The purpose of this document is to provide a brief overview of the midwifery profession in the United States, with particular emphasis on nurse-midwifery and the recent decision by the American College of Nurse-Midwives (ACNM) to accept, as members, certified midwives who do not have a nursing credential.


Midwifery is an ancient profession, with a proud tradition of providing care for women during pregnancy and childbirth. In the United States, midwives have been attending births since colonial times. During the 1920s, a combination of the nursing and midwifery professions, modeled after nurse-midwives practicing in the United Kingdom, led to the formation of the Frontier Nursing Service in Kentucky and the Maternity Center Association in New York. American nurse-midwives trace their history to rural and urban settings where mothers and their babies frequently had little access to health care. From the beginning, nurse-midwives were able to provide that primary care to women and their families. These early experiences provided the first documented evidence in the U.S. that nurse-midwives could reduce the rates of maternal and infant mortality and improve the health of women, especially among vulnerable population.

Nurse-Midwives Today

Over the past 70 years, nurse-midwives in America have continued that tradition. Nurse-midwives practice in collaboration and consultation with other health care professionals, providing primary, gynecological and maternity care to women in the context of the larger health care system. Our partners in providing care include Ob/Gyns, family practice physicians, nurse practitioners, physician assistants, midwives, nurses and doulas. In 1995, nurse-midwives attended more that 200,000 births in the U.S. ACNM is the national organization representing more that 6000 certified nurse-midwives (CNMs) and certified midwives (CMs) from all 50 states and most U.S. territories. ACNM is proud of our twin heritages of nursing and midwifery. We also recognize that this dual preparation is not a basic requirement to provide competent midwifery care to women and their families.

Midwifery in Other Countries

In Europe and many countries throughout the world, midwifery care is the norm for birthing mothers and only high-risk or complicated pregnancies are referred to physicians for medical intervention and management. In those countries, there is uniform agreement on appropriate educational preparation and professional credentialing for midwives and prior nursing preparation may be but is not always a prerequisite. Indeed, the World Health Organization (WHO) has defined a midwife as a person who has completed a prescribed course of studies in an education program that is fully recognized in that country, and acquired the requisite qualifications to be legally licensed to practice midwifery. Studies have documented the quality of care provided by midwives who meet the WHO standard in both industrialized and developing nations.

The ACNM Credentialing Process

Because ACNM believes that a nursing credential is not the only avenue of preparation for midwives to deliver safe and competent care, we have recently moved to develop education programs for midwives who do not wish to earn a nursing credential. The ACNM Certification Council (ACC) has opened its national certification exam to graduates of midwifery education programs approved by our Division of Accreditation (DOA), which in turn is approved as an accrediting agency by the U.S. Department of Education. These "certified midwives (CMs)," as they will come to be known, are educated to meet the same high standards that certified nurse-midwives (CNMs) must meet. These are the standards that every state in the U.S. has recognized as the legal basis for nurse-midwifery practice. CMs, like CNMs, must earn at least a Bachelor's degree. CMs must also complete core science requirements similar to those required for a nurse, and fulfill core midwifery requirements that have always been a part of our education programs. CMs take the same ACC exam as CNMs and study side by side with nurse-midwifery students in some education programs.

The Legal Status of Midwifery

Nurse-midwives practice legally in all 50 states and the District of Columbia. In some 19 states, midwifery is a regulated profession and no registered nurse (RN) credential is required. In eleven more states, midwifery practice by non-nurses is *legal*, but *unregulated*. In at least seven states, the legal status of midwives other than CNMs is in dispute. And finally, in 15 states, one *must* have an RN credential in order to legally practice as a midwife. Midwives without a prior nursing credential are sometimes called "direct entry," "lay," "licensed" or "professional" midwives and their practices usually provide home birth or birth center options for women. The scope of practice for these midwives is frequently more limited that for nurse-midwives. ACNM's decision to certify midwives whose education does not include nursing is consistent with the expanding interest, at the state level, in providing students with alternate paths to midwifery education and with increasing consumer choice as to type of midwife and place of birth.

The Home Birth Option

ACNM respects the desire of women for a natural, normal birth at home. A small percentage of our members provide home birth care, but there are many barriers to doing so. It is difficult and expensive to obtain professional liability coverage for home birth services. It often can be difficult to find physicians who are willing to be on call in case a birth becomes complicated. And, women who live too great a distance from hospitals may not be good candidates for a home birth. Consequently, the majority of CNM attended births take place in free-standing birth centers or hospital birthing rooms. Nevertheless, ACNM continues to support education and practice by CNMs and CMs in *all* setting and recently published a Handbook on Home Birth Practice to guide our students and members on safe home birth practices.

Standards for Practice

Women who have sought the care of midwives for a home birth are, for the most part, well cared for and studies on home births have confirmed the safety of the planned home birth option for healthy women experiencing a normal pregnancy and delivery. However, in states where midwives are unregulated or illegal, appropriate mechanisms to ensure the safety of birthing mothers and their children, as well as sanctions for dangerous practices, may not be in place. State officials have voiced their concerns about the need for appropriate education and clinical preparation to ensure safe outcomes for women. So has the ACNM. It is for this reason that ACNM carefully developed the curriculum and related requirements leading to a certified midwife credential, based on the 70 year history of nurse-midwifery practice in the U.S. We want to make sure that women have the assurance that all practitioners who call themselves midwives meet minimum standards of academic and clinical preparation, consistent with the World Health Organization definition. Further, we believe that all health care professionals who provide maternity care should meet these standards of academic and clinical preparation.

Other Midwifery Credentials

The Midwives Alliance of North America (MANA), another association of midwives, has created its own credential, the certified professional midwife (CPM). MANA has also created an accrediting body, the Midwifery Education and Accreditation Council (MEAC), for midwifery education programs. With MANA's support, the North American Registry of Midwives (NARM) has been established as a certifying body to administer an exam for persons wishing to be certified by NARM as midwives. NARM permits experienced midwives who have not completed a MEAC accredited education program to take its exam. Potentially then, there could be many categories of midwives practicing in a particular state: CNMs, CMs, CPMs, midwives with a state credential, and lay midwives without formal credentials. Clearly, this may cause confusion for consumers, health care institutions and state regulators alike.

Looking Ahead: The ACNM Agenda

ACNM looks forward to the day when there is one, unified profession of midwifery working toward common goals. In the meantime, we will continue to uphold our standards for academic preparation and clinical practice. Study after study has confirmed the quality of care that CNMs provide, with lower rates of cesarean sections, episiotomies, epidurals and technological interventions among low-risk women, and as a result, utilization of fewer health care resources. Studies have also documented that women and families experience a high level of satisfaction when cared for by CNMs. As an organization, ACNM respects the rights of its members and chapters to take independent positions on legislation, regulations or other issues relating to the midwifery profession. We support efforts to legally recognize CMs as qualified practitioners granted the same rights and responsibilities as CNMs. We acknowledge that not every practitioner of midwifery will choose to seek a CNM or CM credential. It is then up to consumers and state governments to determine and evaluate the quality of care provided by each type of midwife, and the value that each credential has for ensuring safe, quality care for women and babies.

Approved, ACNM Board of Directors

September 1997

For a more detailed and comprehensive packet of materials about CNMs and CM in the U.S. and the various issues raised in this paper, please contact ACNM's Department of Professional Services (202)728-9860.