How to become a nurse midwife: CNM pathway and requirements

A Certified Nurse-Midwife (CNM) is an advanced practice registered nurse who provides the full spectrum of women’s health services across the lifespan – from prenatal care and labor support through postpartum recovery, newborn assessment, and primary gynecologic care. The CNM credential is awarded by the American Midwifery Certification Board (AMCB) after completing an accredited graduate program and passing a national certification exam.

Demand for CNMs is climbing against a backdrop of deepening obstetric shortages. 34.6% of all US counties – roughly one in three – qualify as maternity care deserts, meaning no hospital offering obstetric services and no OB/GYN or CNM in practice, per March of Dimes’ 2026 “Nowhere to Go” report published on August 11, 2026. Those counties are home to 2.4 million women of reproductive age and account for about 149,000 births a year. The trend is the more useful number for anyone weighing this career: at least 96 hospital labor and delivery units closed across 35 states between 2024 and early 2026, and in nearly 60% of the affected counties the unit that closed was the community’s only birthing facility. CNMs are a primary solution to that gap, both because they are trained specifically for the full scope of maternity and gynecologic care and because they are licensed to practice independently in a growing number of states.

CNMs practice in hospitals, birth centers, private practices, community health centers, and academic medical centers. Many split their time between inpatient labor and delivery and outpatient prenatal or gynecology clinics. The median salary is around $134,000 per year – see the companion CNM salary guide for the full state-by-state breakdown.

CNM vs CM vs CPM: understanding the credentials

There are three midwifery credentials in the US, and they differ significantly in education, scope, and where they are legally recognized.

The CNM is the broadest credential and the only one recognized in all 50 states with full hospital admitting privileges. The CM offers the same scope but requires a nursing license in only the roughly 13 jurisdictions that recognize it. The CPM is a separate profession entirely – trained for out-of-hospital birth and not licensed for inpatient care or prescribing.

This guide focuses on the CNM pathway. If you are a non-nurse interested in midwifery, note that a small number of programs offer a direct-entry route to the CM credential – see the accreditation section below.

Step-by-step CNM pathway

Step 1: earn an RN license

Every CNM program requires an active, unencumbered registered nurse license. The typical route is a Bachelor of Science in Nursing (BSN), though some programs accept applicants with an Associate Degree in Nursing (ADN) combined with a completed RN-to-BSN bridge. Start with the BSN or complete the bridge before applying: nearly all competitive CNM programs prefer or require a BSN, and some explicitly screen out ADN applicants.

Your undergraduate science grades matter at admission. Physiology, anatomy, microbiology, and chemistry are the foundation of midwifery practice, and graduate admissions committees look at them closely. Aim for a 3.2 GPA or higher, with stronger science grades if possible.

Step 2: gain clinical RN experience

Most ACME-accredited CNM programs do not require prior labor and delivery experience for admission, but experience in women’s health, labor and delivery, postpartum, or the NICU strengthens applications significantly. One to two years as an RN – particularly on an L&D unit or in a women’s health outpatient setting – gives you clinical vocabulary for the personal statement and interviews, and it builds the patient care judgment the program will build on.

Some programs waive the experience requirement for direct-entry applicants, but if you have the option of working first, it pays off. CNM students without prior women’s health exposure often find the clinical transition harder.

Step 3: apply to an ACME-accredited CNM program

Program accreditation for nurse-midwifery is granted exclusively by the Accreditation Commission for Midwifery Education (ACME), which has been recognized by the US Department of Education as the programmatic accreditor since 1982. As of 2025 there are 46 ACME-accredited programs in the United States. AMCB requires graduation from an ACME-accredited program to sit the certification exam; attending a non-ACME school makes you ineligible.

Programs offer two degree pathways:

• MSN in nurse-midwifery – typically 2–3 years; the more common entry point; includes didactic and clinical components within a master’s framework
• DNP with nurse-midwifery specialty – typically 3–4 years; practice doctorate; adds leadership, systems, and quality improvement competencies on top of the clinical midwifery curriculum

Both degrees qualify graduates to sit the AMCB exam. The MSN is currently the majority entry-level pathway, though more programs are transitioning to or adding DNP tracks. See the MSN guide and DNP guide for context on each degree.

Clinical hours vary by program but typically run 600–900 hours of supervised clinical practice, covering the full scope: prenatal, intrapartum, postpartum, newborn, and gynecologic care.

