The art and science of midwifery

ACNM Core Competencies for Basic Midwifery Practice

The Core Competencies for Basic Midwifery Practice include the fundamental knowledge, skills, and abilities expected of new midwives certified by the American Midwifery Certification Board (AMCB). They serve as guidelines for educators, students, health care professionals, consumers, employers, and policymakers. The Core Competencies constitute the basic requisites for graduates of all midwifery education programs pre-accredited or accredited by the Accreditation Commission for Midwifery Education (ACME).

They are inclusive of the hallmarks of midwifery practice. Midwifery practice is based on the Core Competencies for Basic Midwifery Practice, the Standards for the Practice of Midwifery, the Philosophy of the American College of Nurse-Midwives, and the Code of Ethics developed and disseminated by the American College of Nurse-Midwives (ACNM).

Midwives certified by the AMCB assume responsibility and accountability for their practice as primary health care providers for the individuals they serve as defined in the Definition of Midwifery and Scope of Practice of Certified Nurse-Midwives and Certified Midwives. ACNM defines the midwife’s role in primary health care based on the Institute of Medicine’s report, Primary Care: America’s Health Care in a New Era,1 the Philosophy of the American College of Nurse-Midwives,2 and the ACNM position statement, “Midwives are Primary Care Providers and Leaders of Maternity Care Homes.”3 Primary health care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of health care needs, developing a sustained partnership with clients, and practicing within a context of family and community. As primary health care providers, midwives certified by AMCB assume responsibility for the provision of and referral to appropriate health care services, including prescribing, administering, and dispensing of pharmacologic agents.

Midwifery Management and Core Competencies

The concepts, skills, and midwifery management processes identified in the Core Competencies form the foundation upon which practice guidelines and educational curricula are built. Midwives provide health care that incorporates appropriate consultation, collaborative management, and/or referral, as indicated by the health status of the individual. ACNM endorses that health care is most effective when it occurs in a system that facilitates communication across care settings and providers. 4. Individual education programs are encouraged to develop their own methods to address health care issues beyond the scope of the current Core Competencies. Each graduate is responsible for complying with the ACNM Standards for the Practice of Midwifery and the laws of the jurisdiction where they practice. The basis of midwifery education includes an understanding of health science theory and clinical preparation that provide a framework for the development of the necessary clinical competence.

Expanding Scope of Midwifery Practice

The scope of midwifery practice may be expanded beyond the Core Competencies to incorporate additional skills and procedures that improve care for the individuals that midwives serve. Following the completion of basic midwifery education, midwives may choose to expand their practice following the guidelines outlined in Standard VIII of the Standards for the Practice of Midwifery. Since 2012, ACNM has recognized the role of midwives in caring for transgender and gender non-conforming (TGNC) individuals.

The term “TGNC” is used in this document as an umbrella term for all individuals whose gender expression and/or identity differs from their sex assigned at birth.5 Additionally, midwives are aware of the increased risks, barriers to care, and disparities in health outcomes faced by many marginalized communities due to systems of oppression and discrimination. Midwives work to eliminate those obstacles and therefore need a thorough understanding of fundamental concepts related to discrimination and oppression experienced by people of color, women, individuals of diverse gender identities and sexual orientation, immigrants and refugees, and people with disabilities in order to provide culturally safe care. As midwives, we also recognize the threat of increasing maternal mortality, particularly for women of color.

The Core Competencies for Basic Midwifery Practice acknowledge the basic and applied sciences, health systems and policy issues, and clinical skills that serve as the fundamental mechanisms for the profession of midwifery to improve the status and health care for all our clients. Given this information, we consider the use of inclusive non-discriminatory language a powerful tool that may be used to address inequities.

Gender Affirming Midwifery Care

We understand that individuals are influenced by how they are perceived as well as how they identify. We have chosen to use both gendered and gender-neutral terms to represent the full diversity of people who experience pregnancy, birth, and lactation. We also acknowledge and support people who are not childbearing, but are accessing sexual and/or reproductive health care.

These language choices were intended to ensure respect and visibility for all individuals -- including all people who identify as women as well as transgender, gender nonconforming, and intersex individuals. The Core Competencies for Basic Midwifery Practice are reviewed and revised regularly to incorporate changing trends in midwifery practice. This document must be adhered to in its entirety and applies to all settings where midwifery care is provided. Approved March 20, 2020 I. Hallmarks of Midwifery3

