Journal of Midwifery & Women’s Health www.jmwh.

org
Original Research

United States Model Midwifery Legislation and Regulation:

Development of a Consensus Document
Holly Powell Kennedy, CNM, PhD, Jo Anne Myers-Ciecko, MPH, Katherine Camacho Carr, CNM, PhD,
Ginger Breedlove, CNM, PhD, Tanya Bailey, CNM, MSN, Marinah V. Farrell, CPM, Mary Lawlor, CPM, LM,
Ida Darragh, BA, CPM

Introduction: Midwifery is defined and regulated across all 50 United States. However, states’ regulations vary markedly, creating confusion for
policy makers and consumers, and can limit services to women. In 2011, the International Confederation of Midwives released Global Standards
for Midwifery Education, Regulation, and Association, providing guidance for international midwifery for the first time. US organizations
representing midwifery education, regulation, and professional associations (US MERA) agreed to work together on common goals.
Methods: The purpose of this modified Delphi study, conducted by US MERA, was to develop a consensus document on principles of model
US midwifery legislation and regulation. Expert panelists (N = 51) across maternal and child health care professions and consumer groups
participated over several iterative rounds.
Results: The final document establishes guiding principles for US midwifery regulation, including regulatory authority, education, qualifications,
regulation, registration and licensure, standards of practice and conduct, complaints, and third-party payment for services.
Discussion: As more US states recognize and license midwives of all credentials and in every practice setting, we can envision a time when equity,
informed choice, safety, and seamless access to quality midwifery care will be the right of every birthing family.
J Midwifery Womens Health 2018;00:1–8  c 2018 by the American College of Nurse-Midwives.

Keywords: midwifery workforce, health policy, public health

INTRODUCTION follow-up study identified top research priorities to improve

Although midwifery is defined and regulated across all maternal and newborn health. The second top priority was
50 states, the regulations and scopes of practice vary markedly, to “evaluate the effectiveness of midwife-led care when com-
creating confusion for policy makers, insurance companies, pared to other models of care across various settings, particu-
and consumers. Regulations meant to protect the health of larly on rates of fetal and infant death, preterm birth, and low
the public can sometimes end up limiting services to women birthweight.”5(p e777)
by restricting or limiting midwifery practice. One example is US vital statistics reveal that only 8% of women are at-
the ability of midwives to provide contraception, restricted in tended at birth by a midwife.6 The United States is facing a
some states by limits on midwives’ prescriptive authority.1 The maternity care workforce crisis and needs a legal and regula-
purpose of this study was to develop a consensus document tory structure to facilitate the growth of midwifery and fos-
on principles of model US midwifery legislation and regula- ter the ability of midwives to fill that need. The 2012 work-
tion, using a modified Delphi approach. This article reviews force analysis by the American Congress of Obstetricians and
the current status of US midwifery legislation, the process that Gynecologists (ACOG) exposed that one-half of US counties
7 US midwifery organizations took to achieve consensus on lack an obstetrician, a trend that especially leaves rural coun-
principles of model legislation and regulation, the presenta- ties in want of skilled care.7 The ability to practice to the full
tion of the findings, and the formal consensus document. scope of a person’s profession is directly affected by state laws.
This has been particularly challenging for those who are in
the allied health professions, for which clear definitions are
Background lacking.8 This problem is further complicated in the United
The safety, quality, and effectiveness of midwifery care has States by the question of whether appropriate entry into mid-
been documented with decades of study and is associated wifery is only through the profession of nursing. This can re-
with positive outcomes. An extensive review of evidence pre- sult in competition rather than collaboration among profes-
sented in the 2014 The Lancet series on midwifery demon- sionals, as well as create confusion for public consumers and
strated the potential to improve over 50 maternal and new- legislators.
born outcomes and to avert maternal and newborn deaths The United States does not federally regulate the prac-
if quality midwifery care were available to all women, espe- tice of midwifery, and there are several routes to the profes-
cially when situated within integrated health systems.2–4 A sion (Table 1). The majority of midwives practicing in the
United States enter through the profession of nursing.9 Cer-
tified nurse-midwives (CNMs) are licensed in all 50 states
Address correspondence to Holly Powell Kennedy, CNM, PhD, Helen and have initial preparation in nursing. Their licensure, ac-
Varney Professor of Midwifery, Yale School of Nursing, 400 West Cam-
pus Drive, Orange, CT 06516. Email: [email protected]
creditation, certification, and education (LACE) as advanced