Step 4: pass the AMCB certification exam

After graduating, candidates apply to AMCB and sit the national certification exam to earn the CNM credential. Eligibility requires graduation from an ACME-accredited graduate program and an active RN license. As of January 1, 2011, a graduate degree has been required – earlier certificate-only graduates are a legacy cohort.

The exam is 175 multiple-choice questions, computer-based, with a four-hour time limit. Content spans normal and complex antepartum, intrapartum, and postpartum care, newborn care, gynecology, family planning, and pharmacology. The AMCB uses a criterion-referenced cut-score method (updated October 2022) rather than a percentage correct threshold. The national first-time pass rate was 74.5% in 2025, down from 79.7% in 2024 and 84% in 2023 – three consecutive years of decline (2025 AMCB Annual Report). Note that AMCB also publishes an overall rate across all attempts, 69.8% for 2025, which blends in repeat testers passing at 55.5% and is the figure most often misquoted as the first-time rate.

Candidates have a maximum of four attempts. If unsuccessful after four attempts or two years from graduation, the candidate must complete a new midwifery program before trying again.

Step 5: obtain state licensure and prescriptive authority

After passing the AMCB exam, you apply for APRN licensure in the state where you plan to practice. CNMs are licensed as APRNs in all states; the specific title and practice framework vary by state. Most states license CNMs to prescribe Schedule II–V controlled substances, though some require a physician collaborative agreement for prescriptive authority. See the scope of practice section below for the state-by-state breakdown.

Step 6: maintain certification

AMCB certification must be renewed every five years. Renewal requires 20 continuing education credits in core content areas, evidence of ongoing clinical practice, and compliance with AMCB’s recertification standards. The credential lapses if renewal is not completed.

Accreditation and program types

ACME vs historical ACNM accreditation

A distinction worth knowing: prior to 2012, nurse-midwifery programs were accredited by the Division of Accreditation of the American College of Nurse-Midwives (ACNM). ACME was created as an independent accrediting body to separate education accreditation from the professional association – a best practice recognized by the Department of Education. All programs formerly accredited by ACNM’s division transitioned to ACME. Today, ACME is the sole recognized accreditor; “ACNM-accredited” in older materials refers to what is now ACME-accredited.

Direct-entry programs for non-nurses

A small number of programs offer a direct-entry route that does not require prior nursing licensure. These programs train candidates for the Certified Midwife (CM) credential rather than the CNM, since the CNM requires an RN license. Columbia University and SUNY Downstate offer the CM pathway for applicants with bachelor’s degrees in other fields. The CM has identical scope and examination standards as the CNM through AMCB/ACME, but is legally recognized in only 13 jurisdictions – Arkansas, Colorado, Delaware, Hawaii, Maine, Maryland, Minnesota, New Jersey, New York, Oklahoma, Rhode Island, Virginia, and the District of Columbia – which limits practice mobility. Several additional states are pursuing CM licensure, so verify the current list with ACNM before committing to this route.

If your goal is CNM – the credential with full national recognition and hospital privileges – you need the RN license first. The CM pathway trades mobility for accessibility.

Typical program timeline

AMCB certification exam

The AMCB exam covers six primary content domains based on the most recent Midwifery Practice Analysis (a periodic task analysis of entry-level midwifery competencies):

1. Antepartum care
2. Intrapartum care
3. Postpartum care
4. Newborn care
5. Well-woman/gynecologic care and family planning
6. Professional issues and pharmacology

Questions assess knowledge, application, and clinical judgment at the entry-level advanced practice stage. The exam is delivered via computer-based testing through AMCB’s testing partner PSI Services, which operates more than 260 sites across all 50 states and offers appointments five days a week year-round plus at least one Saturday a month. Items appear in random order rather than grouped by content area, deliberately mimicking the mixed caseload of a clinical day, and each question offers four options. Candidates receive official pass/fail results at the conclusion of the exam.

The 74.5% national first-time pass rate (2025) is consistent with the exam’s design as an entry-level competency checkpoint, though the three-year slide from 84% is a meaningful trend rather than noise – it coincides with a period of rapid growth in the number of midwifery programs, and AMCB certified 723 new CNMs and CMs in 2025 against 1,036 candidates examined. Most programs with robust clinical training report pass rates above the national figure. When evaluating programs, asking for first-time AMCB pass rates is as important as looking at program length or tuition, and the widening gap between the national first-time and repeat rates makes program quality a larger factor than it was five years ago.

