Certified Nurse-Midwife: Scope, Prescribing, and Practice Authority

A Certified Nurse-Midwife’s scope of practice covers primary care, gynecological care, family planning, pregnancy and delivery, postpartum recovery, and care of healthy newborns through their first 28 days, along with authority to prescribe medications. How much of that a CNM can do without a physician’s involvement, and which controlled substances they can prescribe, depends on the state where they practice. Roughly half of U.S. states and the District of Columbia give CNMs full independent practice; the rest impose collaborative or supervisory requirements.¹

What a CNM Is Trained to Do

The clinical work of a CNM reaches well beyond the delivery room. The American College of Nurse-Midwives’ Standards for the Practice of Midwifery define the scope to include primary care for patients from adolescence through post-menopause, along with care of healthy newborns during the first 28 days of life.² Annual wellness exams, cancer screenings, and management of common health conditions all fall inside that scope.

On the gynecological side, CNMs perform pelvic exams, Pap smears, and STI screenings. They counsel patients on contraception and can insert and manage long-acting devices like IUDs and implants. During pregnancy, they handle prenatal monitoring, labor support, and delivery, then follow the parent through postpartum recovery and the newborn through early wellness checks.

The midwifery model draws a firm line at low-risk care. When complications appear, the CNM is trained to identify them and hand off to an obstetrician or maternal-fetal medicine specialist. That transition is smooth where collaborative agreements are in place, but can be awkward in hospitals whose bylaws don’t grant CNMs direct admitting privileges.

Telehealth

Prenatal and postpartum visits increasingly happen by video. Federal rules currently allow Medicare beneficiaries to receive telehealth services from anywhere in the country through December 31, 2027, and starting January 1, 2026, CMS allows virtual direct supervision through real-time audio and video for services that don’t involve a surgical global period.³ State telehealth laws add their own layers on top, including licensure in the patient’s state and documentation standards.

Prescribing Medications

Federal law classifies nurse-midwives as “mid-level practitioners” eligible to register with the DEA and prescribe controlled substances, but only to the extent state law authorizes them to do so.⁴ The DEA registration itself doesn’t grant prescribing rights. It gives the CNM a federal registration number once the state has already said yes.

A CNM typically needs three things to prescribe controlled substances: an active state APRN license, a state-issued controlled substance registration, and a DEA number. The DEA requires all state licensing requirements be met before it will issue a registration.⁵ What the CNM can then prescribe depends entirely on state law:

Some states allow CNMs to independently prescribe all controlled substance schedules (II through V).
Others restrict prescribing to Schedules III through V.
Some require a physician co-signature for Schedule II drugs.
Others require a written collaborative agreement that spells out which medications the CNM may authorize.

Beyond controlled substances, CNMs prescribe a wide range of non-controlled medications, authorize medical devices like diaphragms and contraceptive implants, and order diagnostic tests.

Every state and the District of Columbia now runs a Prescription Drug Monitoring Program. Some require prescribers to check the database before every controlled substance prescription; others leave it to the prescriber’s discretion. The trend is toward mandatory checks, and failure to check when state law requires it can trigger disciplinary action.

Practice Authority: Full, Collaborative, or Supervised

In most states, CNMs are regulated by the State Board of Nursing. A small number use a joint regulatory model involving both the Board of Nursing and the Board of Medicine.¹ The state’s Nursing Practice Act sets what a CNM can and cannot do, continuing education requirements, and disciplinary penalties.

Independence falls into three broad categories:

Full practice authority. The CNM evaluates patients, diagnoses conditions, manages treatments, and prescribes medications without any required physician relationship. Around 27 jurisdictions (26 states plus the District of Columbia) grant this level of autonomy.¹
Collaborative agreement. The CNM must maintain a formal written agreement with a physician that outlines protocols for consultation, referral, and sometimes co-management of specific conditions. The physician doesn’t need to be physically present but must be available.
Supervisory requirement. A few states require direct physician oversight for some or all CNM activities. This is the most restrictive model and is becoming less common as states update their practice acts.

The legislative movement over the past decade has been toward full practice authority, with states citing the shortage of obstetricians in rural counties as the practical driver: requiring midwives to find a collaborating physician where none exists defeats the purpose of training them.