1526-9523/09/$36.00 doi:10.1111/jmwh.12727 
c 2018 by the American College of Nurse-Midwives 1
 ✦ Midwifery is defined and regulated differently across all 50 states, creating confusion for policy makers and consumers,
which can limit services to women.
✦ Implementation of principles of model midwifery legislation, as identified in this study, can assist states to effectively reg-
ulate the practice of midwifery, protect public health, and increase access to services for families.
✦ The last 10 years of US midwifery have seen unprecedented bridging and collective understanding across chasms that
seemed impossible to navigate. This consensus document is a step in the right direction.

practice registered nurses (APRNs) are guided by the Na- movement with little regulation or certification, many di-
tional Council of State Boards of Nursing’s 2008 Consen- rect entry midwives have become certified professional
sus Model for APRN Regulation, which identifies nurse- midwives (CPMs) and are licensed and regulated in
midwifery as one of 4 APRN roles.10 Although many of 31 states.
the tenets of the document support autonomous midwifery Regulation through licensure sets standards for educa-
practice, it does not recognize that some midwives are not tion, clinical training, and governmental oversight and ac-
nurses.9 countability. Historically, without licensure, complaints or
In an effort to address the maternity workforce shortage, concerns about care are more likely to be addressed in crimi-
the American College of Nurse-Midwives (ACNM), in col- nal or civil courts rather than through administrative review.13
laboration with the Accreditation Commission for Midwifery Licensure provides a framework for regulation, which benefits
Education (ACME) and the American Midwifery Certifica- consumers and midwives, and also brings midwives into the
tion Board (AMCB), developed an equivalent educational and community of health care providers. This helps ensure that
certification pathway for the certified midwife (CM) who is consumers have better access to care that meets their needs
not a registered nurse. CMs are licensed in only 5 states, in and facilitates a more collaborative system of care based on
part because of the LACE restrictions. Half of the US states optimal use of existing resources.
have laws that prohibit CNMs/CMs from full-practice au- Vedam and colleagues have created a scoring system to
thority. Six require physician supervision, although ACNM demonstrate how states fare on integrating midwifery through
and ACOG state in their joint statement on practice rela- regulation.14 The score includes scope of practice, regulatory
tions that “Obstetrician-gynecologists and CNMs/CMs are agency, level of autonomy and requirements for physician
experts in their respective fields of practice and are educated, supervision, access to Medicaid, and prescriptive authority.
trained, and licensed, independent providers who may col- They found that states with higher integration scores (more
laborate with each other based on the needs of their patients. favorable regulation) had higher rates of spontaneous vagi-
Quality of care is enhanced by collegial relationships charac- nal births, higher vaginal birth after cesarean rates, and lower
terized by mutual respect and trust, as well as professional re- cesarean rates. Infants born in these states have lower rates
sponsibility and accountability.”11 (p 1) of preterm birth and low birth weight. Although the reasons
Direct entry midwives (often referred to as other mid- for these outcomes are multifactorial, this critical study high-
wives on birth certificate data) provide most of the care for lights the potential impact of midwifery legislation on birth
women who give birth outside of hospitals in the United outcomes and the importance of achieving national consen-
States.12 Although their profession began as a grassroots sus on principles of model legislation.