I. The art and science of midwifery are characterized by the following hallmarks: A. Recognition, promotion, and advocacy of menarche, pregnancy, birth, and menopause as normal physiologic and developmental processes B. Advocacy of non-intervention in physiologic processes in the absence of complications C. Incorporation of evidence-based care into clinical practice D. Promotion of person-centered care for all, which respects and is inclusive of diverse histories, backgrounds, and identities E. Empowerment of women and persons seeking midwifery care as partners in health care F. Facilitation of healthy family and interpersonal relationships G. Promotion of continuity of care H. Utilization of health promotion, disease prevention, and health education I. Application of a public health perspective J. Utilizing an understanding of social determinants of health to provide high-quality care to all persons including those from underserved communities K. Advocating for informed choice, shared decision making, and the right to selfdetermination L. Integration of cultural safety into all care encounters M. Incorporation of evidence-based integrative therapies N. Skillful communication, guidance, and counseling O. Acknowledgment of the therapeutic value of human presence P. Ability to collaborate with and refer to other members of the interprofessional health care team Q. Ability to provide safe and effective care across settings including home, birth center, hospital, or any other maternity care service

II. Components of Midwifery Care

The professional responsibilities of midwives certified by AMCB include but are not limited to the following components: A. Promotion of the hallmarks of midwifery B. Knowledge of the diverse history of midwifery C. Knowledge of the legal basis for practice D. Knowledge of national and international issues and trends in women's, TGNC, perinatal, and neonatal care E. Support for legislation and policy initiatives that promote quality health care F. Knowledge of health disparities G. Knowledge of issues and trends in health care policy and systems H. Advocacy for health equity, social justice, and ethical policies in health care I.

Appropriate use of technology and informatics to improve the quality and safety of health care J. Broad understanding of the bioethics related to the care of women, TGNC individuals, neonates, and families Approved March 20, 2020 4 K. Practice in accordance with the ACNM Philosophy, Standards, and Code of Ethics L. Ability to evaluate, apply, interpret, and collaborate in research M. Participation in self-evaluation, peer review, lifelong learning, and other activities that ensure and validate quality practice N. Development of critical thinking and leadership skills O. Knowledge of certification, licensure, clinical privileges, and credentialing P. Knowledge of practice management and finances Q. Promotion of the profession of midwifery, including participation in the professional organization at the local and national level R. Support of the profession’s growth by understanding the importance of precepting midwifery students and demonstrating basic teaching skills S. Knowledge of the structure and function of ACNM T. Ability to consult, collaborate, and refer with other health care professionals as part of a health care team

III. Components of Midwifery Care: Midwifery Management Process

The midwifery management process guides all areas of clinical care. When engaging in the management process, the midwife: A. Obtains all necessary data for the complete evaluation of the client B. Identifies problems or diagnoses and health care needs based on correct interpretation of the subjective and objective data C. Anticipates potential problems or diagnoses that may be expected based on the identified risk factors D. Evaluates the need for immediate intervention and/or consultation, collaborative management, or referral to other health care team members as dictated by the condition of the client E. Develops a comprehensive evidence-based plan of care in partnership with the client that is supported by a valid rationale, is based on the preceding steps, and includes therapeutics as indicated F. Assumes responsibility for the safe and efficient implementation of a evidencedbased plan of care including the provision of treatments and interventions as indicated G. Evaluates effectiveness of the treatments and/or interventions, which includes repeating the management process as needed

IV. Components of Midwifery Care:

Fundamentals Knowledge of the following subject areas is fundamental to the practice of midwifery: A. Anatomy and physiology, including pathophysiology B. Normal physical, psychological, emotional, social, and behavioral development, including growth and development related to gender identity, sexual development, sexuality, and sexual orientation C. Reproductive and perinatal epidemiology and basic epidemiologic methods relevant to midwifery practice Approved March 20, 2020 5 D.

Research and evidence-based practice E. Nutrition and physical activity F. Pharmacokinetics and pharmacotherapeutics G. Principles of individual and group health education and counseling H. Health care ethics I. Clinical genetics and genomics J. Diversity, equity, and inclusion

V. Components of Midwifery Care

Midwifery care includes the independent management of primary health screening, health promotion, and the provision of care from adolescence through the lifespan as well as the neonatal period using the midwifery management process. While each person’s life is a continuum, midwifery care can be divided into primary, preconception, gynecologic/reproductive/sexual health, antepartum, intrapartum, and post-pregnancy care.

