Certified Nurse Midwife
A certified nurse midwife, sometimes referred to as a CNM or simply a nurse midwife, is an advanced-practice registered nurse (post-baccalaureate) who specializes in women's reproductive health and childbirth. Not only do they attend to women during pregnancy, childbirth, and post-partum, they also are responsible for preventive women's health maintenance.
Why Are Certified Nurse Midwives So Important?
Nurse midwives differ from physicians primarily because they are first and foremost nurses. They approach patient care with a holistic view - not only focusing on the physical needs of the patient, but the mental and psychosocial needs as well.
According to the American College of Nurse-Midwives (ACNM), the benefits of Certified Nurse Midwife (CNM) assisted births include:
- Lower rates of cesarean births
- Lower rates of labor induction/augmentation
- Significant reduction of third and fourth-degree perineal tears
- Less use of regional anesthesia
- Higher rates of breastfeeding
Additionally, women cared for by CNMs were more likely to receive:
- Prenatal education
- A more hands-on approach and closer relationship with their provider
- Fewer technological and invasive interventions
From a financial standpoint, the use of CNMs in obstetric and gynecological care can reduce health care costs. This is due to:
- An increase in access to care
- Less invasive medical interventions required
- Reduced number of cesarean births
- Reduced use of pharmacological pain management interventions
Using a midwife also opens the possibility of home births—an option which helps lessen the mother's anxiety and reduce the possibility of feeling "rushed," which may result in labor-inducing drugs or cesarean delivery.
Those interested in the field of midwifery should enjoy working with women from various backgrounds, enjoy educating patients and promoting preventive and holistic health. They should be skilled in building trusting relationships and should be able to remain unbiased, work well under pressure, and be able to provide support during emotionally charged events.
Certified Nurse Midwife Education Requirements and Training
Nurse midwives are advanced-practice registered nurses who have completed a minimum of a Master's of Science in Nursing (MSN) degree. A Doctor of Nursing Practice (DNP) is a post-graduate degree and is another option, but is not required for entry-level nurse midwifery.
To advance to an MSN, a student must first complete an accredited nursing program and obtain a Bachelor's of Science in Nursing (BSN) degree. After that, the successful completion of the NCLEX-RN is needed for licensure. The length of time it takes to complete an MSN program depends on the nurse's starting point:
- Nursing students enrolled in a BSN program complete in about four years
- RN to BSN takes about two years
- BSN to MSN takes about two years
Both online programs and classroom programs are available to accommodate students. Both types have pros and cons depending on students' needs, therefore researching individual schools is encouraged.
The training needed to become a nurse midwife is incorporated in the advanced degree program. General advanced-practice courses are completed in the first part of the program. Once the general courses are completed, students can choose a midwifery specialty track. Additionally, since there can be a lot of overlap between Women's Health Nurse Practitioner (WHNP) curriculum and midwifery, many programs offer dual certification for each.
Requirements for midwifery programs vary from institution to institution. The American College of Nurse-Midwives lists the forty schools that are accredited by the Accreditation Commission for Midwifery Education and describes which degrees are available (MSN, DNP, etc.).
They also have a reference list in which prospective students can review the various requirements for the different midwifery programs and explore available options. For example, some institutions:
- Allow non-nurses into the curriculum
- Do not require experience in nursing or labor and delivery before admission
- Offer an ADN to MSN bridge program
- Require a BSN before admission
- Offer an accelerated entry to the nurse midwifery program
Due to the considerable variability in program requirements, students are encouraged to visit the website to see which institution would best fit their needs.
The curriculum for nurse midwifery can vary depending on the student's starting point and educational institution, but should include courses and clinical practice rotations focusing on:
- Health promotion and maintenance
- Advanced pathophysiology
- Advanced health assessment
- Pharmacology for advanced practice nurses
- Primary care of women
- Role of the nurse midwife
- Care during pregnancy, labor, birth, and postpartum, to include newborn care
- Women's health
Schools that offer DNP programs also include courses in education, leadership, and advocacy.
Certified Nurse Midwife Program Specialties
While there are no formal specialties for nurse midwives (it is a specialty in and of itself), they can choose which clinical focus area to work in, such as:
- Primary care/clinics
- Birth centers
- Community health centers
Examination, Licensure, and Certification
After completing graduate or post-graduate education with a focus in midwifery, candidates can apply and test for certification. The American Midwifery Certification Board (AMCB) outlines the requirements for testing/certification such as:
- Submitting proof of licensure as an RN or NP
- Completion of a graduate program accredited by the Accreditation Commission for Midwifery Education (ACME)
- Verification by the director of the NM program confirming all program requirements were met, along with the date of completion
- Attestation by the director of the NM program that the applicant performs at a safe, competent beginner level
Applicants can attempt the exam four times, but all attempts must be within 24 months of program completion. Certification is valid for five years, and the AMCB offers re-certification options.