Table 1. Types of Licensed and Certified Midwives in the United States

Title Description
Certified nurse-midwife Educated through a program accredited by the Accreditation Commission for Midwifery Education
(CNM) (ACME). Certified by the American Midwifery Certification Board (AMCB). Enters midwifery
profession as a nurse. Recognized in all 50 states.
Certified midwife (CM) Educated through a program accredited by the Accreditation Commission for Midwifery Education
(ACME). Certified by the American Midwifery Certification Board (AMCB). Does not enter
midwifery profession as a nurse. Recognized in 5 states.
Certified professional midwife Educated through a program accredited by the Midwifery Education Accreditation Council (MEAC)
(CPM) or through the Portfolio Evaluation Process. Certified by the North American Registry of Midwives
(NARM). Recognized in 31 states.
Licensed midwife (LM); direct Some states have their own certification mechanisms to license midwives.
entry midwife (DEM)

2 Volume 00, No. 0, xxxx 2018

 Table 2. US Midwifery Regulation, Education, and Association (US MERA) Organizations
Organization Description Website
Organizations specific to CNMs/CMs
American College of Nurse-Midwives Professional association for CNMs/CMs http://www.midwife.org
(ACNM)
Accreditation Commission for Midwifery Accredits midwifery programs that prepare CNM/CMs; http://www.midwife.org/Program-
Education (ACME) recognized by the US Department of Education Accreditation
American Midwifery Certification Board Provides the certifying examination for CNM and CMs; http://www.amcbmidwife.org
(AMCB) accredited by the National Commission for
Certifying Agencies
Organizations specific to CPMs
Midwifery Education Accreditation Accredits midwifery programs that prepare CPMs; http://meacschools.org
Council (MEAC) recognized by the US Department of Education
North American Registry of Midwives Provides the certifying examination for CPMs; http://narm.org
(NARM) accredited by the National Commission for
Certifying Agencies
National Association of Certified Professional organization for CPMs http://nacpm.org
Professional Midwives (NACPM)
Organization that includes all types of midwives
Midwives Alliance of North America Professional organization to which many types of https://mana.org
(MANA) midwives belong

Abbreviations: CM, certified midwife; CNM, certified nurse-midwife; CPM, certified professional midwife.

METHODS is frequently used in the creation of formal definitional state-

Context for the Study
ments on topics that might be perceived differently by various
stakeholders who serve as expert panelists.22 It is an anony-
After decades of sometimes contentious debate, the US mid- mous iterative process beginning with a first round of open-
wifery community has made great strides in working col- ended questions given to a panel of experts and continuing
laboratively in recent years. In 2010, ACNM, the Midwives until consensus is achieved. The process included identifica-
Alliance of North America (MANA), and the National Associ- tion of the expert panelists, development of statements for
ation of Certified Professional Midwives (NACPM) agreed to the first Delphi round, conduct of Round I, development of
develop a consensus statement on normal physiologic birth, a a draft consensus statement based on Round I data, Round
topic upon which they were likely to find common agreement. II for ranking of the consensus statement, refinement of the
After several years of work, they published a seminal docu- consensus statement, endorsement by the midwifery organi-
ment that has become a foundation for numerous resources to zations, and dissemination.
help clinicians, institutions, and women make decisions about We modified the traditional Delphi method in several
childbearing care and practices.15,16 ways. First, we selected the expert panelists through 2 Del-
The International Confederation of Midwives (ICM) has phi rounds conducted by US MERA members. Second, we
approved global standards for midwifery education, regula- held several face-to-face meetings interspersed with the Del-
tion, and association.17–19 After the release of these docu- phi rounds. Finally, we drew upon the ICM Global Stan-
ments, the ACNM president reached out to the other US mid- dards for Midwifery Regulation and the founding values and
wifery organizations, inviting them to work collaboratively to principles of regulation to develop the 42 statements used in
examine how these standards could benefit US midwifery.20 Round I.17–19 These standards establish the social contract
Out of those discussions, an organization of US Midwifery that regulation represents between the midwifery profession
Education, Regulation, and Association (US MERA) was and society, which requires professional responsibility and ac-
established with a formal memorandum of understanding countability, high standards of midwifery care, and maintain-
(Table 2).21 One of the first efforts of this group was to develop ing the trust of the public. ICM identified benchmarks for
a consensus document on principles of model midwifery leg- assessment of good regulation, including its necessity, ef-
islation and regulation. fectiveness, flexibility, proportionality, transparency, account-
ability, and consistency.
A small working group of representatives from each of the
Delphi Method US MERA organizations managed the Delphi process, which
Table 3 portrays the detailed steps used in our modified Del- was facilitated by the first author. The study was approved
phi approach for this study. The traditional Delphi method by Shenandoah University, and response to the first-round

