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Introduction   

When hearing the phrase nurse midwifery, what comes to mind? Whether you’re new to nursing or have been a nurse for many years, nurse midwifery is a booming field with lots of potential for nursing from all specialties and educational backgrounds. Practitioners in the field of gynecology and reproductive health are always in demand in healthcare settings. The information in this course will serve as a valuable resource for nurses interested in learning more about nursing midwifery as a career path or in general. 

Defining Nurse Midwifery 

What Is Nurse Midwifery? 

Nurse midwifery is when a registered nurse is certified as a certified nurse midwife (CNM). Certified nurse midwives are a type of advanced practice registered nurse (APRN), and CNMs work in all 50 states. Similar to other APRNs, CNMs have prescriptive authority, provide direct patient care, and also, deliver babies. APRNs cannot deliver babies unless they are CNMs since CNMs have specialized training for delivering babies. While CNMs are often known for their baby-catching skills and love for labor and delivery, there is more to being a nurse midwife than delivering babies alone (1,4). 

Midwives, whether they are nurse midwives or otherwise, have been at the forefront of births and care for pregnant people for hundreds of years. It is also important to note that different types of midwives practice in the United States. Certified professional midwives (CPMs) and licensed midwives (LMs) also practice midwifery, but they do not practice nurse-midwifery and follow different licensing, educational paths, and scope of work regulations compared to CNMs.  

In the United States, midwifery is often viewed as a career of social change. Presently, less than 20% of all births in America are attended by a CNM. The United States also has some of the worst maternal health outcomes, especially for people of color, and midwives have historically been at the forefront of reproductive health change for several communities. Before the formalization of nurse-midwifery education, several Black and Indigenous communities in the United States relied heavily on midwifery care as community care in their communities (1,2,3,4). 

Presently, CNMs have increased in popularity as an APRN career path given the flexibility of the work, the scope of work, the compensation, and the work within communities. In fact, despite declining birth rates in America, there are several parts of America in which there are no licensed birthing professionals, causing what is known as maternity care deserts.  

CNMs often play a critical role in health care delivery for parents, their babies, and communities. That said, a nurse midwife, also known as a certified nurse midwife (CNM), is a growing career path with countless opportunities nationwide. CNMs are regulated by the American College of Nurse Midwifery (ACNM) and work alongside healthcare professionals of all disciplines regularly to provide patient care (3). Because nurse-midwifery is such a wide nursing career path, there are many nursing midwifery career options, such as midwifery research, birth consultant opportunities, direct patient care, and more (1,2,3,4).  

At its core, nurse midwifery involves critical thinking skills, patience, and communication when working with families, parents, babies, and healthcare professionals. Nurse midwifery takes an extremely personal moment in someone’s life and makes it memorable and as safe as possible. Nurse midwives often see their patients throughout the entire pregnancy, provide preconception counseling, provide postpartum care, and work with patients and their communities on overall health outcomes. While nurse midwifery can be a challenging career, many CNMs report high levels of satisfaction in their career path (1,2,3). 

How and Where Are Certified Nurse Midwives Working? 

Almost every healthcare organization and system in America hires APRNs. While mainstream depictions of midwives show midwives working in birth centers or doing home births only, most CNMs do not work in birth centers. Many CNMs work in hospitals all over the United States, private practices, public health departments, correctional facilities, community health centers, birth centers, and more. Some CNMs also establish their own business and work as independent birth consultants as well. Some CNMs also perform home births. Depending on state and local regulations and scope of work requirements, CNMs often work with a collaborating physician regarding births in the event of birth complications or surgical interventions. The extent of the work of a CNM can depend on their training, scope of work at their workplace, and local and state regulations, as every state has its regulations for the scope of work for APRNs and CNMs in particular (1,3). 

What Educational Requirements Are Needed to Work as a Certified Nurse Midwife?  

CNMs can be any nurses of any licensure or educational background who obtain a degree in nurse-midwifery. Most nurse midwifery degrees are at the master’s or doctoral level. Typically, a nurse will earn their bachelor’s degree in nursing and then progress to obtain a master’s degree in nurse-midwifery. Some people go directly from a bachelor’s to a graduate-level degree in nurse-midwifery in what is known as direct-entry or direct-access programs.  

However, some graduate-level programs often require at least a few years of experience as a labor and delivery nurse before applying for a nurse-midwifery graduate-level program (1,2,3,4).  

If you are interested in learning more about the educational path to becoming a CNM, it is recommended to look into specific school requirements, as requirements for admission to various graduate-level nurse-midwifery programs can vary significantly. After someone has completed their graduate-level studies in nurse-midwifery, they can then apply to take their certifying CNM exam through ACNM (3). Like education and career paths, consider doing your research into various nursing midwifery careers near you if this is a path you are interested in.  