Scope of practice

CNMs are licensed to provide the following services, subject to state-specific variation:

• Antepartum care – all prenatal visits, ultrasound interpretation, laboratory ordering and management, high-risk comanagement
• Labor and delivery – management of normal and some complex labors; rupture of membranes; episiotomy; vacuum-assisted delivery (state/facility dependent); managing fetal monitoring; epidural coordination with anesthesia
• Postpartum care – maternal recovery assessment; lactation support; mental health screening; wound management
• Newborn assessment – immediate newborn examination and care; APGAR scoring; early feeding support; neonatal resuscitation
• Gynecologic care – well-woman exams; Pap smears; STI screening and treatment; contraception management including IUD insertion; menopause management
• Prescriptive authority – medications including controlled substances in most states; oxytocin, misoprostol, analgesics, antibiotics, hormonal therapies

Prescriptive authority by state

CNM practice authority varies significantly across states. Per the American College of Nurse-Midwives, the landscape divides into three tiers:

• 31 states plus DC – autonomous practice: CNMs are licensed and regulated to practice and prescribe to the full extent of their education and training, with no physician agreement required
• 17 states – a signed collaborative practice agreement with a physician is required as a condition of licensure for at least some services, most often prescribing
• 2 states – physician supervision of CNM practice is still required, the most restrictive arrangement remaining

Those three tiers account for all 50 states and DC. Be wary of state-count breakdowns that sum to more than 51 jurisdictions; the collaborative and supervisory categories are frequently double-counted in secondary sources.

The table below shows prescriptive authority for a selection of high-volume states:

State laws evolve. Always verify current requirements with the state board of nursing before accepting a position or applying for licensure.

CNM salary and job outlook

The median salary for nurse midwives is $134,040 per year, with a mean of $136,980, based on BLS OEWS data for SOC 29-1161 (May 2025). Top-paying states include California ($203,840 median), Hawaii ($170,110), and Massachusetts ($159,800). The national spread is wide – $93,620 at the 10th percentile, $116,510 at the 25th, $157,400 at the 75th, and $188,320 at the 90th.

For a full state-by-state salary breakdown, experience tiers, and setting comparisons, see the companion CNM salary guide.

The broader BLS grouping of nurse anesthetists, nurse midwives, and nurse practitioners is projected to grow 35% from 2024 to 2034 – far faster than the average for all occupations. Demand for CNMs specifically is driven by three factors: the maternal care desert crisis, OB/GYN workforce retirements, and growing evidence supporting CNM-led care quality. CNMs with full practice authority in high-shortage rural states are among the most in-demand advanced practice providers in healthcare right now.

CNM vs CRNA vs NP: choosing an APRN specialty

All three are APRN roles requiring graduate education and national certification, but the training, scope, and career trajectory differ substantially.

The CNM is the right path if your passion is women’s reproductive health and the care of childbearing families. CRNAs earn more but require more time in school (doctoral mandate since 2025) and prior ICU experience – see our CRNA pathway guide for the full picture. NPs have the broadest specialization options and the most flexible career paths – see the NP guide for comparison.

If you are drawn to mental health work, the PMHNP pathway is worth reviewing before committing – it is a distinct APRN specialty that pairs well with women’s mental health but is structurally different from midwifery.

Is CNM right for you?

The CNM role suits people who want sustained relationships with patients across the arc of reproductive health – often seeing the same patient through preconception, pregnancy, birth, and postpartum. The work is relational, high-stakes at delivery, and frequently extends outside office hours in inpatient settings.

A few honest trade-offs to consider:

The career takes 6–7 years from high school to credential. The clinical training is rigorous and time-intensive. Unlike ICU-bound CRNA candidates, you do not need specialized prior experience, but you do need a clinical foundation and a graduate degree.

Practice authority matters where you want to work. If you are drawn to rural or underserved settings – where the need is greatest – look for states with full practice authority. A required physician collaborative agreement is workable but adds overhead, especially in shortage areas where collaborating physicians are themselves in short supply.