Journal of Midwifery & Women’s Health r www.jmwh.org 3

 Table 3. Modified Delphi Steps
Step Description
1. Identification of Expert panelists in a Delphi study represent those with critical knowledge for the topic of study, in this case,
expert panelists the essential elements for midwifery licensure and regulation. Each of the US MERA organizations
identified 5 members to serve as expert panelists (N = 35). These panelists anonymously nominated 27
additional potential expert panelists with the goal of including a wide range of perspectives and experience.
Once identified, they were anonymously ranked by the US MERA members and retained if 75% of the
group achieved a mean rank ࣙ5 on a 1-7 Likert scale.
2. Identification of A small US MERA working group (the 8 authors of this article) anonymously identified key content areas to
Delphi statements be addressed in the document. These were composed into 42 initial statements in alignment with the
International Confederation of Midwives Global Standards for Midwifery Regulation (2011) as applied in
the US regulatory context and formatted into Round I.
3. Round I survey Round I was sent to the 51 expert panelists who were asked to rank the importance of each statement on a 1-7
Likert scale to be included in the consensus document. Panelists could also comment on the statements.
There was a 92% (n = 47) response rate in Round I. Statements were retained if 75% of the panelists
achieved a mean rank of ࣙ5 on a 1-7 Likert scale.22 Forty statements were retained.
4. Development of The small US MERA working group clustered the 40 retained statements into thematic areas and drafted a
consensus statement working consensus statement. This was carefully constructed to also address the comments provided in
Round I. The working group shared the first draft of the consensus statement with their US MERA
colleagues, soliciting comments, which were addressed in the next draft.
5. Round II survey The draft consensus statement was sent to the 47 expert panelists who completed Round I. They were asked to
note agreement on whether the statement reflected critical issues for midwifery regulation, whether any
critical elements were missing, and whether clarification was needed. The constituent working group
carefully evaluated all of the comments and responded in the revisions. Some minor changes were made for
clarity and an additional paragraph was added in the introduction about midwives’ partnership with
women; this was drawn directly from the ICM Essential Competencies for Basic Midwifery Practice.33
Some suggestions were simply not applicable to the document or the context of
regulation.
6. Endorsement and The final document was endorsed by the seven US MERA organizations in October 2015.23
dissemination

Abbreviations: US MERA, US Midwifery, Education, Regulation, and Association.

Delphi indicated the expert panelists’ voluntary consent to ument by the small US MERA working group and circulated
participate. All data were collected electronically through an to the expert panelists in Round II; 77% (n = 36) responded to
online survey data tool (Survey Monkey, Inc.; San Mateo, the following questions: 1) Does the document address criti-
CA). Data were stored on a password-protected computer. cal issues for US midwifery legislation and regulation? (Yes:
The written comments in Round I were content analyzed, us- 100%) 2) Are there missing elements? (Yes: 19%; No: 81%;
ing ATLAS.ti (Version 6; ATLAS.ti GmbH, Berlin)32 to orga- suggestions were mostly beyond the scope of this exercise) 3)
nize and manage the data. The qualitative data were used to Are there areas in need of clarification? (Yes: 16%; No: 84%;
enhance understanding of the statements before they were in- some sentences were clarified in the document based on the
corporated into the consensus document. Round I statements comments). The document underwent minor revisions after
were retained if 75% of the panelists achieved a mean rank of Round II and was returned to each of the US MERA organi-
greater than or equal to 5 on a 1-7 Likert scale. zations for their approval.
The major sections of the final consensus document in-
RESULTS clude midwifery regulatory authority, education and qual-
ifications, regulation, registration and licensure, scope and
A total of 51 expert panelists were identified. Each of the US
conduct of practice, complaints, malpractice and liability in-
MERA organizations identified 5 panelists (N = 35), and 16
surance, and third-party payment for services. The complete
were identified from other related organizations or disciplines
consensus statement can be viewed in Supporting Informa-
from a nominated field of 27 (Table 4). The initial survey
tion: Appendix S1.23 An overview of the content areas, han-
was distributed to the 51 panelists with a 92% (n = 47) re-
dling of expert comments, and decision points during the
sponse rate, in which 40 of the 42 statements were retained.
study follows.
The 40 statements were organized into a draft consensus doc-