Furthermore, every workplace has different requirements for nurses interested in nurse-midwifery careers. For instance, some workplaces prefer on-the-job training instead of additional formalized education. Some workplaces will not consider applications without labor and delivery nursing experience, even if you have a graduate-level degree in nurse-midwifery. Consider doing your research into nurse-midwifery before deciding to go back to school if this is a career path you are interested in (3). 

Nurse Midwifery Landscape 

Like nursing careers in general, salary varies by state, such as California or Arkansas, and place of employment, such as large healthcare organizations or private practices. Like other nursing career paths, CNMs with more experience tend to have a higher salary than CNMs without experience. It is important to understand that average salaries can vary depending on prior nursing experience, work location, qualifications, and place of employment (3,4).  

In addition to salary, with the rise of telemedicine, remote patient monitoring, and other aspects of virtual nursing care, nurse midwifery is expected to increase in demand in more remote parts of America and maternal care deserts (1,3).  

Possible places of employment for CNMs include universities, hospitals, private practices, clinical research facilities, community health centers, telehealth companies, pharmaceutical companies, correctional facilities, birth centers, the military, health care organizations, and more. This is not an exhaustive list by any means, as new companies and places are hiring for CNMs, such as larger technology companies and schools as well.  

Scope of Work 

People often think that CNM only delivers babies 24/7. While CNMs deliver babies, expected workloads and job duties can vary depending on the full job description.  

Some common tasks associated with CNMs include: (1) providing well-woman care throughout the lifespan, including contraceptive counseling, menopausal symptom management, and prenatal care; (2) delivering babies vaginally and working with collaborating physicians in the event of a C-section; (3) managing postpartum complications, such as postpartum hemorrhage or postpartum depression; (4) administering immunizations and interpreting labs; (5) monitoring parent and fetal health; (6) collaborating with various health care professionals for perinatal health outcomes, such as working with doulas, maternal-fetal specialists, and more; and (7) providing evidence-based information to patients regarding their health concerns.  

That was quite the list, but that is not 100% of tasks for CNMs. That’s just the tip of the iceberg, especially as more CNMs work in settings that are not focused only on the birthing process. Depending on where a CNM works, CNMs may provide more prenatal care than care during the delivery process. Some CNMs do not deliver babies at all. Some CNMs only work in hospitals, whereas some CNMs only work in private practices. It is also important to remember that the scope of work for a CNM mostly depends on that nurse’s education, training, qualifications, nursing regulations, and workplace practices (1,2,3,4).  

Nurse Midwifery and Healthcare 

CNMs are not going anywhere. There is a significant demand for CNMs, especially in rural and underserved areas in the United States and globally. Birthing outcomes in America are among some of the worst in the developed world, and midwives have consistently been shown to provide quality care and have excellent patient care outcomes. Healthcare in general is expecting a higher demand for CNMs as older OB/GYNs and midwives in general retire and as America has a larger aging population (1,2). 

In terms of workplace dynamics, unfortunately, burnout is a common concern for many CNMs. The leading cause of burnout among CNMs is the practice environment. Many CNMs often report not being able to practice to the full extent of their scope of work and having to deal with administrative concerns on the job. If you are considering being a CNM, it is recommended to take your time to assess the workplace environment and administration before working there.  

Many people choose to become a CNM for their love of birthing and community building. However, many things can affect the overall quality of life as a CNM, such as the types of schedules you would work on, the income and benefits, the number of deliveries you are expected to attend, and the number of patients you are expected to see. Negotiating and discussing your needs prior to accepting a position is essential to prevent burnout and to ensure a long career as a CNM (1,3,4).  

Nurse Midwifery Alternative Career Paths 

While there is a growing demand for CNMs and the need for providers to provide direct patient care, especially when delivering babies, there are also several career paths for CNMs. If you are interested in reproductive health care, birth care, and women’s health, but not sure if you want to provide direct patient care long-term, here are some alternative career paths for CNMs: (1) nurse educator, (2) legal nurse consultant, (3) nurse-midwifery professor, (4) nurse researcher, (5) nurse writer, or (6) birth consultant.  

Many CNMs also complement their midwifery skills with additional training as a lactation consultant, doula, or placenta encapsulation specialist. Some CNMs also work in other aspects of birth work before becoming a nurse or while working as a nurse before studying to be a CNM (1,2,3,4).  

Nursing Considerations 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several healthcare settings. Patients turn to nurses for guidance, education, and support. While the scope of work of CNMs can vary state by state and by various workplaces, here are some general insights into the role of CNMs in patient care. 

• Take a detailed health history. Often, prenatal health, including a history of sexually transmitted infections (STIs) and depressive thoughts or anxiety, are dismissed in health care settings, even in OB/GYN health settings. CNMs have some of the highest rates of patient satisfaction and are known for reducing health disparities in several marginalized communities. If a patient is complaining of symptoms, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other healthcare professionals, advocate for that patient to the best of your abilities. Take the time to establish care with that patient.  

