Managing Your Practice

Lay midwives and the ObGyn: Is collaboration risky?

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ObGyns have a long history of collaboration with their nurse-midwife colleagues—possibly one of the strongest collaborative traditions in medicine. But when lay midwives enter the picture, does collaboration become a risky proposition for you?



“We have indeed in America medical practitioners not inferior to the best elsewhere; but there is probably no other country in the world in which there is so great a distance and so fatal a difference between the best, the average, and the worst.”

—Flexner report from 19101

ObGyn is a risky specialty, with no guarantee of a perfect outcome, even with the best education, training, and skills. Does collaboration make it riskier? Or can collaboration help you deliver high-quality care to your patients?

This article explores these questions as they relate to provision of health care in collaboration with midwives—specifically, certified nurse midwives (CNMs), who are approved by the American Midwifery Certification Board, and certified professional midwives (CPMs), who are not. (See thebox for a more detailed discussion of different types of midwives in practice today.)

Who’s who in the midwifery world

Got acronym fatigue? Here’s a rundown of the various credentials and certifying organizations.

The American College of Nurse-Midwives (ACNM) is a professional organization established in 1955 for certified nurse midwives and certified midwives. ACNM sets standards for academic preparation and clinical practice. For more information, visit

The American Midwifery Certification Board (AMCB) is the certification organization affiliated with ACNM. This board was formerly called the ACNM Certification Council (ACC). Certification by AMCB is equivalent to certification by ACC.

In 1997, AMCB opened its national certification exam to non-nurse graduates of midwifery education programs and issued the first certified midwife credential. Since 2010, a graduate degree has been required for entry into clinical practice for both certified nurse midwives and certified midwives.

Certified midwife (CM). In 1996, the ACNM adopted standards for the certification of direct-entry midwives. These midwives undergo the same certification process as certified nurse midwives, but their training does not include education in nursing. CMs must pass the same certification exam as CNMs and must have a master’s degree.

CMs are licensed in only three states: New Jersey, New York, and Rhode Island. New York had the first CM training program and was the first state to recognize the CM credential. It is the only state that has one unified framework for licensing all midwives—both CNMs and CMs.

Certified nurse midwife (CNM). A midwife who has training in both nursing and midwifery. A master’s degree is required for certification. These midwives typically have prescriptive authority for most drugs; are eligible for third-party reimbursement, including Medicaid; and practice independently or in collaborative practice with physicians.

Certified professional midwife (CPM). In the mid 1990s, the CPM credential was developed jointly by the Midwives Alliance of North America (MANA), the North American Registry of Midwives (NARM), and the Midwifery Education Accreditation Council (MEAC). There is no single standard for education; both apprentice-only–trained midwives and midwives who undergo university-affiliated training use the title CPM.

A CPM can learn through a structured program, through apprenticeship, or through self-study. Another route to the credential is current legal recognition to practice in the United Kingdom. CPMs must pass a written and practical exam for certification.

According to MANA, 24 states recognize the CPM credential as the basis for licensure or use the NARM written exam. Some of these states use a different nomenclature. For example, licensed midwife (LM) is used in California, Idaho, Oregon, and Washington; licensed direct-entry midwife (LDM) is used in Utah; and registered midwife (RM) is used in Colorado.


Moving away from a physician-oriented system

Like it or not, change is under way. Subtle but important shifts are taking place in the way maternity care is provided in your community.

The challenges facing our specialty? Ensuring that the highest levels of patient safety and quality care are maintained. And educating federal and state lawmakers, insurers, and the public accordingly.

Free-standing birth centers are gaining prominence

The Patient Protection and Affordable Care Act (ACA) establishes alternative pathways for maternity care. Congress, state lawmakers, and insurers want to know: Can access to quality maternity care be provided at lower cost outside of hospitals or by nonphysicians? The answer isn’t clear.

Under the ACA, free-standing birth centers are a Medicaid maternity-care choice for low-income women. Birth centers appeal to lawmakers and insurers because of their lower cost. For example, in 2008, the average facility cost for a vaginal delivery in a hospital, with no complications and no newborn charges, was $8,920. In 2010, the average facility cost for a similar delivery at a birth center was $2,277.2,3

We know that dollars alone don’t tell the full story—but they’re easy listening to lawmakers’ ears.

Since 2010, Medicaid payments are allowed to go to state-licensed, free-standing birth centers even if they are not operated by or under the supervision of a physician. Before the ACA became law, Medicaid paid only for services provided in ambulatory centers under the supervision or oversight of a physician.


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