A. A midwife demonstrates the knowledge, skills, and abilities to provide primary care of the individuals they serve, including but not limited to:

1. Applies nationally defined goals and objectives for health promotion and disease prevention

2. Provides age-appropriate physical, mental, genetic, environmental, sexual, and social health assessment

3. Utilizes nationally defined screening and immunization recommendations to promote health and detect and prevent diseases

4. Applies management strategies and therapeutics to facilitate health and promote healthy behaviors

5. Utilizes advanced health assessment skills to identify normal and deviations from normal in the following systems: a. Breast b. Cardiovascular and hematologic c. Dermatologic d. Endocrine e. Eye, ear, nose, oral cavity, and throat f. Gastrointestinal g. Genitourinary h. Mental health i. Musculoskeletal j. Neurologic k. Respiratory l. Renal

6. Applies management strategies and therapeutics for the treatment of common health problems and deviations from normal, including infections, self-limited conditions, and mild and/or stable presentations of chronic conditions, utilizing consultation, collaboration, and/or referral to appropriate health care services as indicated Approved March 20, 2020 6

7. Assesses for safety, including dysfunctional interpersonal relationships, sexual abuse and assault, intimate partner violence, structural violence, emotional abuse, and physical neglect A midwife demonstrates the knowledge, skills, and abilities to provide preconception care, including but not limited to:

1. Performs thorough evaluation including complete health history, dental history, family history, relevant genetic history, and physical exam

2. Assesses individual and family readiness for pregnancy, including physical, emotional, psychological, social, cultural, and sexual factors

3. Identifies and provides appropriate counseling and education related to modifiable and non-modifiable risk factors, including but not limited to immunization status, environmental and occupational factors, nutrition, medications, mental health, personal safety, travel, lifestyle, family, genetic, and genomic risk

4. Performs health and laboratory screenings

5. Counsels regarding fertility awareness, cycle charting, signs and symptoms of pregnancy, pregnancy spacing, and timing of discontinuation of contraceptive method

6. Addresses infertility, gamete banking, and assisted reproductive technology, utilizing consultation, collaboration, and/or referral as indicated

C. A midwife demonstrates the knowledge, skills, and abilities to provide comprehensive gynecologic/reproductive/sexual health care, including but not limited to:

1. Understands human sexuality, including biological sex, intersex conditions, gender identities and roles, sexual orientation, eroticism, intimacy, conception, and reproduction

2. Utilizes common screening tools and diagnostic tests, including those for hereditary cancers

3. Manages common gynecologic and urogynecologic problems

4. Provides comprehensive care for all available contraceptive methods

5. Screens for and treats sexually transmitted infections including partner evaluation, treatment, or referral as indicated

6. Provides counseling for sexual behaviors that promotes health and prevents disease

7. Understands the effects of menopause and aging on physical, mental, and sexual health

a. Initiates and/or refers for age and risk appropriate screening

b. Provides management and therapeutics for alleviation of common discomforts

8. Identifies deviations from normal and appropriate interventions, including management of complications and emergencies utilizing consultation, collaboration, and/or referral as indicated Approved March 20, 2020 7

D. A midwife demonstrates the knowledge, skills and abilities to provide care in the antepartum period, including but not limited to:

1. Confirmation and dating of pregnancy using evidence-based methods

2. Management of unplanned or undesired pregnancies, including:

a. Provision of or referral for options counseling, supporting individualized decision-making based on patient needs

b. Provision of or referral for medication abortion as consistent with the individual’s ethics in support of patient autonomy and in line with state scope of practice and licensing statutes

c. Referral for aspiration or surgical abortion as indicated

3. Management of spontaneous abortion, including:

a. Recognizing threatened, inevitable, complete, or incomplete spontaneous abortion

b. Supporting physiologic processes for spontaneous abortion and addressing emotional support needs

c. Counseling, management, and/or referral for inevitable or incomplete spontaneous abortion, as appropriate - including options for medication management, aspiration, and surgical care procedures

d. Recognizing indications for and facilitating collaborative care or referral, as appropriate

e. Providing follow-up services for preconception or pregnancy prevention depending on patient need

4. Uses management strategies and therapeutics to promote normal pregnancy as indicated

5. Utilizes nationally defined screening tools and diagnostics as indicated

6. Educates client on the management of common discomforts of pregnancy

7. Examines the influence of environmental, cultural, and occupational factors, health habits, and maternal behaviors on pregnancy outcomes

8. Screens for health risks, including but not limited to intimate partner genderbased violence, infections, and substance use and/or dependency

9. Provides support and education regarding emotional, psychological, social, and sexual changes during pregnancy

10. Provides anticipatory guidance related to birth, lactation and infant feeding, parenthood, and change in the family constellation

11. Identifies deviations from normal and institutes appropriate interventions, including management of complications and emergencies

12. Applies knowledge of placental physiology, embryology, fetal development, and indicators of fetal well-being

E. A midwife demonstrates the knowledge, skills, and abilities to provide care in the intrapartum period, including but not limited to the following:

