommended hospitalization for all deliveries and the gradual abolition of midwifery.
However, proponents of the practice of midwifery were not easily silenced, and by 1925 midwifery began its slow rebirth in the U.S. in the form of nurse-midwifery, thanks to the founding of the Frontier Nursing Service by Mary Breckenridge. While working as a public health nurse for the Red Cross in France during World War I, she became familiar with the British nurse-midwives, who possessed the training necessary to serve as trustworthy healthcare providers. She brought this knowledge back to the States, thus enhancing the practice and giving it a renewed credibility in women’s eyes.
But the nurse-midwife practice did not move from home births until the mid-1950s, when a number of inner-city teaching hospitals developed midwifery services to help deal with the post-war baby boom. Despite their relatively small numbers, nurse-midwives remained influential healthcare providers, playing a significant role in the development of childbirth education and the promotion of breastfeeding, and more.
By the 1970s, the role of nurse-midwives began to broaden—thanks, in part, to national certification for nurse-midwives and a number of studies that found positive outcomes and cost savings associated with nurse-midwifery care. Certified nurse-midwife-attended births increased from about one percent in the mid-1970s to accounting for nearly 12 percent of all vaginal hospital births in 2013.
Today’s certified nurse-midwives are valued and trusted healthcare providers who provide women with a low-tech, high-touch alternative to traditional gynecologic and obstetrical care.
So what, exactly, is a certified nurse-midwife (CNM)? The answer to that question is multidimensional:
Certified Nurse-Midwives have an Advanced Level of Education and Training
Although the scope of practice for certified-nurse midwives varies according to state law, certified nurse-midwives must possess the same qualifications in all U.S. states:
- A registered nurse (RN) or advanced practice registered nurse (APRN) license: Unlike certified midwives (CMs) and certified professional midwives (CPMs), certified nurse-midwives come from a background in nursing. Most states license CNMs as APRNs, while some license them independently or with an endorsement to their standard RN license. In all cases, CNMs must maintain licensure in order to practice in the U.S.
- A graduate-level education in nurse-midwifery: CNMs must possess a graduate-level degree in nurse-midwifery. The most widely recognized graduate degree for nurse-midwives is the Master of Science in Nursing (MSN), although master’s-prepared RNs may also complete post-master’s certificate programs and doctoral programs in nurse-midwifery. The Accreditation Commission for Midwifery Education (ACME) is the sole accrediting agency for nurse-midwifery education programs in the U.S.
MSN degrees allow students to build upon their RN competencies as to demonstrate a greater depth and breadth of knowledge, and an increased complexity of skills and interventions. MSN Nurse-Midwifery degree programs prepare RNs to take the national certification examination to become a Certified Nurse-Midwife.
- National certification as a certified nurse-midwife: Nurse-midwives must pass a national certification examination and earn national certification as a certified nurse-midwife (CNM) through the American Midwifery Certification Board (AMCB). To qualify to sit for the CNM examination, candidates must possess a valid RN license and must have graduated from an ACME-accredited nurse-midwifery program. National certification has been a requirement for CNM practice since 1971.
Certified Nurse-Midwives are Licensed Healthcare Providers with Prescriptive Authority in All 50 States
Certified nurse-midwives possess legal authority to practice in all U.S. states, as well as the District of Columbia. Therefore, they must earn licensure through the state in which they practice.
Nurse-midwives practice midwifery under Boards of Nursing in 44 states (including 5 states where they are jointly regulated by Boards of Nursing and Boards of Medicine), while in the remaining states, they are regulated by Boards of Midwifery, Boards of Health, or Boards of Medicine.
Twenty-six states (as of February 2016) follow the APRN Consensus Model and recognize CNMs as independent healthcare providers:
- Alaska
- Arizona
- Colorado
- Connecticut
- Delaware
- Hawaii
- Idaho
- Iowa
- Kentucky
- Maine
- Maryland
- Massachusetts
- Minnesota
- Montana
- Nevada
- New Hampshire
- New Mexico
- North Dakota
- Oklahoma
- Oregon
- Rhode Island
- Utah
- Vermont
- Washington
- Washington D.C.
