1. Callister, Lynn Clark PhD, RN, FAAN

Article Content

A landmark and comprehensive work focusing on birth outcomes, access, quality, and choice in the United States has recently been published (National Academies of Sciences, Engineering, and Medicine [NASEM], 2020). One of the concerns addressed the confusion that currently exists about midwifery care for policy makers, public and private insurance carriers, healthcare delivery systems, and consumers.


Overwhelming data exist documenting harm that can occur through failure to provide appropriate levels of care, and care disparities that have an effect on the most vulnerable, referred to as care that is characterized as being "too little too late." There are also data on overuse of unnecessary interventions, referred to as "too much too soon." In both instances, the restrictive scope of state practice laws for midwifery practice, barriers to the provision of midwifery care, and confusion about differing models of midwifery preparation contribute to less than optimum maternal and infant outcomes.


Compared with peer high-resource countries globally that have single path to midwifery practice with midwives participating in 50% to 75% of births, in stark contrast in the United States, only 10% of births are attended by midwives (certified nurse midwives and certified midwives). In the United States, there is variation in density of midwives in each state, varied scope of practice across states with differing regulatory statues, and lack of third-party reimbursement. These factors contribute to women not being able to access midwifery care.


In the United States, there are three distinct types of midwives with nationally recognized credentials and different education and training requirements. Certified nurse-midwives (CNMs) are licensed in 50 states and certified midwives (CMs) are licensed in six states, both require academic and clinical preparation, including a master's degree. CNMs provide well-woman care across the lifespan including maternal-newborn care and are advanced practice registered nurses (APRNs), whereas CMs do not have undergraduate nursing education and are not nurses. A third type of midwifery preparation in the United States is the certified professional midwife (CPM), which is direct entry practice based on the portfolio/apprentice model. CPMs practice in birth centers and attend home births, often lacking reliable systems for referral and collaborative care. A comparative chart that summarizes these three pathways to midwifery practice in the United States can be found in the NASEM (2020) report.


Vedam et al. (2018) mapped integration of midwifery care across the United States through using the Midwifery Integration Scoring System (MISS). They created a 50-state database focusing on regulatory practices across states, access to midwifery care, and maternal-newborn outcomes by state. These data focus on care provided by CNMs and CMs.


States were ranked according to 2014-2015 MISS scores ranging from 17 out of 100 points in North Carolina to Washington State with highest score of 61. Higher scores were associated with significantly higher rates of spontaneous vaginal births, vaginal birth after cesarean, and breastfeeding. Higher scores were also associated with lower rates of preterm birth, low birthweight infants, neonatal deaths, higher levels of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes. These findings persisted when controlling for the proportion of African American births (Vedam et al., 2018).


The American College of Nurse-Midwives, the Accreditation Commission for Midwifery Education, and the American Midwifery Certification Board acknowledge work of the APRN Consensus Work Group that seeks to develop a Consensus Model. The American College of Obstetricians and Gynecologists has endorsed the principles of APRN consensus.


Although issues are complex related to U.S. midwifery practice, there is a need for nationwide regulatory statues, equitable reimbursement, and increased availability of midwifery care for low-risk childbearing women using a single model of academic and clinical preparation as per peer countries. High-quality evidence supports importance of focus on a model of midwifery care characterized by thorough risk assessment, enhanced respect for women, and appropriate level of care "the right amount at the right time" to promote positive outcomes for women and newborns (NASEM, 2020).




National Academies of Sciences, Engineering, and Medicine. (2020). Birth settings in America: Outcomes, quality, access, and choice. The National Academies Press.[Context Link]


Vedam S., Stoll K., MacDorman M., Declercq E., Cramer R., Cheyney M., Fisher T., Butt E., Yang Y. T., Powell Kennedy H. (2018). Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS ONE, 13(2), e0192523.[Context Link]