Midwifery Scope of Practice
Midwifery, an ancient profession that focuses on pregnancy, childbirth, and postpartum care, has been evolving to meet the needs of modern healthcare. However, the scope of practice in midwifery varies widely across the United States, with different states having distinct laws and regulations governing what midwives are allowed to do. These variations are influenced by factors such as local healthcare needs, political climates, and the historical development of midwifery in each region.
What is midwifery?
Midwifery is a healthcare profession that focuses on the care of women during pregnancy, childbirth, and the postpartum period. Midwives also provide gynecological care, family planning services, and support for breastfeeding and newborn care. The midwifery model of care emphasizes a holistic, patient-centered approach, often prioritizing natural childbirth and minimizing medical interventions unless necessary.
Midwives are trained to recognize and manage normal, low-risk pregnancies and births, but they also have the expertise to identify when a patient needs to be referred to a physician for higher-level care. Midwifery practice can vary depending on the type of midwife, which we’ll discuss next.
Types of Midwives in the US
There are several types of midwives in the U.S., and their scope of practice is influenced by their training, certification, and the state in which they practice. The three main types of midwives are Certified Nurse-Midwives (CNMs), Certified Midwives (CMs), and Certified Professional Midwives (CPMs).
1. Certified Nurse-Midwives (CNMs)
CNMs are licensed healthcare professionals who have completed both nursing and midwifery training. They are certified by the American Midwifery Certification Board (AMCB) and are qualified to provide a wide range of services, including prenatal care, labor and delivery support, postpartum care, and general women’s health services. CNMs often work in hospitals, clinics, and birth centers.
2. Certified Midwives (CMs)
Certified Midwives have similar training to CNMs but do not have a background in nursing. They are also certified by the AMCB and provide a comparable range of services. However, CMs are recognized in fewer states, limiting their ability to practice nationwide. CMs tend to work in birth centers or provide home birth services.
3. Certified Professional Midwives (CPMs)
CPMs are trained specifically in out-of-hospital births, such as home births or births in birthing centers. They are certified by the North American Registry of Midwives (NARM). CPMs often work independently or in collaboration with other healthcare providers. Their scope of practice focuses on low-risk pregnancies, and they typically do not work in hospital settings. CPMs are licensed in some states but are unregulated or restricted in others.
State-by-State Variations in Midwifery Scope of Practice
The scope of practice for midwives is determined by state law, which can vary dramatically across the U.S. While some states have broad and progressive laws that allow midwives to practice autonomously, others impose strict limitations on what midwives can do. Let’s explore some of these variations.
1. States with Full Practice Authority
In states with full practice authority, midwives—especially CNMs—are allowed to provide care without the direct supervision of a physician. These states recognize the autonomy of midwives to prescribe medications, perform certain medical procedures, and manage births without requiring a collaborative agreement with a doctor. Examples of these states include:
- New Mexico
- Oregon
- Washington
- Massachusetts
In these states, midwives can provide comprehensive prenatal, birth, and postpartum care in both hospital and out-of-hospital settings. The laws in these states are based on the idea that midwives are highly trained professionals capable of delivering safe and effective care.
2. States with Collaborative or Supervisory Requirements
In many states, midwives—particularly CNMs—must work under a collaborative agreement or be supervised by a physician. These agreements outline the scope of the midwife’s practice and establish guidelines for when the midwife must consult with or refer a patient to a doctor. Examples of states with restrictive practice environments include:
- Texas
- North Carolina
- Georgia
In these states, midwives may face limitations on their ability to prescribe medications or perform certain procedures. While CNMs are more likely to be integrated into hospital-based care, the restrictions can limit their ability to offer the full range of services they are trained to provide.
3. States with Restricted Practice for CPMs
Certified Professional Midwives (CPMs) face even more significant restrictions in some states. In states where CPMs are not licensed, they are unable to practice legally, which can severely limit access to out-of-hospital birth options for women. States like Alabama and North Carolina do not recognize CPMs at all, making it difficult for women to access home birth midwives.
However, states like Florida and Colorado license CPMs and allow them to practice independently, giving women more options for out-of-hospital births.
4. Midwifery-Friendly States
Several states have created regulatory environments that are highly supportive of midwifery. In these states, midwives can practice independently and have access to public health funding for midwifery services. Examples of midwifery-friendly states include:
- California: Offers a wide range of practice opportunities for both CNMs and CPMs.
- Vermont: Supports midwives through progressive licensing laws and insurance reimbursement.
- Alaska: Has long recognized the importance of midwives, particularly in rural and underserved areas.
The Impact of Midwifery Regulations on Access to Care
The variations in midwifery scope of practice across the U.S. have a significant impact on access to care for pregnant women. In states where midwives can practice autonomy, women have more options for both in-hospital and out-of-hospital births. They can also benefit from the holistic, low-intervention approach that midwives are known for.
In contrast, states with restrictive laws may limit access to midwifery care, particularly for women seeking home births or those who live in rural areas where hospitals and doctors are less accessible. The lack of licensure for CPMs in some states can leave a gap in maternity care, particularly for women who prefer an out-of-hospital birth experience.
The Future of Midwifery in the US
The future of midwifery in the U.S. will likely depend on ongoing efforts to standardize the profession and expand the scope of practice across more states. As more evidence supports the safety and effectiveness of midwifery care—particularly in low-risk pregnancies—there may be a push for broader licensing and full practice authority for midwives in states that currently restrict their practice.
There is also a growing recognition of the role that midwives can play in addressing maternal health disparities. In communities where women face barriers to accessing healthcare, midwives can offer more personalized, community-based care, helping to reduce maternal mortality and improve outcomes for mothers and babies.
Conclusion
The scope of practice in midwifery varies widely across the U.S., with some states offering midwives full autonomy while others impose significant restrictions. These variations have a profound impact on the availability of midwifery services and the options available to pregnant women. By understanding the regulatory landscape, we can better advocate for the expansion of midwifery care to improve maternal health outcomes and increase access to this vital profession.
As the demand for personalized, patient-centered care continues to grow, midwifery is poised to play an even larger role in the future of maternity care in the U.S.
