What Good Midwifery Looks Like

Midwifery should be safe, respected, and integrated into the health care system. That’s already the case in many countries—and it can be true in the U.S., too.

We don’t need to eliminate home birth. We need to make sure it’s practiced by midwives who are fully qualified, professionally accountable, and part of a functioning care system.

The Certified Nurse Midwife (CNM) model already meets these standards. We should expect no less from any provider attending births.

1. Require a Graduate-Level Education

No one should attend births independently without a graduate-level education. Physicians, CNMs, nurse practitioners, and physician assistants all complete advanced academic and clinical training. Even registered nurses with bachelor's degrees are not permitted to independently manage care.

In other countries where midwives practice with bachelor’s degrees, they do so within integrated systems and under physician oversight. In the U.S., a graduate degree is the minimum standard for anyone caring for both mothers and newborns.

2. Require a State License and Protect the Title of Midwife

All midwives should be licensed by their state. Licensure brings oversight, regulation, and accountability. It also establishes a legal standard of care that protects both patients and providers.

Practicing midwifery without a license should carry legal penalties in every state—just as it does for nurses, physicians, and other health professionals.

Additionally, the title “midwife” must be legally protected. No one should be allowed to advertise or represent themselves as a midwife unless they meet state licensing and educational requirements. In many states today, anyone can call themselves a midwife regardless of training—a dangerous loophole that confuses the public and puts families at risk.

Protecting the title and requiring licensure are baseline expectations for any profession that deals with life and death.

3. Require AMCB Certification

All midwives should be certified by the American Midwifery Certification Board (AMCB)—the national credentialing body for CNMs and Certified Midwives (CMs). This certification:

• Meets International Confederation of Midwives (ICM) standards

• Is recognized in all 50 states

• Is associated with lower neonatal mortality compared to CPM certification

AMCB-certified midwives are trusted by major organizations like ACOG and AAP. If midwifery is to be safe and sustainable, this must be the baseline.

4. Limit Practice to Low-Risk Pregnancies and Require Newborn Care Competency

Out-of-hospital birth should be limited to clearly defined low-risk pregnancies, as recommended by:

• The American Academy of Pediatrics (AAP)

• The American College of Obstetricians and Gynecologists (ACOG)

• The College of Midwives of British Columbia (Canada)

• The Royal Dutch Organisation of Midwives (Netherlands)

At a minimum, out-of-hospital care should exclude:

• Prior cesarean birth (VBAC)

• Breech or non-cephalic presentation

• Multiple gestation

• Gestational age <37 or >41+6 weeks

• Meconium-stained fluid

• Ruptured membranes >24 hours

• Maternal illness or pregnancy complications (e.g., diabetes, hypertension)

Midwives must also be trained and credentialed to care for newborns, including emergency stabilization and resuscitation.

5. Require Integration with Hospitals and Physicians

Midwives must not operate in isolation. Safe midwifery care depends on:

• Access to labs, imaging, and prescribing

• Consulting or shared care agreements with physicians

• Transfer protocols with local hospitals

• Hospital admitting privileges wherever possible

When complications arise, patients deserve continuity—not abandonment. Integration isn’t optional. It’s a matter of safety.

6. Require Public Reporting of Outcomes

States should require that midwives report:

• Fetal, neonatal, and maternal outcomes

• Emergency transfers

• Type of provider and intended birth setting

Reports should be reviewed and published by an independent public agency—modeled after Oregon’s successful system. Transparency protects families and builds public trust.

7. Require Malpractice Insurance

Malpractice insurance:

• Holds providers individually accountable

• Protects families when something goes wrong

• Prevents Medicaid and state systems from absorbing preventable harm

Any state that allows midwives to practice without malpractice insurance has a responsibility to ensure families are fully informed of that fact—before care begins, although there remains a question if informed consent is ever enough protection.

A Better Path Forward

This isn’t about limiting birth options. It’s about ensuring every mother—whether at home, in a birth center, or in a hospital—receives care that is:

• Skilled

• Transparent

• Safe

• Accountable

Midwifery doesn’t need a loophole. It needs a standard.

Let’s raise the bar.