What  IS A NURSE-MIDWIFE?

DON'T WORRY! We get this question ALL THE TIME.

 

There is a lot of confusion in the community about what a midwife is exactly, let alone what a nurse-midwife is. We are used to being asked if we are the same as a doula (a doula is an invaluable member of a birth team who provides non-medical support to women and their partner during labor). We get shocked looks when people hear that we work in a variety of settings, including hospitals. In fact, many nurse-midwives in California work for well-known healthcare organizations like Kaiser or the UC Healthcare Systems, where they hold faculty positions and train incoming medical students and resident physicians during their first few years of obstetrics and gynecology programs. We're kind of a big deal! We are experts at normal birth.

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Midwives can function in many different roles, which vary based on their training, certifications, and licensure. There are several types of midwives, and you can learn more about some of the other types of midwives HERE.

In California, there are approximately 1,200 Nurse-Midwives. Nurse-midwives attend approximately 11% of all the vaginal births in California, of which 95% occur in the hospital.

Nurse-midwives, or "certified nurse-midwives" (CNMs) are masters-prepared or doctorally-prepared nurses who have first completed training in nursing and have taken the registered nursing license exam. In addition to training as a nurse, the nurse-midwife has completed a higher education program (either a master's or doctoral degree with a focus in midwifery) and performed hundreds to thousands of additional clinical hours both managing primary care patients and attending births during their training. After the completion of a higher education program, Certified Nurse-Midwives sit for an additional national certification exam. Nurse-midwives are entitled to apply for a furnishing license and a DEA license from the state of California after the completion of their education and licensing, allowing us to independently prescribe medications to the patients we are treating. 

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Another common question we hear is: what is the difference between a nurse and a nurse-midwife? The difference between a registered nurse and a Certified Nurse-Midwife is that a registered nurse supports the care of a patient by carrying out orders from a provider (a physician or a Certified Nurse-Midwife, for example), while the Certified Nurse-Midwife has an increased scope of practice that allows them to diagnose and treat patients within their area of expertise, including independently managing the birth of a baby. The area of expertise for a nurse-midwife includes both primary care and maternity care for healthy women and their families. For example, nurse-midwives may independently delivery a baby in an uncomplicated vaginal delivery or, in consultation with a physician, may treat a patient with uncomplicated primary hypertension. Nurse-midwives can even assist physicians in the operating room with routine or emergency cesarean births. Like all healthcare providers, the Nurse-midwife performs patient care within their designated scope of practice. Nurse-midwives are an integral part of team-based care. In the team-based approach, nurse-midwives can also co-manage moderate-risk clients in consultation with a physician. In this model of care, the physician attends to the medical needs of the client, while the nurse-midwife attends to the birth. It is through this approach that every patient, especially those with diverse needs, gets the right care at the right time by a diverse group of providers.

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California's Nurse-Midwifery Scope of Practice

The CA nurse-midwife provides the necessary supervision, care and advice in a variety of settings to women during pregnancy, labor and postpartum periods, conducts deliveries on his or her own responsibility and cares for the newborn and the infant. This includes preventive measures and the detection of abnormal conditions in mother and child and procurement of physician assistance and consultation when indicated, and execution of emergency care until physician assistance can be obtained. The nurse-midwife also provides well-woman care including interconceptional periods, and family planning needs. For any activities provided outside of this scope, the CNM utilizes standardized procedures as described in Section 2725 of the Code. (CCR § 1463)

Whether the nurse-midwife is practicing as a home birth provider or working in the hospital setting, the nurse-midwife provides independent patient care while practicing collaboratively with provider counterparts, like physicians, anesthesiologists, social workers, registered nurses, and case managers to deliver safe, cost-effective care to healthy women and their families. Like all medical professionals, nurse-midwives are bound by a code of ethics and adhere to a well-defined scope of practice.

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In recent years, California has been in the spotlight for a growing healthcare crisis. Organizations like the CDC and the WHO have reported higher cesarean birth rates and worsening maternal child health outcomes across the country. There is a growing lack of access to healthcare for patients in rural and urban areas due to the high cost of healthcare or loss of insurance coverage. The goals set fourth by the Healthy People 2020 Initiative for maternal-child care will not be met by the year 2020. There is an increasing gap in quality and access to care for women and families of color, resulting in higher maternal mortality rates for those women. Additionally, California is facing a growing healthcare provider shortage as less and less primary care physicians and obstetricians are entering the workforce.