4 Volume 00, No. 0, xxxx 2018

 Table 4. Expert Panel (N = 51) of Stakeholders with Knowledge Critical to Understanding Issues of US Midwifery Legislation and Regulation
US MERA
Organizations (n = )a Other Organizations (n = )b Individuals (n = )
ACME Commonsense Childbirth Maternal and child health researcher (1)
ACNM American College of Obstetricians and Gynecologists Practicing certified nurse-midwife with
AMCB Childbirth Connection/National Partnership for Women & experience in midwifery legislation (1)
Families Consumer advocate (2)
MANA International Center for Traditional Childbearing Legislative advocate (2)
MEAC Citizens for Midwifery
NACPM The Big Push
NARM Association of Women’s Health, Obstetric and Neonatal Nurses
Association of Midwifery Educators
Improving Birth
California Families for Access to Midwives

Abbreviations: ACME, Accreditation Commission for Midwifery Education; ACNM, American College of Nurse-Midwives; AMCB, American Midwifery Certification
Board; MANA, Midwives Alliance of North America; MEAC, Midwifery Education Accreditation Council; NACPM, National Association of Certified Professional
Midwives; NARM, North American Registry of Midwives; US MERA, US Midwifery, Education, Regulation, and Association.
a
Each group had 5 representatives.
b
Other organizations had one representative each.

Midwifery Regulatory Authority develop criteria and processes to assess the equivalence of ap-
plicants who do not meet the requirements of US-accredited
The experts identified the importance of a midwifery-specific
midwifery education, as well as to assess readiness to return
regulatory authority with adequate statutory powers to ef-
to practice of midwives who have been out of practice for a
fectively regulate autonomous midwifery practice. It is com-
defined period.
mon in many states that regulatory authority is connected
to another or broader authority, such as a board of health
professionals or, most commonly, a nursing authority. In these
Regulation, Registration, and Licensure
scenarios, a midwifery-specific authority must retain final au-
thority over midwifery regulation (such as a subcommittee of Midwives are regulated at the state level upon completion of
the board). The majority of members of the midwifery regu- an education program accredited by an agency recognized by
latory authority should reflect the diversity of midwives and the US Department of Education and passage of a national
midwifery in the state. They should be appointed through certification examination administered by a certifying agency
a transparent process of nomination and selection. There that is accredited by NCCA. This enables uniformity of prac-
should be a provision for public members of the midwifery tice standards and facilitates freedom of movement of mid-
regulatory authority who, ideally, represent the interests and wives across state jurisdictions. Only those authorized under
diverse perspectives of childbearing women. The chairperson the relevant legislation may use the midwifery title endowed
of the midwifery regulatory authority must be a midwife, cho- by that legislation. Midwives holding more than one national
sen by members of the group. midwifery credential will be authorized to practice as per-
mitted by state law. The legislation sets the criteria, stan-
dards, and processes for initial midwifery licensure and/or
Education and Qualifications
licensure renewal and demonstrations of continuing compe-
The midwifery regulatory authority is responsible for adopt- tency. The midwifery regulatory authority maintains a regis-
ing standards for midwifery education and accreditation of ter of midwives and makes it publicly available. This includes
midwifery education programs and institutions. These are a range of licensure statuses, such as provisional, temporary,
consistent with the education standards adopted by the na- conditional, suspended, and full licensure. The authority de-
tional certifying bodies (AMCB, North American Registry fines expected standards of conduct and what constitutes
of Midwives [NARM]), which are accredited by the National unprofessional conduct or professional misconduct and im-
Commission for Certifying Agencies (NCCA) and accrediting poses, reviews, and removes penalties, sanctions, and con-
agencies (ACME, Midwifery Education Accreditation Coun- ditions on practice. It is important that the authority collect
cil [MEAC]) and recognized by the US Department of Ed- information about midwives and their practices to contribute
ucation. The authority recognizes midwifery education pro- to workforce planning and research.
grams and institutions leading to the qualification prescribed A unique addition to the consensus document, which was
for midwifery licensure when accredited by nationally recog- lacking in the ICM global standards, was the provision that
nized accrediting agencies (ACME and MEAC) and relies on the midwifery authority works in collaboration with indige-
national certifying agencies (AMCB and NARM) to establish nous or other unique communities to consider licensure re-
criteria and processes to assess midwives educated in other quirements or exemptions that encompass religious or cul-
countries. The above-named agencies are also expected to tural needs. This is in accordance with Article 24 of the