Certified nurse midwives also must register with their state's Board of Nursing. Some states offer certification simply by applying, if the graduate program meets the state's educational standards. Otherwise, nurses can submit certification obtained through the AMCB. Nurses are encouraged to check their state Board of Nursing to identify specific requirements.
Learn more about midwifery schools and post master's midwifery graduate certificate programs.
All midwives provide prenatal, labor and delivery, and postnatal care to patients. The major differences can be found in education requirements as well as scope of practice.
A Certified Midwife (CM) has obtained his or her certification through the American Midwifery Certification Board (AMCB), has completed an undergraduate degree, and completed required health and science courses as part of their Midwifery Program. It is important to note that this individual does not have to have an undergraduate degree in a medical specialty but rather has taken courses to fulfill the requirements.
The CM scope of practice includes primary healthcare services for women from adolescence through menopause, family planning, prenatal, childbirth, post-partum care, STI prevention/treatment as well as a broad array of education and counseling services. CMs only in certain states have the ability to prescribe medications and obtain licensure. This certification is not recognized in some states.
A Certified Nurse Midwife (CNM) has also obtained certification through the AMCB. One of the major differences between a CM and CNM is the CNM has completed an undergraduate nursing degree and obtained their RN license. The CNM, like the CM, has completed the Midwifery Program. The major difference between the CM and CNM is that in all states, CNMs have the ability to prescribe medications and obtain licensure.
The scope of practice of Certified Professional Midwives (CPMs) is narrowed to prenatal, childbirth, postpartum, and 6-8 weeks of care for mother and baby following delivery. CPMs do not have any prescribing abilities in any states. However, in some they can obtain additional education requirements for medications administration. In more than half of the United States, the CPM can obtain licensure that is regulated by different licensing agencies.
While CNMs are trained to handle certain aspects of labor and recognize potential complications, they also know when to seek collaboration with an OBGYN MD. For example, complications can arise such as a drop in fetal heart rate or excessive bleeding. The midwife is trained to bring an OBGYN in to manage the situation and perform the necessary interventions that are outside his or her scope of practice.
Vacuum-assisted delivery involves using a suction device to guide the baby through the birth canal. This procedure is done to help avoid a C-section. As with any medical intervention, there are risks associated with vacuum-assisted births such as minor scalp injuries, skull injuries, hematomas, and hemorrhage. Depending on the state and employer, CNMs can perform vacuum-assisted deliveries if trained and comfortable doing so.
Forceps delivery involves using forceps to extract the baby as the mother pushes. As with vacuum-assisted delivery, there are risks involved which include soft tissue damage in both mother and baby, as well as lacerations. CNMs can perform forceps delivery if trained to do so, but this ultimately depends on the state and employer.
CNMs are not permitted to perform C-sections. However, some states and organizations allow nurse midwives to act as first-assist during the procedure. This means they can help apply pressure to remove the baby, keep the surgical field clear of blood (via suction and blotting), suturing, and even sometimes closing.
Women’s Health Nurse Practitioners are APRNs who specialize in the care of women throughout the lifespan. They focus on reproductive and gynecological health as well as preventive health maintenance. Additionally, some can address specific chronic health issues. Certified Nurse-Midwives also manage the reproductive health of women, but focus mainly on pregnancy, labor, and childbirth.
The education for both WHNPs and CNMs is similar. Both are advanced-practice nurses who complete either a master's degree or higher. However, students may choose either the Women's Health track or the Certified Nurse Midwife track. While the course of study is similar and may have overlap, the CNM track emphasizes labor, childbirth, and the immediate post-partum and neonatal period.
Both WHNPs and CNMs can work in clinic settings. WHNPs can act as a patient’s primary care provider. This means that they can care for patients from an early age through the aging years. They can work in the inpatient setting as well, such as in emergency rooms or rounding on patients who are admitted with women’s health-related conditions. They may even work alongside physicians as first-assist during surgical procedures.
