Certified Nurse-Midwives (CNM)

[sirI]

Certified nurse-midwives (CNM) are educated in the two disciplines of nursing and midwifery. They provide primary healthcare to women of childbearing age including: prenatal care, labor and delivery care, care after birth, gynecological exams, newborn care, assistance with family planning decisions, preconception care, menopausal management and counseling in health maintenance and disease prevention. CNMs attend a very small percentage of births in the United States.

The CNM dates back to the early 1920's when Mary Breckinridge started a program in Kentucky using nurses from other countries. As the need for licensed professional nurses grew, programs started growing and now all CNM must be educated as RN's, complete a Nurse-Midwifery program, and become certified as nurse-midwives. Programs must adhere to the standards of midwifery practice in the United States as set forth by the American College of Nurse-Midwives (ACNM).

The CNM works closely with Obstetricians and Gynecologists (OB-GYN physicians). They take on what is considered "low-risk" pregnancies. Should the midwife recognize the gravida is high-risk, he/she will consult and refer immediately to the OB-GYN. The majority of CNM work in hospitals and in poor, rural townships/cities. They also are employed in birthing centers and Health Departments. The role of the CNM has greatly enhanced the quality of healthcare for women in the past 40 years in areas where OB-GYNs are not available.

Scope of Practice

• Physical Assessment
• Prescription privileges
• Education
• Referrals and consultations
• General health of women and the newborn
• General uncomplicated lady partsl birth of the gravida and immediate care of the newborn

Regulation of the CNM

• The state Board of Nursing (BON) licenses the RN
• Only graduates of an accredited midwifery program are eligible to sit for certification as CNM

CNM Education

For the past several years, there has been much discussion about the education process for the APRN. Most APRN programs have moved to the Doctor of Nursing Practice (DNP) as the minimum entry into practice for Nurse Practitioners (NP) and the DNP or Doctor of Nurse Anesthesia Practice (DNAP) for Certified Nurse Anesthetists (CRNA). The Clinical Nurse Specialist (CNS) seems to follow along the same lines.

According to the 2020 FAQ from the American College of Nurse-Midwives (ACNM):

Quote

The type of academic credit and degree awarded may be different for each program. All (Accreditation Commission for Midwifery Education) ACME-accredited midwifery education programs award a Masters Degree and/or Doctor of Nursing Practice (DNP) degree; some programs offer a master's completion option for CNMs who do not have Master's degrees; and several programs offer a post-graduate certificate option for those graduate-prepared advanced practice nurses who want to expand their practice to include midwifery. Upon graduation from an ACME-accredited program, individuals are eligible to take the national certifying exam offered by the American Midwifery Certification Board (AMCB). Upon successful completion of this exam, individuals are granted a Certificate in either Nurse-Midwifery or Midwifery.

Educational Programs (not all-inclusive)

Georgetown University School of Nursing and Health Studies - (MS, BSN to DNP)

Texas Tech University Health Sciences Center School of Nursing - (MSN, Post Graduate Certificate)

Baylor University College of Nursing - (Doctor of Nursing Practice-DNP)

California State University, Fullerton School of Nursing  - (MSN/Post-Master's Certificate)

University of Colorado, Anschutz Medical Campus, College of Nursing  - (MS, Post-Graduate Certificate, DNP )

Emory University Nell Hodgson Woodruff School of Nursing  - (DNP, BSN-MSN, MSN or MSN/MPH, Post Graduate Certificate)

Vanderbilt University School of Nursing - (MSN, Post Graduate Certificate)

Differences between CNM and Lay Midwife

The difference between the two is their training.

Lay midwives are not nurses, rather, they're those who have had direct training in midwifery through self-study and the majority, apprenticeship. Some lay midwives later decide to enter into a Masters Nursing Program and combine Nurse-Midwifery with the program.

A licensed midwife is sanctioned by her/his state after she/he passes a test administered by the state's medical board licensing division. Licensing requirements differ among states; some, like Oregon, do not require licensing at all. Lay midwives in eight states - Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, Virginia, and Wyoming - and in the District of Columbia legally are not able to become licensed midwives. So while you may be able to have a legal homebirth in those states, a lay midwife could risk arrest by attending.

