When practicing as a midwife whether a Certified Nurse Midwife (CNM), Certified Midwife (CM), Certified Professional Midwives (CPM), Licensed Midwife (LM), or Direct Entry Midwife (DEM), you need to understand your state, national, and international scope of practice. Standards of care and scopes of practice are put into effect to make clear guidelines of training, skills, and competencies for consumers, medical community, and fellow midwives. If I say I am a Certified Nurse Midwife, we have a national certification with AMCB to reference. ACNM and NARM have a clearly written scope of practice reference for midwives. Each state will make more detailed scope of practice requirements. Some states will allow twins, VBACs and breech deliveries to be done by midwives with additional training. Some states won’t.
When you start practicing and running your own business, you need to be even more aware of those scope of practice guidelines. If there is a question of your competency and a patient case is brought to the Board regulating your license and certification, those guidelines will be referenced. It becomes very confusing when consumers don’t even know what a midwife can do, let alone our own midwifery colleagues. I strongly encourage each midwife today to find their state and national guidelines of scope. Make sure your policies and procedures reflect that current standards of care.
We are low risk care providers and each state determines what is considered low risk. Some states require a written collaboration to practice. Some states will specifically say what patients a midwife can and can’t take care of. Vague states are actually harder to practice in, because when something comes up for investigation, there isn’t a clear guideline to reference. When things are up for interpretation, that is when conservative management and policies benefit your midwifery practice.
Each midwifery certification and licensure has different services that can be offered. Typically a CNM and CM can get hospital privileges, provide primary care and gynecological services after pregnancy, first assist with cesarean sections, and order ultrasounds, labs, and additional testing at local medical services. Gyn procedures like IUD insertions, wart removals, colposcopies, nexplanon insertions, and infertility treatment can be done with additional certifications and trainings. Performing ultrasounds can be done with additional certifications for CNMs. CPMs, LMs, and DEMs, in most states do not offer those services and refer to a CNM or doctor for additional support.
It is so important for each business owner and even employee to understand their scope of practice. If you work for a hospital and they are asking you to take care of a patient outside of your scope of practice, make sure a collaborating physician is involved in that care whether co-signs your note or sees the patient every other visit in conjunction with midwife. Work closely with our medical community on aspects of care that are not part of independent scope of practice. We want to serve women and do it within the educational background and skillset of our midwifery training.
I worry about midwifery practices that push the envelope of scope of practice and standards of care. When there is a question of competency or standards, it creates a ripple in the midwfiery community that is hard to get over. When there is a bad outcome, which happens at some point when caring for mothers and babies, we want our practice to have policies, standards, and scope of practice clearly defined and followed by entire midwifery team. Safety and risk reduction should be our number one priority for our midwifery practices.
There are specific variations of normal that need to be closely evaluated if should be cared for with an independent midwifery practice. Trial of labor after cesarean section is considered a high risk pregnancy by most medical national associations. Make sure your state midwifery board has a position statement to reference about VBACs and midwifery scope for those women. There are position statements on a national level that VBAC can be attempted in a Accredited Birth Center within certain distance from local hospital that can provide immediate OB services if warranted. I can’t find a single national or local organization that support VBAC and home births. If you offer that service, just understand that if care is put under investigation, we are being held to national and state organizations that don’t directly support that option in home setting and scope of midwives.
Take some time and really list all of your midwifery services being offered, your perceived scope of practice, and look at state and local regulations. Does your current midwifery mission, standards of care, and services being offered reflect what the midwifery boards and medical associations position on those topics? We want to be safe, protect our license, and protect our families. Keep care within our scope and know when to refer to the medical community for services outside of our midwifery scope of practice.