Foundations For Legal Midwifery Practice: State Legislation

Foundations of CNM Legal Practice, cont. (a)

State Legislation of Practice Environments and Collaborative Agreements:

Professional associations with other healthcare providers, such as physicians, are varied among States in regard to mandatory written collaborative contracts. The legislative requirements for CNMs/CM vary from State to State. Legislation-imposed collaborative agreements affect whether CNMs/CMs can provide maternity care to the full extent of their education, training and scope of practice. Every State has designated the specific practice environments for CNMs. Some States allow CNMs and APRNs to practice with complete autonomy. Other States require some level of physician oversight or supervision. Certain States require written, signed collaborative agreements with physicians in order to practice and attain prescriptive authority. Currently, about 27 States allow full autonomy in practice, including prescriptive authority. As of this writing, these States are: Washington, Oregon, Nevada, Montana, Idaho, Wyoming, Utah, Colorado, Arizona, New Mexico, North Dakota, South Dakota, Minnesota, Iowa, Illinois, New York, West Virginia, Maine, Delaware, Vermont, New Hampshire, Rhode Island, Connecticut, Massachusetts, Maryland, New Jersey and District of Columbia. Virginia has a hybrid model which requires that CNMs are not fully independent and must show evidence of a “consultation agreement” with a physician. Texas, Oklahoma, Michigan, Kentucky, Nebraska, and Georgia require a written collaborative agreement for prescriptive authority, only. Kansas, Wisconsin, Missouri, Arkansas, Louisiana, Mississippi, Alabama, Indiana, Ohio, Pennsylvania, South Carolina, and Georgia require only a collaborative agreement. Georgia has a bewildering hybrid model that requires supervision in 13 State jurisdictions and a collaborative agreement everywhere else. 1

The American College of Nurse-Midwives maintains that safe, quality care is best achieved when CNMs and CMs have independent, full practice authority within the context of their scopes of practice. ACNM maintains that independent practice is not defined by the CNM/CM’s place of employment, employer-employee relationship, requirement for physician signed agreements, or the methods of reimbursement for services. ACNM also emphasizes that independent does not mean alone, for clinical situations in which prudent practitioners would seek the assistance of another qualified practitioner. 2

Collaboration is the process whereby health care professionals jointly manage a patient’s care. The goal of collaborations is to share authority while providing quality care within each provider’s particular scope of practice. Policy makers are urged to develop laws and regulations that allow CNMs and CMs to provide independent maternity care within their scope of practice, with the decision to consult or collaborate left to the discretion of the CNM or CM. This process fosters responsible consultation, effective collaborative management, and seamless transfer of care if this becomes necessary.3

Language provided by the American College of Nurse-Midwives and the American College (Congress) of Obstetricians and Gynecologists offers a mechanism for consultation, collaboration, and referral when nurse-midwifery patients experience changes in their condition which may require physician involvement in a midwifery patient’s care. Since CNM/CM Standards of Practice require a collaborative relationship between midwife and physician, it has been an ongoing source of frustration for nurse-midwives that State legislatures, frequently heavily lobbied by physicians, have felt it necessary to draft specific legislation constraining nurse-midwifery practice, when a CNM-physician relationship is already provided for in the ACNM Standards for the Practice of Nurse-Midwifery. The requirement for a written collaborative agreement is still the law in several States. ACNM and ACOG have specifically agreed upon principles which guide both professions to understand their individual, collaborative and independent responsibilities.4

Regulatory barriers present a significant challenge to CNM/CM practice. Data compiled by the ACNM indicate that midwives who are not CNMs are illegal in 10 States, 12 States have no laws or regulations about non-nurse-midwives, and two States prohibit CNMs from attending home deliveries. Three particularly challenging regulatory requirements for CNM practice are (1) the requirement for physician supervision or a written collaborative agreement, (2) the requirement for physician supervision of prescriptive authority in otherwise independent CNM practices, and (3) legislation governing midwives and out-of-hospital birth. These agreements interfere with access to midwifery care in several ways. Hospital credentialing and/or admitting privileges may be denied if the CNM/CM is not able to find a physician willing to sign a collaborative contract. Third-party reimbursement may also be denied without a physician-midwife contractual agreement, even if the services provided are clearly within the CNM’s scope of practice. Insurance companies will deny CNMs/CM’s professional status to open their own practices as Professional Limited Liability Corporations. These requirements not only affect access to midwifery care but severely limit the individual midwife from earning a living.5

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1 ACNM, Quick Reference Practice Environment as of June, 2018.

2 ACNM Position Statement: Independent Midwifery Practice. Clinical Practice Committee. December 2017

3 ACNM Collaborative Agreements between Physicians and Certified Nurse-Midwives and Certified Midwives.

4 ACNM/ACOG Joint Statement of Practice Relations Between Obstetrician and Certified Nurse-Midwives

5 Walker, D. et.al. (May 31, 2014) “Midwifery Practice and Education; Current Challenges and Opportunities.” OJIN: The Online Journal of Issues in Nursing. Vol. 19, No. 2, Manuscript 4.

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