Practicing within Your Midwifery Scope
As midwives, we are always balancing notion that birth is a medical procedure versus being natural. With today’s society, birth is considered a skilled “procedure” that needs a trained professional present. If that profession (whether being a Certified Nurse Midwife, Certified Midwife, Certified Professional Midwive, or Direct Entry Midwife), there is still needed training, educational core competencies met, and skills needed to attend a birth with a women. Many midwives choose to be more than a care provider during pregnancy and birth. Some midwives even push the envelope of what is defined as the scope of a midwife. Last thing any midwife wants to do is be considered practicing medicine without a license.
Know your state laws. Some states don’t allow certain licensure types to practice or have no midwifery regulations at this time. Michigan just recently created midwifery licensure. Certified Midwives only have a few states that recognize that educational pathway. When looking at becoming a midwife, it is just as important to understand the different types of midwives as what services can be offered within that defined scope. Certified Nurse Midwives have national recognition and state variations of authority and practice scope. There are some states that don’t allow a midwife to own their own business. Michigan doesn’t allow a CNM to own an independent midwifery practice. Know where you want to practice and what service you want to offer at your practice.
ACNM (American College of Nurse Midwives) defines a midwife as the following: Midwifery as practiced by certified nurse-midwives (CNMs®) and certified midwives (CMs®) encompasses a full range of primary health care services for women from adolescence beyond menopause. These services include the independent provision of primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods; admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. These services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.
There are always additional skills a midwife can add to her resume like circumcision, first assist during cesarean sections, insertion nexplanon or IUDs, biopsies, and other gynecological procedures. Those skills need to come from certification or documented apprenticeship from a competent care provider to hold up in court that training was provided. Additional certifications like Electronic Fetal Monitoring, Inpatient Obstetrics, NRP, PALS, ACLS, BLS, or First Assist will help show that additional education was accomplished. Your experience and reference from colleagues and past clients will also help your scope definition and skill set.
Midwives can get into a gray zone when national standards contradicts they way he or she is currently practicing. For example, offering VBAC in home setting with three prior cesarean section. No national or local organization will consider this a low risk delivery and part of the scope of a midwife. Breech is considered in some states a variation of normal (like Texas). There are additional training and continuing education courses needed to show these unique skills are present. Many midwives have said to, I have been doing it for thirty years and have the skills for “X, Y, or Z.” My response is always the same. “If you go to court or have a licensing board evaluating your scope and competencies for a specific case, it will always come down to national and state laws, scope, and standards of care.” Even if you have done VBAC for women having 3 prior cesarean sections in the past with good outcomes, that is not the national standards of care for a midwife.
When starting out your practice and continuing to maintain your established practice, keep up with national and local regulations. Things change with standards as new evidence comes out. Scope of practice guidelines fluctuate to needs and training being provided to midwives. Continuing education courses are essential to keep up with ever changing guidelines around birth and gynecological services offered to women. State laws change creating midwifery licensure and defining local standards that midwives can provide within their practicing state. Join local midwife support groups and advocate to autonomy within our defined scope. Women deserve to have choices and not be restricted from midwifery care. Support your community by knowing your scope of practice and standards of care present in your local region.