Journal of Midwifery & Women’s Health r www.jmwh.org 5

United Nations Declaration on the Rights of Indigenous Peo- Mandated third party insurance payment, including Med-
ple, which states, “Indigenous peoples have the right to their icaid, was considered an important aspect of midwifery
traditional medicines and to maintain their health practices, regulation.
including the conservation of their vital medicinal plants, ani-
mals and minerals. Indigenous individuals also have the right
DISCUSSION
to access, without any discrimination, to all social and health
services.”24 (p 9) This has been enacted in Quebec, Canada, This study provided the opportunity for 7 US midwifery or-
where a provincial statute allows Aboriginal midwives to prac- ganizations to work collaboratively to address the complex is-
tice without being registered members, provided that the na- sues of regulating practice in the United States. We were able
tion, group, or community has entered into an agreement with to adapt international standards for midwifery regulation to
the government. the US context using a modified Delphi approach. The pro-
cess encouraged the organizations to look beyond their own
territories to achieve compromise and consensus, which was
Scope and Conduct of Practice an additional outcome besides the consensus document itself.
The midwifery regulatory authority defines the scope of prac- The strength of the study is the production of a final docu-
tice of midwives based upon the definition and scope of prac- ment that succinctly summarizes the essential principles and
tice established by the professional midwifery associations provides common language for legislators and policy makers
and the national certifying bodies. This includes the defini- to understand the foundations of the principles. The limita-
tion of standards of practice and ethical conduct. tion may have been the exclusion, through the Delphi ranking
approach, of some expert panelists who might have added to
the discussion.
Complaints The Lancet Global Health published a global identifi-
cation of future research priorities to improve maternal and
As part of protecting public health, there must be a mecha-
newborn health outcomes.5 It demands that we ask differ-
nism for consumers and stakeholders to register concerns or
ent questions to address complex and systemic challenges in
complaints. Midwifery legislation sets out the powers and pro-
pregnancy and childbirth care; access to midwifery care in
cesses for receipt, investigation, determination, and resolution
the United States is one of those challenges. The Patient Pro-
of complaints. Mechanisms must be in place to ensure that the
tection and Affordable Care Act increased financial access to
regulatory authority has a duty to act fairly, including treat-
health care for all US citizens, including requiring maternity
ment without bias and a fair hearing. The midwifery regu-
care as an essential health benefit.25–27 Yet access to midwifery
latory body has policy and processes to manage complaints
care remains limited, in part because of outdated or poorly
related to competence, conduct, or health impairment in a
written laws and regulations. The changing US health care
timely manner. The legislation should provide for the separa-
environment may pose even greater challenges, especially if
tion of powers between the investigation of complaints and the
Medicaid funds become limited. Ensuring that women have
hearing and determining of charges of professional miscon-
access to high-quality midwifery care in all 50 states and the
duct. Management processes for complaints need to be trans-
District of Columbia has promise to improve maternal and
parent and unbiased, include the right to a fair hearing, and
newborn outcomes.
be led by a team of members of the profession.
Health inequities exist across the United States in ma-
ternal and newborn care and outcomes. The estimated US
Malpractice and Liability Insurance maternal mortality rate increased in most states from 2000
to 2014, and US maternal mortality continues to rank 33rd
Several statements about malpractice and liability coverage among industrialized nations.27,28 Most measured outcomes
were placed into Round I to reflect the context of US birth demonstrate marked disparities between infants of color and
care, even though these were not part of the ICM global their white counterparts.29 Over 40% of US births are reim-
standards. These were the 2 statements from the first Del- bursed through Medicaid—a profound reflection of infants
phi round that did not score high enough to be retained. Just being born into poverty.30 Interestingly, the states with poor
as most health professionals are not universally required by midwifery integration scores are among those with the high-
states to purchase malpractice insurance, midwifery regula- est Medicaid reimbursement rates and the poorest birth out-
tion does not require licensed midwives to purchase profes- comes, especially among black infants.14 Toward the end of
sional liability insurance. However, a licensed midwife who the Delphi study, another organization joined US MERA, the
does not carry professional liability insurance will be re- International Center for Traditional Childbearing. This was in
quired to inform clients of this and obtain written informed part due to a growing appreciation for the inequities in mater-
acknowledgment. nity care and the underrepresentation of women of color in
the midwifery profession.31
This study provided a structure for examining US mid-
Third-Party Payment for Services
wifery regulation. The findings provide a foundation for li-
The ICM Global Standards for Midwifery Regulation are censure and regulation of all midwives in the United States, an
silent on reimbursement of services. However, the working important public health issue. The collaborative work and
group for the first Delphi round believed it would be im- agreements of US MERA have been instrumental to the pro-
portant to learn the expert panelists’ stance on this issue. fessional progress of CPMs and CMs in the United States.