The salary is strong, though well short of CRNA or physician levels. At a median of $134,040, CNMs earn roughly $36,500 more than the RN median of $97,550, and sit marginally above the national NP median of $132,300. Top earners in high-demand states clear $188,000 at the 90th percentile. The gap to CRNAs, at a $236,590 median, is the one to keep in view if pay ceiling is your deciding factor. For most people entering midwifery the driver is clinical mission rather than earnings.

Birth can be unpredictable. Midwifery is not a nine-to-five role. Hospital CNMs carry call schedules and work overnight shifts. If you prefer highly predictable hours, an outpatient or birth center practice model offers more structure – at some cost to volume and income.

If you have clarity on the mission and can handle the on-call reality, the CNM path leads to one of the most autonomous, clinically meaningful, and needed roles in US healthcare.

Key takeaways

• The CNM credential requires an RN license, an ACME-accredited graduate degree (MSN or DNP), and passing the AMCB exam. Total time from high school is typically 6–7 years.
• ACME is the sole accreditor for nurse-midwifery programs – AMCB eligibility depends on graduating from an ACME-accredited school.
• The AMCB exam is 175 questions, four hours, with a 74.5% first-time pass rate nationally in 2025 – down from 84% in 2023.
• 31 states plus DC grant CNMs autonomous practice and prescriptive authority. Seventeen require a collaborative agreement and two still require physician supervision.
• Demand is driven by a worsening maternity care desert crisis affecting 34.6% of US counties, with 96 labor and delivery units closing across 35 states between 2024 and early 2026.
• The median CNM salary is $134,040; California, Hawaii, and Massachusetts are the top-paying states.

References

1. U.S. Bureau of Labor Statistics, “Nurse Midwives,” Occupational Employment and Wage Statistics (OEWS), SOC 29-1161, May 2025. National median annual wage $134,040, mean $136,980; percentiles $93,620 (P10) to $188,320 (P90); state medians California $203,840, Hawaii $170,110, Massachusetts $159,800.
2. U.S. Bureau of Labor Statistics, “Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners,” Occupational Outlook Handbook, 2024–2034 projections. Combined-category projected employment growth 35%, approximately 32,700 annual openings.
3. American Midwifery Certification Board (AMCB), “Candidate Handbook: Certification Examination in Nurse-Midwifery and Midwifery,” January 2, 2026 edition. Exam format (175 multiple-choice items, four-hour limit, items presented in random order, unidentified pretest items scattered throughout), eligibility, the four-attempt/24-month limit from date of program completion, and cut-score methodology. AMCB’s testing partner is PSI Services (260+ sites).
4. American Midwifery Certification Board (AMCB), “2025 Annual Report.” First-time pass rate 74.5% (2025), 79.7% (2024), 84% (2023); overall all-attempts rate 69.8%; 1,036 candidates examined and 723 new CNM/CM certificants in 2025.
5. Accreditation Commission for Midwifery Education (ACME), “Accredited Programs Directory and Standards,” 2025. List of ACME-accredited programs and accreditation criteria.
6. American College of Nurse-Midwives (ACNM), “Scope of Practice for Certified Nurse-Midwives and Certified Midwives,” 2024. Clinical scope and services.
7. American College of Nurse-Midwives (ACNM), “Full Practice Authority.” Practice environment tiers: 31 states plus DC license and regulate CNMs autonomously, 17 require a signed collaborative practice agreement, and 2 require physician supervision.
8. March of Dimes, “Nowhere to Go: Maternity Care Deserts Across the U.S.,” 2026 Report, published August 11, 2026. 34.6% of US counties classified as maternity care deserts (2.4 million women of reproductive age, ~149,000 annual births); 5.8 million women and 358,000 infants in counties without full maternity care access; 96 labor and delivery unit closures across 35 states between 2024 and early 2026. Supersedes the 2024 edition’s 35.1% figure.
9. American College of Nurse-Midwives (ACNM), “Certified Midwife Credential,” midwife.org, 2026. The 13 jurisdictions recognizing the CM credential: Arkansas, Colorado, Delaware, Hawaii, Maine, Maryland, Minnesota, New Jersey, New York, Oklahoma, Rhode Island, Virginia, and the District of Columbia.
10. Columbia University School of Nursing, “Direct-Entry Midwifery (CM) Program Overview,” 2024. Direct-entry Certified Midwife pathway.
11. U.S. Department of Education, “Nationally Recognized Accrediting Agencies,” 2024. Recognition of ACME as the programmatic accreditor for nurse-midwifery education.