The APRN Compact, developed by the National Council of State Boards of Nursing, would allow advanced practice nurses to hold one multistate license and practice across all compact member states. Enactment is still in progress, so its reach remains limited. A CNM planning to work across state lines should check whether both the home state and the destination state have adopted it.

Practicing outside the authorized scope, prescribing without proper authority, or falling short of standard-of-care expectations can trigger board investigations. Consequences run from mandatory education and supervised practice to fines, license suspension, or revocation. Serious cases involving patient harm can also produce criminal charges or civil malpractice lawsuits. Every malpractice payment made on a CNM’s behalf, regardless of amount, must be reported to the National Practitioner Data Bank within 30 days, with no minimum dollar threshold and no exemption for confidential settlements.⁶

Hospital Privileges and Delivery Settings

Where a CNM can deliver babies depends on hospital credentialing policies and state law. CMS has clarified that federal Medicare rules do not prevent hospitals from credentialing and granting privileges to CNMs.⁷ There is an important split based on the patient’s insurance:

Medicare patients. If a CNM admits a Medicare beneficiary, that patient must also be under the care of a physician (MD or DO) to satisfy Medicare’s conditions of participation.
Non-Medicare patients, including Medicaid. CMS does not require physician oversight. Hospitals can allow CNMs to independently admit and manage these patients based on their own bylaws and state law.⁷

Without hospital admitting privileges, a CNM managing a home or birth center delivery who encounters a complication requiring hospital transfer must hand care over to a physician at the door. Collaborative agreements are meant to smooth that hand-off, but gaps in continuity can still occur.

Freestanding birth centers, which are staffed primarily by CNMs, operate under the National Standards for Birth Centers published by the American Association of Birth Centers. These standards cover facility safety, staffing, quality improvement, and transfer protocols.⁸

How Billing Rules Shape What CNMs Do

Federal payment rules define the outer boundary of covered CNM services. Under Medicare, CNM services have been reimbursed at 100 percent of the physician fee schedule since 2011, so a CNM performing a covered service is paid the same as a physician performing the same service.⁹ Federal law defines covered CNM services broadly: anything the midwife is legally authorized to perform under state law that would otherwise be covered if a physician performed it.¹⁰

Medicaid goes further. Federal law makes nurse-midwife services a mandatory benefit that every state Medicaid program must cover. The statute explicitly says this coverage applies “whether or not the nurse-midwife is under the supervision of, or associated with, a physician,” and it reaches beyond maternity care to any service the midwife is legally authorized to provide.¹¹ State reimbursement rates vary and are often set as a percentage of physician fees.

Billing either program requires a National Provider Identifier on every claim; Medicare will reject any claim missing the NPI.¹²

What This Scope Does Not Cover

The scope described here applies specifically to Certified Nurse-Midwives, and by extension to Certified Midwives in states that recognize them. It does not apply to Certified Professional Midwives (CPMs), who are certified by the North American Registry of Midwives rather than the American Midwifery Certification Board, do not require a nursing license or college degree, and are generally limited to out-of-hospital births in the roughly two-thirds of states that license them. Prescriptive authority, hospital privileges, and Medicare and Medicaid reimbursement at the levels described above attach to the CNM credential specifically because it combines nursing licensure with midwifery certification.

1
National Conference of State Legislatures. Certified Nurse Midwife Practice and Prescriptive Authority
2
American College of Nurse-Midwives. Standards for the Practice of Midwifery
3
Centers for Medicare & Medicaid Services (CMS). Telehealth FAQ
4
Diversion Control Division. Mid-Level Practitioners Authorization by State
5
Diversion Control Division. Registration Q&A
6
National Practitioner Data Bank (NPDB). NPDB Guidebook – Reporting Medical Malpractice Payments
7
Centers for Medicare & Medicaid Services (CMS). Reinforcement of Interpretive Guidance for Nurse Midwives – QSO-23-22-Hospital
8
American Association of Birth Centers. Birth Center Standards
9
eCFR. 42 CFR 414.54 – Payment for Certified Nurse-Midwives Services
10
Office of the Law Revision Counsel. 42 USC 1395x – Definitions
11
Social Security Administration. Social Security Act Section 1905
12
eCFR. 42 CFR 424.506 – National Provider Identifier on All Enrollment Applications and Claims