• Review medication history at every encounter. Oftentimes, in busy clinical settings, reviewing health records can be overwhelming. While millions of people take medications, many people take medications and are no longer benefiting from the medication. Ask patients how they are feeling on the medication if their symptoms are improving, and if there are any changes to medication history. Make sure to specify if the patient is taking any over-the-counter supplements or herbs as well.  

• Ask about family history, especially in prenatal care settings. Several studies speculate pre-eclampsia, morning sickness, and other pregnancy-related conditions to be genetic. If someone is complaining of symptoms that could be related to a more serious health condition, ask if anyone in their immediate family, such as their parent or sibling, experienced similar conditions.   

• Be willing to be honest with yourself about your comfort level discussing topics and providing education on medication and health conditions. If you are not comfortable discussing something, please refer to another staff member. 

• Communicate the care plan to other staff involved for continuity of care. For several patients, pregnancy, prenatal care, and other health care often involves a team of mental health professionals, nurses, primary care specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 

• Stay up to date on continuing education related to midwifery and birth work, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other healthcare professionals and educate your patients with the latest information.  

• Many people in the general public are not aware of the scope of work for CNMs or even know that midwives still exist as a profession. Be sure to take your time and explain to your patients your work, your capabilities, and your collaborating team members’ roles as well. There are also many stigmas and stereotypes of midwives, so please make sure to take your time explaining your scope of work and your birth philosophy and practices.  

How can nurses identify if they are interested in a career in nurse-midwifery?  

Truly, a career in nurse-midwifery is rewarding personally, professionally, financially, and emotionally. CNMs are among a fast-growing group of APRNs, and many CNMs report high levels of satisfaction with their work. That said, CNMs often can be awake for up to 24 hours straight for deliveries depending on their job, can see 25 patients a day in addition to being on-call for deliveries, and can often be overwhelmed with the role of administration and paperwork as many nurses are. If a nurse is interested in nurse-midwifery, they should consider why they want to be a midwife and what they love about birth work. Nurses should also consider how comfortable they are with the unpredictable nature of birth, the responsibility associated with birth, and the experience of being a direct care provider. CNMs have so many opportunities in this work as both a nurse and APRNs.  

If you think you are interested in a career in nurse-midwifery, doing your research and assessing the job market are great starting points to see if this is a career path for you. If you are considering being a CNM, I would recommend that you ask yourself if you truly are passionate about birthing people, babies, health, nursing, and education. 

What should patients know about certified nurse midwives?  

Patients should know that CNMs are a type of APRN who can perform several tasks similarly to other healthcare professionals. Patients should be aware that CNMs do not perform C-sections or other major surgeries.  

Upcoming Research 

There is extensive publicly available literature on nurse-midwifery in evidence-based journals and nursing research. 

Case Study #1 

Beth is a 33-year-old woman working as a labor and delivery nurse. She has worked in labor and delivery nursing for four years and enjoys her work. She also volunteers as a doula with her local community health center when she has the time. Beth has worked with some CNMs at the local hospital, but she does not see any CNMs in her local OB/GYN office.  

Beth’s supervisor emails the unit about a local nursing school hosting a graduate program seminar with programs on nurse midwifery, pediatric nurse practitioner, and nurse anesthesiology. Beth talks to some of her coworkers on the unit, and one of them is thinking about attending the session since she likes watching the CRNAs work in the operating room for C-sections.  

Case Study #1 Continued 

Beth is finishing up a shift, and her patient is delivering a baby on all fours. The CNM, Beth, and two other labor and delivery nurses are helping this mom in her second stage of labor. Beth is documenting all the events in labor but is impressed by the CNM’s calm demeanor and handling of this stressful situation. Beth’s patient has pre-eclampsia, a history of domestic violence, and is GBS positive, all risk factors for several pregnancy complications. After an hour of pushing, Beth’s patient delivers an 8lb2oz baby, and the mom has no vaginal tears. Beth is impressed with this delivery and wants to ask the CNM some questions about her time as a CNM before the shift ends.  

Case Study #1 Continued 

A few weeks later, Beth attended the graduate program event on nurse-midwifery and other nursing programs. Her coworker is looking into the CRNA program, while Beth is looking into the CNM program. Beth also asks her supervisor if her employer is willing to reimburse her for tuition or if she can work part-time while in the program. Beth enjoys working at the hospital, but she is also curious about birthing outside of a hospital setting as well. Beth also has never worked at an outpatient clinic, and she would like to explore her CNM options.  

Conclusion

Nursing and birthing are here to stay, and nurse midwives are at the forefront of this change. While many people are unaware of the role of CNMs and their prevalence in many healthcare settings, CNMs provide essential healthcare to thousands of people every day in America.  

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