Liability Insurance for the CNM

Many Insurance companies will not cover the CNM. The following is one company that provides competitive premiums for the CNM and Midwifery Student.

Contemporary Insurance Services

Salary (2020)

According to salary.com, the average annual salary in the U.S. is $110,963 with a range between $102,034 and $125,739.

According to Glassdoor, the national average salary for a CNM in the U.S. is $106,576.

 

[sirI, MSN, APRN, NP]

mamagui said:

...so, I guess midwifery is both, depending on the type midwife. Also, the scope of practice is distinct for a CNM as they provide well woman care across the lifespan, have prescriptive authority, etc., whereas the CM focuses mostly on perinatal care.

Correct.

Seems somewhat confusing when there are really 5 types of those who practice midwifery, but only those who are Certified Nurse Mid-wives (CNM) are classified as APRN and have prescription privileges. For those in states that do not recognize the CNS and/or the CNM it really becomes confusing.

[sirI, MSN, APRN, NP]

queenanneslace said:

Midwifery and Childbirth in America - Judith Rooks - Google Books

Go to page 247, there's a good overview of the development of both the CPM and the CM credentials by MANA and ACNM respectively.

CMs do not have recognition by most states - perhaps, because state BONs license CNMs dually as nurses and CNMs, or advance practice nurses. There is some concern that if CNMs are licensed as APRNs - as many states are currently pushing for uniform APRN licensure across multiple advance practice nurse specialties, that barriers to recognition of the CM credential will be increased.

Thank you for the book link, queenanneslace. And, agree there could be many barriers for those who seek the CM credential as opposed to the CNM cred. In the state(s) where they are already in practice and if this becomes a greater issue, they will still be allowed to practice and not required to be CNM; in other words, they will not be dis-enfranchised unless they decide to move to another state where the CNM is required. So, as long as they stay in their own state, this will not be problematic.

It is like when those who first started practicing as NP's. They were not required to have a Masters degree. They only had to be a nurse (diploma, ADN, etc.) and be certified as an OB-GYN NP by the NCC; but required no formal training as an NP. Then, a few years ago, a Masters Degree was required along with the NCC certification. They could could still practice as NPs w/o the degree and some still do, but they must do so in their own state. If they relocate, the NP must then be required to have a Masters in order to even be classified as an APRN and many must use the credential, RNP. But, they were not dis-enfranchised.

Most of the midwives with whom I associate are CNM in a hospital setting (and, are Masters-prepared CNM). I do remember, as a child, a Lay Midwife who worked in rural Louisiana and delivered many babies w/o any difficulties at all.

I asked in my original Article had anyone read the book or seen the TV movie (starring Sissy Spacek), Midwives? I don't recall what type of midwife she was. I'm thinking she was a Lay Midwife, although I am not certain. I do remember seeing certificates hanging on the wall of her office. It is a good movie (the book as I recall was much better as books usually are in comparison to the movie).

[queenanneslace, ADN, MSN, APRN, CNM]

I would refer you to the ACNM website and find where the CM scope of practice - by credential - is limited to perinatal care only. This is not true.

Yes CMs are limited by licensing laws in different states, this does not negate the fact that their training and competencies are equivalent to the CNM.

Midwifery - as represented by the ACNM - created a non-nurse credential: the CM - which is a Master's prepared midwife. So this goes back to the original question. Is midwifery truly a subspeciality of nursing if there are non-nursing routes to certification? The Varney Burst article outlines quite nicely the history of nurse-midwifery, midwifery's relationship to nursing, and ramifications for midwifery if the profession is defined as an APRN specialty.

As far as I know, no other APRN specialty has created a non-nurse credential. So the CM is somewhat of a problem child in the APRN world, isn't it?

I think it is a fascinating discussion. If it became accepted that non-nurses could assume an APRN role, why stop at midwives? Would CRNAs need to be nurses? NPs? Would other advance practice nursing roles waive the RN requirement? I can't see that happening. But it makes for an interesting discussion.

