EDITORIAL
CLINICAL BOUNDARIES: WHAT PARAMETERS DETERMINE A
MIDWIFE’S SCOPE OF PRACTICE?
What are the clinical boundaries of midwifery practice?
Who decides which skills or practices are within an
individual midwife’s scope of practice? And, perhaps
most importantly, how is this information documented
and sanctioned? The answers to these questions are an
integral part of the infrastructure that supports midwifery
practice in all settings. This issue of the Journal of
Midwifery & Women’s Health (JMWH) examines the
boundaries of clinical midwifery practice and the pro-
cesses used to identify and endorse these boundaries.
Midwifery is a profession with a clear purpose, one
that is succinctly stated in the etymology of the word
midwife: “with women.” Those who enter midwifery
often do so out of a reverence for the normal process of
pregnancy, labor, and birth. Thus, midwifery is a health
care discipline in which a focus on the individual client
is the unifying principle of the profession’s philosophy
and the practitioner’s purpose (1). Yet, midwifery is also
a profession that uses skills and techniques primarily
associated with other health care professions such as
medicine, nursing, and social work. A profession with
boundaries that overlap with those of other disciplines
must negotiate scope of practice issues with the practi-
tioners who share the responsibility for providing health
care to a specific population (2). The factors that deter-
mine clinical parameters of midwifery practice play a
critical role in the development of midwives as profes-
sionals and in the growth of the profession as a whole.
This is just the beginning. Midwives must frequently
reassess their clinical practice boundaries in response to
changes in the professions with which they collaborate,
especially nursing and medicine. In addition, they must
conform to ever-changing federal regulations, state laws,
and policies instituted by other statutory or regulatory
bodies. Most importantly, the imperatives present in any
individual clinical setting often change because health
status is fundamentally dynamic. It is no wonder that
midwifery practice, which seems clearly based on a
simple philosophy, is complex, difficult to articulate, and
subject to misunderstanding.
There are five reasons why the criteria that determine
the clinical parameters of midwifery practice require
attention now. First, the last decade has seen an expo-
nential increase in the number of certified nurse-mid-
wives (CNMs) and certified midwives (CMs) (3). As the
profession grows and expands rapidly into settings new
448 Journal of Midwifery & Women’s Health • Vol. 45, No. 6, November/December 2000
© 2000 by the American College of Nurse-Midwives
Issued by Elsevier Science Inc.
to midwifery, the need for clear definitions becomes
paramount. Second, midwives are increasingly expand-
ing their scope of practice. Recent expansion into pri-
mary care is an excellent example of how an alteration in
practice patterns changes scope of practice (4). The care
of medically complex patients and use of technologies
such as ultrasonography also alter the clinical boundaries
of independent practice and require redefinition of the
criteria for collaborative care. Third, the delivery of
health care and medical care in this country is undergoing
profound structural and organizational transformation.
Geographic maldistribution of health care providers and
changing reimbursement patterns are constraining mid-
wifery practice in some areas and supporting expansion
in others (5). Finally, the parameters of clinical practice
must be clearly articulated for one other important
reason; the number of midwifery students in the United
States is increasing rapidly. Students and new graduates
are in critical need of clear guidelines for the parameters
that will circumscribe their clinical practice.
The factors that establish the “clinical parameters of
practice” or “scope of practice” can be divided into four
arenas. First, every midwife has boundaries for safe
practice she or he has defined individually. Second, every
midwifery service has practice guidelines or policies.
Third, the American College of Nurse-Midwives
(ACNM) has documents that describe midwifery, and
these are the guidelines most commonly relied on by the
fourth arena, which is the legal authority to practice as
determined by state or federal statutes and regulations.
Schuiling and Slager review each of these arenas in-
depth elsewhere in this issue of JMWH.
Individually, all midwives have an internalized set of
clinical boundaries that both delimit the situations one
manages independently and define those wherein a col-
laborative interaction with other health care professionals
is indicated. Despite what many midwives believe are
strong and clear internalized parameters, turf wars be-
tween “collaborating” health care professionals occur
with frightening regularity. Malpractice suits that involve
midwifery care invariably center on a problem that arose
from a clinical collaboration that was not well defined.
