Referral and consultation practices vary with the class of midwife. Nurse- midwives are registered nurses with specialty training in midwifery. All laws governing nursing licensure and practice apply to nurse-midwives. As a consequence, nurse- midwife practice is usually well regulated and reliable even in states that do not otherwise regulate midwives. Although there are special considerations in working with independently practicing nurses, referral and consultation with nurse- midwives does not pose the ethical and legal problems of working with lay midwives.

The training of lay midwives varies enormously. Some have been through extensive training and apprenticeship programs; some may be physicians or nurses who are not licensed in the United States; others are self-taught from books or experience; and some have virtually no training or skills. A state may license and regulate lay midwives as extensively as nurses or physicians, but few do. There are contradictory reasons for allowing lay midwifery. Some groups argue for lay midwives because of their opposition to the medicalization of pregnancy. Others believe that lay midwifery compromises the health and safety of pregnant women. They point to the lack of lay cardiologists and urologists as evidence that lay practice on women is tolerated only because of the low status of women in the legal system.

Physicians must be wary about practicing with lay midwives. If they are inadequately trained, they are much more likely to delay physician referrals until the patient is in grave danger. The most dangerous situation is lay midwives who practice under the umbrella of an antimedical religious group. Some states specifically exempt religious healers from state laws forbidding the practice of medicine without a license. Even states that forbid or regulate independent midwifery may allow religious practitioners to practice without supervision.

States that regulate the practice of midwifery are often lax in enforcing these regulations. A physician who knows that an individual is practicing midwifery in violation of the law must report such practice to the proper authorities—the board of medical examiners, the board of nursing examiners, or the police—and not practice with such an individual under any circumstances. However, the physician should assist a patient who is in danger, even if that means taking over the patient from the illegal midwife. Reporting the illegal practice establishes that the physician was not condoning or participating in the practice.