- Wyoming
While all states confer prescriptive authority to CNMs, just 22 states (as of February 2016) allow CNMs independent prescribing authority:
- Washington
- Oregon
- Idaho
- Montana
- Wyoming
- Nevada
- Utah
- Colorado
- Arizona
- New Mexico
- Alaska
- Hawaii
- North Dakota
- Minnesota
- Iowa
- Washington D.C.
- Maine
- Vermont
- New Hampshire
- Massachusetts
- Connecticut
- Rhode Island
Certified Nurse-Midwives Focus on a Holistic Approach to Gynecological and Obstetrical Care
One of the major differences between nurse-midwives and gynecologists/obstetricians is that nurse-midwives offer a more holistic—low tech, high-touch—approach to care. While the medical model of care tends to focus on managing problems and complications through the use of routine care and the use of technological interventions, the midwifery model of care instead focuses on:
- Health, wellness, and prevention
- Labor and birth as a normal, physiological process
- Minimal interventions
- Individualized care
The ACNM’s Core Competencies for Basic Midwifery Practice recognizes the skills and competencies all new nurse-midwives must possess. This includes integrating the following holistic-focused hallmarks of the practice of midwifery:
- Recognizing that menarche, pregnancy, birth, and menopause are normal physiologic and developmental processes
- Advocating for no interventions in the normal process and in the absence of complications
- Incorporating scientific evidence into clinical practice
- Promoting woman- and family-centered care
- Empowering women as partners in healthcare
- Facilitating the health family and interpersonal relationships
- Promoting continuity of care
- Ensuring the implementation of health promotion, disease prevention, and health education
- Promoting the public healthcare perspective
- Providing care to vulnerable populations
- Advocating for informed choice, shared decision-making, and the right to self-determination
- Integrating cultural humility
- Incorporating evidence-based alternative and complementary therapies in education and practice
- Communicating, guiding, and counseling
- Appreciating the therapeutic value of human presence
- Collaborating with other members of an interprofessional healthcare team
Certified Nurse-Midwives Provide a Full Range of Healthcare Services to Women from Adolescence On
Certified nurse-midwives provide a full range of healthcare services for women, including:
- Primary care
- Gynecologic and family planning services
- Preconception care
- Care during pregnancy
- Childbirth and the postpartum period
- Care of the normal newborn during the first 28 days of life
CNMs assess, diagnose, and treat patients. Their services also include health promotion, disease prevention, and individualized wellness education and counseling. Some of their duties include:
- Conducting initial and ongoing physical examinations
- Ordering and interpreting laboratory and diagnostic tests
- Prescribing medications, including contraceptives and controlled substances
- Admitting, managing, and discharging patients
CNMs focus on normal, healthy pregnancies. However, they are educated to recognize the signs and symptoms of less-than-normal conditions and consult with other members of the multidisciplinary healthcare team when problems or issues arise.
CNMs work in a variety of settings, including:
- Hospitals
- Women’s health clinics
- Midwifery practices
- OB/GYN practices
- Private homes
- Birthing centers
Certified Nurse-Midwives Provide High Quality Care with Excellent Outcomes
The growth of midwifery care is supported by research that demonstrates midwifery care is associated with high-quality care and is comparable to care provided by obstetricians/gynecologists. Further, some studies have found that patients experience better outcomes with nurse-midwives than obstetricians/gynecologists.
According to the American College of Nurse-Midwives (ACNM), patients of nurse-midwives report high levels of patient satisfaction, and midwifery care results in lower costs due to fewer interventions, which are often unnecessary, expensive, and invasive.
Further, research has found that midwifery care for low-risk women reduces the infant mortality rate in hospitals and birth centers compared with physicians caring for women with the same low risk factors. Similar studies found that CNM care is associated with:
- Higher rates of breastfeeding
- Lower rates of C-sections
- Lower rates of labor induction and augmentation
- Lower use of regional anesthesia