6 Volume 00, No. 0, xxxx 2018

Since this consensus document was approved in late 2015, ing board member of Phoenix Allies for Community Health,
5 states have used the principles to achieve licensure for CPMs. a free primary care clinic in Arizona.
However, challenges still remain. A common argument put
Mary Lawlor, CPM, LM, has been in home birth practice since
forth by states against a separate midwifery authority is the
1981 and is the Executive Director of the National Association
cost to support a relatively small group of professionals. In
of Certified Professional Midwives.
this case, there needs to be advocacy for the alternative of
a subcommittee of another health professional board that Ida Darragh, CPM, BA, is the Executive Director of the North
is led by midwives, according to the consensus document. American Registry of Midwives Board of Directors and has
CPMs frequently navigate complex relationships with other extensive experience with development of certification path-
care providers and the legal system in states where midwives ways and state regulation.
are not regulated, yet there is a demand for their services. It
is clear that midwifery regulation in 19 states does not meet CONFLICT OF INTEREST
the demand for care or the professional capacity of CPMs or
direct entry midwives and in 45 states of CMs. The authors have no conflicts of interest to disclose.
The US MERA agreements have solidified some consis-
tent guidelines for midwifery education and practice in accor- ACKNOWLEDGMENTS
dance with international standards, but they can seem confus-
The authors would like to thank Ellie Daniels, CPM, for her
ing or arbitrary to midwives, consumers, and policy makers
contributions to understanding how the consensus document
mired in the politics of US maternity health care. States are us-
has been implemented at the state level and all of the mem-
ing the US MERA legislative consensus document with vary-
bers of US MERA for their collective effort to develop the
ing success. However, there is much work ahead to thought-
consensus document and advocacy for quality maternal and
fully disseminate the document and to educate legislators and
newborn care.
policy makers on the importance of regulating midwifery in
all states in the interest of public health. It will require a uni-
fied commitment to an ongoing exploration of the issues as SUPPORTING INFORMATION
they arise. Just as some labors are long and hard, pushing both Additional Supporting Information may be found in the on-
woman and midwife to their own private edges of discour- line version of this article at the publisher’s Web site:
agement and exhaustion, there is sometimes no better answer
than support, advocacy, and patient passage of time to bring Appendix S1. Principles for Model US Midwifery Legislation
about the birth. The last 10 years of US midwifery have seen & Regulation
unprecedented bridging and collective understanding across
chasms that seemed impossible to navigate until now. As more REFERENCES
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