 

Fortunately, nurse-midwives can be part of the solution to this epidemic in California. Nurse-midwives are well known to have better outcomes for women during pregnancy care than the popularized medical model of care. Nurse-midwives follow the nursing-model of care that practices a physiologic approach to pregnancy and heath management. The physiologic approach to birth means that nurse-midwives treat pregnancy like a natural process, rather than an illness or disease. The nursing model looks at the whole patient, addressing the individuals needs from physical, emotional, and psychological considerations. In birth, the nurse-midwife is trained to care for healthy patients with less interventions than the medical model, resulting in increased use of non-pharmaceutical methods of pain and labor management. The nurse-midwife can boast a plethora of advantages for their patients using this approach, including lower cesarean birth rates, higher successful vaginal birth after a past cesarean delivery, fewer episiotomies, less narcotic use, fewer medical interventions during labor, less perineal trauma, higher rates of breastfeeding, better outcomes for patients facing racial disparities, and better maternal and neonatal health outcomes both during and after pregnancy.

 

Additionally, nurse-midwives are staunch advocates for patients, including getting involved at the state level to improve maternal-child health outcomes through changing legislation. Nurse-midwives have historically fought for better access to safe, cost-effective healthcare for all patients, and continue to fight for anti-racism and reproductive justice for all Californians today. The California Nurse-Midwives Association (CNMA) is the professional organization that represents the professional nurse-midwives in California. CNMA works with its members to organize advocacy efforts at local and state levels of government in California. CNMA believes that Californians deserve equal access to maternity care, and that every family deserves a midwife. 

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You can learn more about Nurse-midwives HERE, learn more about the California Nurse Midwives Association HERE, our exciting advocacy efforts HERE, and you can even meet some of the midwives of California on our Meet the Midwives page HERE  to see the faces of real midwives who provide excellent patient care every day to families across the state. If you are a family considering pregnancy, we encourage you to consider midwifery care with your next baby, and to always keep midwives on your mind when you visit the ballot box!

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Elizabeth Kicko, MS-RN, CNM, PHN, WHNP-BC

Media Team

CNMA

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Edited by Holly Smith, CNM

Health Policy Committee Chair

CNMA

References

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  • Yiska Loewenberg Weisband, Mark Klebanoff, Maria F. Gallo, Abigail Shoben and Alison H. Norris,Birth Outcomes of Women Using a Midwife versus Women Using a Physician for Prenatal Care, Journal of Midwifery & Women's Health, 63, 4, (399-409), (2018).

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  • Craigin, Leslie; Kennedy, H. Linking Obstetric and Midwifery Practice With Optimal Outcomes. 10 Nov 2006. Journal of Obestrics Gynecology and Neonatal Nursing, 35, 779‐785; 2006

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  • Maria Freytsis, Julia C. Phillippi, Kim J. Cox, Amy Romano and Leslie Cragin, The American College of Nurse‐Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models, Journal of Midwifery & Women's Health, 62, 1, (101-108), (2016).
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  • Heather M. Bradford, Women's Health and Maternity Care Policies: Current Status and Recommendations for Change, Supporting a Physiologic Approach to Pregnancy and Birth, (301-329), (2013).
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  • Lisa Kane Low and Rebeca Barroso, Supporting a Physiologic Approach to Labor and Birth, Supporting a Physiologic Approach to Pregnancy and Birth, (49-76), (2013).
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  • Juliana Olphen Fehr, Using the Optimality Index–US to Teach Midwifery Students to Recognize and Implement Evidence‐Based Practices That Promote Optimal Outcomes in Perinatal Health, Journal of Midwifery & Women's Health, 58, 5, (531-537), (2013).
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  • Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by the American College of Nurse‐Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives, Journal of Midwifery & Women's Health, 57, 5, (529-532), (2012).
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  • Julia S. Seng, Emeline Mugisha and Janis M. Miller, Reliability of a Perinatal Outcomes Measure: The Optimality Index–US, Journal of Midwifery & Women's Health, 53, 2, (110-114), (2010).
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  • Mary Ann Stark, Barb Rudell and George Haus, Observing Position and Movements in Hydrotherapy: A Pilot Study, Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37, 1, (116-122), (2008).
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  • Robin Jordan and Cindy L. Farley, The Confidence to Practice Midwifery: Preceptor Influence on Student Self‐Efficacy, Journal of Midwifery & Women's Health, 53, 5, (413-420), (2010).
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  • Lisa Kane Low, Julia S. Seng and Janis M. Miller, Use of the Optimality Index‐United States in Perinatal Clinical Research: A Validation Study, Journal of Midwifery & Women's Health, 53, 4, (302-309), (2010).
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  • Patricia Aikins Murphy and Judith T. Fullerton, Development of the Optimality Index as a New Approach to Evaluating Outcomes of Maternity Care, Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 6, (770-778), (2006).
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  • Holly Powell Kennedy, A Concept Analysis of Optimality in Perinatal Health, Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 6, (763-769), (2006).

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  • Roa Altaweli, Christine McCourt, Mandie Scamell and Katherine Curtis Tyler, Ethnographic study of the use of interventions during the second stage of labor in Jeddah, Saudi Arabia, Birth, , (2018).