[biggolp]

I would like to reiterate that in the few states where the CM credential is recognized, the scope of service is identical to that of the CNM.

In the two schools that prepare non-nurses for this certification, the non-nurses sit side-by-side with the nurses and take the identical classes (after a single-semester bridge).

They then sit for the same Boards and are certified by the same body (ACMB) as either CMs or CNMs (depending on whether or not they are RNs)

In my state, the CMs also deliver in hospitals.

[LibraSunCNM, BSN, MSN, CNM]

sirI said:

I asked in my original Article had anyone read the book or seen the TV movie (starring Sissy Spacek), Midwives? I don't recall what type of midwife she was. I'm thinking she was a Lay Midwife, although I am not certain. I do remember seeing certificates hanging on the wall of her office. It is a good movie (the book as I recall was much better as books usually are in comparison to the movie).

Yes, I have read it and seen the made-for-TV movie version. She is described in the book as a "lay midwife," having learned via an apprenticeship model. This term really isn't used much in reality though, which is the issues I take with this article. "Lay midwife" describes someone who learns ONLY through apprenticeship, and there are not many midwives who were trained that way.

The majority of non-nurse midwives are Certified Professional Midwives, whose course of study is outlined and regulated by the North American Registry of Midwives (NARM). Using the term "lay midwife" to refer to ANY non-nurse midwife gets a bit tricky because it lumps people like CPMs, whose education is strictly and carefully regulated, with any random person off the street who attends some births and calls him/herself a midwife (not that that is common!).

I loved the book but I don't think it is a good representation of the complexities facing midwifery in the U.S. today.

[mamagui]

queenanneslace said:

I would refer you to the ACNM website and find where the CM scope of practice - by credential - is limited to perinatal care only. This is not true.

You are right! I was looking at a nice table that compare the scope of practice and education of different types of midwives and realized that CM's do, indeed, have the same scope of practice. I did not realize this beforehand, as we have no CM's here in South Carolina. It seems as they even have prescriptive authority (according to the chart).

I do take some issue with them having the same education as nurse midwives because they are not required to completing a nursing program prior to graduate studies in midwifery, nor do they have to pass the NCLEX. This is not to say that they are not perfectly competent midwives, however they are NOT nurses.

[mamagui]

LilyRoseCNM said:

"Lay midwife" describes someone who learns ONLY through apprenticeship, and there are not many midwives who were trained that way.

Lay midwives still exist in the US, although their dubious legal status and the advent of credentialed midwifery programs have eliminated many.

In other countries, however, lay-midwives greatly outnumber college educated ones. My husband is from Guatemala and his grandmother was a traditional midwife who learned from her mother. Most midwives there are not formally trained, although there are at least 2 schools run in part by American midwives, whose goal is to educate traditional midwives with more modern practices.

[LibraSunCNM, BSN, MSN, CNM]

mamagui said:

Lay midwives still exist in the US, although their dubious legal status and the advent of credentialed midwifery programs have eliminated many.

In other countries, however, lay-midwives greatly outnumber college educated ones. My husband is from Guatemala and his grandmother was a traditional midwife who learned from her mother. Most midwives there are not formally trained, although there are at least 2 schools run in part by American midwives, whose goal is to educate traditional midwives with more modern practices.

You're quite right, I should have clarified that I mean only in the U.S. are "lay midwives" uncommon. Certainly worldwide they are the largest group of midwives, and thank goodness they exist at all! So many women are dying in childbirth due to a lack of basic care.

As for CMs, I'm in NYC, where one of our 4 midwifery education programs, SUNY Downstate, created the CM credential in the late 1990s. Here CMs abound and are viewed as interchangeable with CNMs in terms of licensing, scope of practice, and prescriptive authority. Sometimes I forget that most of the rest of the country doesn't recognize the credential or really understand it. I see the merits of the CM credential, as well as the merits of having a foundation in nursing, and am fairly neutral on the issue. I know for a fact there are many CNMs who would like the CM credential eliminated.

[mamagui]

mm, I'd have to say I'm neutral on the subject as well, given that we don't have them here....I am always interested in learning more, however :)