In clinics, CNMs educate patients on family planning, prenatal health, and the labor process. CNMs spend a significant amount of time in hospitals and birth centers. They care for patients during the antepartum, intrapartum, and postpartum periods. Additionally, they assess and stabilize a newborn following birth. They may also intervene/refer during abnormal birth situations, or when a mother or fetus needs more intensive care.
As with any healthcare provider, malpractice cases threaten even the most cautious certified nurse-midwife.
Depending on the organization or facility the CNM is employed, malpractice insurance may or may not be required. Some organizations provide malpractice insurance for their providers, and therefore, additional coverage is not necessary for employment. However, many would argue the benefits of carrying additional coverage because employer-paid coverage may not be adequate in covering financial losses, and representation may be lacking in quality.
The cost of malpractice insurance can vary. Cost can depend on the state of employment, years of experience, setting, and the coverage chosen. CNMs tend to pay more the more years of experience they have (more deliveries mean more potential for lawsuits). The cost can be as low as $5,000-$6,000 per year or exceed $20,000 per year. CNMs in a group practice may pay lower rates depending on how many providers they are in practice with. Additionally, some physicians who are engaged in a collaborative agreement with a CNM due to their state's scope of practice laws may even be charged fees by the CNM’s malpractice insurance company.
CNMs may consider doing further research with the following companies:
The hours a certified nurse midwife (CNM) works vary depending on the organization, facility, or practice group, as well as their preference. Some can work 8-hour days, 40 hours a week in the clinic. Some may work 10 or 12-hour shifts in the hospital. Some may work both shifts during a workweek.
Additionally, since childbirth is unpredictable, and babies are not always born during business hours, some CNMs may also be on call for 24-hour periods of time. A shift could be incredibly busy with laboring mothers, or an entire shift can go by without one admission. CNMs must also be prepared to work overnight shifts as well.
Because of the variable shifts available, certified nurse midwives should visit the organization’s website or speak with a manager or HR department before applying to discuss scheduling needs. Most facilities are flexible in their scheduling, but nurse midwives should conduct a little research beforehand.
While CNMs have many benefits, many parents-to-be and even student nurses interested in a career as a CNM are curious as to their limitations in the delivery room. For example, are there any situations in which a CNM is not qualified to assist? More specifically, delivering multiples (twins, triplets, etc.)?
CNM roles and duties are dependent on the state, as each state has its own scope of practice laws. Some states allow independent practice while others require an MD present. It also depends on the facility or organization. Some private practices may enable CNMs to manage delivering multiples, while others do not. Larger organizations frequently have specific practice limitations as well.
In short, from an educational standpoint, a certified nurse-midwife CAN manage multiple births. The question is if they are restricted by state and organizational regulations. CNMs should check with their state board of nursing to determine their specific scope of practice and for any physician oversight/collaborative agreement requirements. Additionally, they should check with their employer to find out if there are any facility-based restrictions. Above all, a CNM needs to feel comfortable asking for assistance when needed.
Many expecting parents explore the midwife-led birth option but are concerned as well as curious about the care they will receive when the time comes to give birth. It’s important to recognize that nurse-midwives are advanced-practice nurses, therefore have more extensive formal education and clinical training than registered nurses. They are often precepted by other nurse-midwives and have physician oversight while in training. A certain number of clinical hours are required to graduate and obtain certification. Rest assured, nurse midwives are well-prepared to care for patients during the prenatal period as well as the labor and birthing process.
The American College of Nurse-Midwives report that midwife-led births resulted in:
- Lower Cesarean rates
- Lower rates of labor induction
- Reduced perineal tears
- Lower use of regional anesthesia
- Higher breastfeeding rates
In addition to the above, births attended to by midwives are enhanced as a result of the Midwife Model of Care. This model emphasizes monitoring not only the physical implications of childbirth but the psychological and social well-being of the patient. Patients also can enjoy individualized education, counseling, and post-partum support.
While midwife-led births are patient-centered and as safe as physician-led births, it should be noted that midwives are trained to recognize potential complications and collaborate with physicians when necessary.
According to the Bureau of Labor Statistics, advanced practice nurses, in general, have a promising job outlook. The field is expected to grow 31% by 2024—much faster than average. Growth is projected to occur due to health care legislation leading to a higher number of health care consumers, a nationwide physician shortage, and a stronger push for preventive health maintenance.
With babies being born every minute, and with many parents-to-be exploring alternative birthing scenarios which don't always involve a traditional hospital environment, the employment outlook for CNMs in particular remains positive. With the option to work in a variety of women's health settings, or to take on patients on their own in certain states, CNMs have the opportunity to shape their careers as they see fit.