This paradox between philosophic clarity and the out-
comes in day-to-day practice reflects the difficulty inher-
ent in maintaining clear clinical parameters. Several
articles that illustrate this complexity in reviews of
several medical conditions that both require collabora-
1526-9523/00/$20.00 • PII S1526-9523(00)00083-0
tion and are encountered frequently are featured else-
where in this issue of JMWH.
Midwifery practices rely on written practice guidelines
that define the clinical boundaries for care within a
specific institution. These guidelines articulate the pro-
cess for consultation, collaboration, and transfer of care
and describe the relationships with other members of the
health care team. Traditionally, individuals or small
groups in practice write practice guidelines together.
They are directed toward the logistics of the setting and
the practice preferences, training, and competencies of
the midwives and physician consultants who collaborate
in that setting. Although this process has internal or
“practice-specific” validity, practice guidelines may or
may not support individual decisions made in specific
situations. Thus, practice guidelines, as they have devel-
oped historically, provide weak protection against med-
ical/legal challenges. The emergence of evidence-based
methodologic may provide the answer to this problem,
because they can be used to construct practice guidelines
in a manner that results in a research-based yardstick for
specific midwifery practices where such evidence is
available. The article by Carr that appears elsewhere in
this issue of JMWH describes the process used to create
evidence-based practice guidelines.
As the professional organization for CNMs and CMs,
the ACNM has devoted much of its time and energy in
striving for statutory independence and recognition.
Through this process, many documents have been devel-
oped that define midwifery practice (6). The Core Com-
petencies for Basic Midwifery Education (7) define the
basic knowledge, skills, and behaviors expected of a new
practitioner. As they are updated, accredited midwifery
education programs incorporate the skills listed in this
document into their curriculum. Avery reviews the his-
tory and current use of this essential ACNM document in
another article appearing in this issue of JMWH.
It must be recognized that most practicing midwives
graduated before the current revision of the core compe-
tencies and may not have accrued all of the skills
currently itemized. Thus, The Guidelines for Incorporat-
ing New Procedures is one essential ACNM document
that all midwives should be familiar with and use when
indicated (8). Originally written in 1987 and last revised
in 1992, this document provides a process for research-
ing, evaluating, and integrating into one’s scope of
practice those procedures or skills that are not clearly
delineated in the core competencies.
Despite individual clarity, practice protocols, and clear
guidelines available from the ACNM, questions about
the boundaries of midwifery practice come to the staff at
ACNM headquarters daily from both within the profes-
sion and from those considering relationships with mid-
wives. When one applies overlapping boundaries defined
by many different entities to the moving target that all
Journal of Midwifery & Women’s Health • Vol. 45, No. 6, November/December 2000
clinical settings are, it is easy to understand why “clinical
parameters of practice” is such a slippery concept.
In 1993, the Journal of Nurse-Midwifery devoted a
special issue to the topic of Advanced Nurse-Midwifery
Practice. The lead article in that edition reviewed the
reasons why midwives must systematically evaluate and
document new skills and listed criteria for optimal
collaborative management in clinical settings (9). The
concepts presented in that article are perhaps even more
relevant today. Just as students and new graduates need
clearly defined boundaries for entry into practice, mid-
wives in practice for longer than a few years need a
process for redefining the clinical parameters of practice.
Finally, it is important to acknowledge that rapid
expansion in numbers, vertical expansion into new tech-
niques and skills, and horizontal expansion into new
areas of practice set the stage for a serious increase in
malpractice suits directed against midwifery care (10).
Midwives must be clinically current and competent, and
they must practice safely. They must do so in health care
settings that are changing rapidly and demanding new
roles. They must know and use the documents that help
define midwifery practice and/or offer guidance for
self-assessment, and they must be willing to reevaluate
their clinical parameters of practice on an ongoing basis.
This issue of JMWH reviews the factors that play a
role in determining the clinical boundaries of one’s scope
of practice from historic, global, and clinical viewpoints.
The articles presented herein are respectfully dedicated
to all midwives in clinical practice by the team of
contributing authors.
Tekoa King, CNM, MPH
Home Study Program Coordinator
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