1. Confirms and assesses labor and its progress

2. Performs ongoing evaluation of the laboring person and fetus Approved March 20, 2020 8

3. Identifies deviations from normal and implements appropriate interventions, including management of:

a. Complications

b. Abnormal intrapartum events

c. Emergencies

4. Facilitates the process of physiologic labor and birth

5. Provides support for physical, psychological, emotional, spiritual, and social needs during labor and birth

6. Applies pharmacologic and non-pharmacologic strategies to facilitate coping of the person in labor

7. Performs the following skills independently: a. Administration of local anesthesia b. Management of spontaneous vaginal birth c. Management of the third stage of labor d. Episiotomy, as indicated e. Repair of episiotomy, first and second-degree lacerations F. A midwife demonstrates the knowledge, skills, and abilities to provide care in the period following pregnancy, including but not limited to: 1. Manages physical involution following pregnancy ending in spontaneous or induced abortion, preterm birth, or term birth 2. Utilizes management strategies and therapeutics to facilitate a healthy puerperium, including managing discomforts 3. Identification and management of postpartum mental health 4. Explains postpartum self-care 5. Discusses psychological, emotional, and social coping and healing following pregnancy 6. Counsels regarding the readjustment of significant relationships and roles 7. Facilitates the initiation, establishment, and continuation of lactation where indicated; and/or counseling about safe formula feeding when indicated 8. Advises regarding resumption of sexual activity, contraception, and pregnancy spacing 9. Identifies deviations from normal and appropriate interventions, including management of complications and emergencies G. A midwife demonstrates the knowledge, skills, and abilities to independently manage the care of the well neonate (newborn immediately after birth and up to 28 days of life), including, but not limited to, the following: 1. Understands the effect of prenatal and fetal history and risk factors on the neonate 2. Prepares and plans for birth based on ongoing assessment 3. Utilizes methods to facilitate physiologic transition to extrauterine life that includes, but is not limited to, the following: a. Establishment of respiration Approved March 20, 2020 9 b. Cardiac and hematologic stabilization, including cord clamping and cutting c. Thermoregulation d. Establishment of feeding and maintenance of normoglycemia e. Bonding and attachment through prolonged contact with neonate f. Identification of deviations from normal and their management g. Emergency management, including resuscitation, stabilization, and consultation and referral as needed 4. Evaluates the neonate, including: a. Initial physical and behavioral assessment of term and preterm neonates b. Gestational age assessment c. Ongoing assessment and management of term, well neonate during first 28 days d. Identification of deviations from normal and consultation and/or referral to appropriate health services as indicated 5. Develops a plan in conjunction with the neonate’s primary caregivers for care during the first 28 days of life, including the following nationally-defined goals and objectives for health promotion and disease prevention: a. Teaching regarding normal behaviors and development to promote attachment b. Feeding and weight gain, including management of common lactation and infant feeding problems c. Normal daily care, interaction, and activity d. Provision of preventative care that includes, but is not limited to: i. Therapeutics according to local and national guidelines ii. Testing and screening according to local and national guidelines iii. Need for ongoing preventative health care with pediatric care providers e. Safe integration of the neonate into the family and cultural unit f. Provision of appropriate interventions and referrals for abnormal conditions, including, but not limited to: i. ii. iii. iv. v. vi. vii. Minor and severe congenital malformation Poor transition to extrauterine life Symptoms of infection Infants born to mothers with infections Postpartum depression and its effect on the neonate Stillbirth Palliative care for conditions incompatible with life, including addressing the psychosocial needs of a grieving parent. g. Health education specific to the needs of the neonate and family Approved March 20, 2020 REFERENCES 10 1. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health Care in a New Era. Washington, DC: National Academy Press; 1996. 2. American College of Nurse-Midwives. Our philosophy of care. http://www.midwife.org/Child-Page-3. Accessed December 17, 2012. 3. American College of Nurse-Midwives. Midwives are primary care providers and leaders of maternity care homes. Position statement. http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/ 000000 000273/Primary%20Care%20Position%20Statement%20June%202012.pdf. Published June 2012. Accessed December 17, 2012. 4. American College of Nurse-Midwives. Joint statement of practice relations between obstetrician gynecologists and certified nurse midwives/certified midwives. Position statement. http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/00000 0000224/ACNM-College-Policy-Statement-(June-2018).pdf Accessed June,13, 2018. 5. American College of Nurse-Midwives. Transgender/Transsexual/Gender Variant Health Care. Position statement http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/ 0000000000278/Transgender%20Gener%20Variant%20Position%20Statement% 20December%202012.pdf Accessed May 3, 2018. 6. American College of Nurse-Midwives. Forging our future: ACNM 2015-2020 strategic plan. http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000005401/2015-20-StrategicPlanExecSummary-FINAL-061715.pdf. Accessed March 27, 2018. Source: Basic Competency Section, Division of Advancement of Midwifery Approved by the ACNM Board of Directors: October 27, 2019 Approved March 20, 2020 1

1American College of Nurse-Midwives. Core Competencies for Basic Midwifery Practice.

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