Nurse midwives have a wide variety of responsibilities and duties in the field of women's health. The ACNM lists the core competencies in detail that all nurse midwives should demonstrate. Responsibilities include:
- Women's health maintenance
- Encouraging preventive health screenings/tests
- Educating on women's health issues such as sexuality, responsible sexual behaviors, and menopause
- Recognizing and treating gynecological disorders such as infertility, sexually transmitted diseases and infection, as well as urogynecological disorders
- Family planning
- Educating on available contraception, allowing patients to make informed choices
- Educating, treating, or referring for infertility
- Educating/counseling on unexpected pregnancies
- Educating, counseling, and treating the various concerns surrounding menopause
- Antepartum period
- Confirming and dating pregnancy
- Educating on environment, health habits, and nutrition in relation to pregnancy health
- Screening for domestic violence, substance abuse, and high-risk behaviors during pregnancy
- Screening/testing for potential congenital disabilities with the consent of the mother
- Monitoring fetal development, and recognizing deviations from the normal progress of gestation
- Intrapartum period
- Assessing labor and labor progress
- Monitoring the mother and fetus during labor, and recognizing deviations from normal labor
- Managing complications during labor, including emergencies
- Administering pharmacological and non-pharmacological interventions for pain
- Facilitating labor if needed
- Delivering the newborn
- Performing episiotomies (first and second degree) if needed
- Delivering the placenta
- Postpartum care
- Assisting mother with uterine massage after birth
- Educating mothers on physiologic changes that can last until six weeks after birth, including:
- Potential discomforts
- Psychosocial coping
- Resuming sexual activity and contraception
- Recognizing and treating deviations from normal postpartum progress
- Newborn care
- Facilitating the transition from fetus to newborn, including:
- Establishing and maintaining newborn respirations
- Cord clamping
- Stabilizing the temperature of the newborn
- Assisting with feeding/latching
- Promoting bonding and attachment
- Recognizing deviations from the normal newborn period, and managing complications
- Evaluation and treatment of the newborn to include
- Initial physical assessment (APGAR)
- Ongoing assessment for well newborns up to twenty-eight days of life
- Monitoring feeding and weight gain
- Educating caregivers on normal newborn care
- Ordering preventive care/screenings such as:
- Eye ointment
- Vitamin K injections
- Hearing tests
- Intervening or referring for abnormal conditions/situations to include:
- Congenital malformations
- Poor transition to extrauterine life
- Postpartum depression
- Facilitating the transition from fetus to newborn, including:
Nurse midwifery can be an enriching, yet challenging career. A typical work setting for nurse midwives includes:
- Developing an emotional involvement with patients. Nurse midwives must interact closely with women and families. They must work hard to educate patients on common women's health issues and monitor them through the life span which can include births, but also end-of-life care. This leads to close caregiver/patient relationships that are valued both by the midwife as well as the patient.
- Potential occupational hazards. As with any profession in health care, nurse midwives are exposed to bloodborne pathogens, infectious diseases, and other possible contaminates. They must always practice safely and use personal protective equipment when providing patient care during a high-risk procedure.
- Occasional high-stress situations. Nurse midwives are sometimes faced with busy, stressful shifts that can include emergencies. They need to be able to work well under pressure and think and act quickly while maintaining safety. They should also have an adequate support system to help them cope with the stress and emotions many caregivers experience.
- Remaining aware of legalities/scope of practice concerns. Nurses, especially advanced-practice nurses, must be careful and accurate in their work. Medical errors can cause harm or even the death of patients. They need to be up to date on standards of care and practice, technology, and safe practices. Home births can isolate mothers from quick emergency care, so nurse midwives that assist in home births need to have a plan in place to safely deliver newborns in the home-based setting. Carrying malpractice insurance is highly recommended for health care providers, especially advanced practitioners.
According to Payscale, nurse midwives earn a median salary of $90,672 annually. This can vary depending on state/city of residence, type of employer, and degree held.
According to the ACNM, certified nurse midwives and certified midwives (non-nurses) attended 332,107 births in 2014, which accounted for 8.3% of total births in the U.S. While this percentage may not seem like much, certified nurse midwives accounted for more than 90% of midwife-assisted births. Additionally, the rate of midwife-assisted births has risen every year since 1989.
The states with the highest employment of nurse midwives according to the Bureau of Labor Statistics are:
- New York
Get more precise details of a midwife salary.