State Legislation of Midwifery Practice Environments
Collaborative Agreements Among States
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Professional associations with other healthcare providers, such as physicians, are varied among States in regard to mandatory written collaborative agreements. The legislative requirements for CNMs/CMs vary from State-to-State. This affects whether CNMs can provide reproductive care to the full extent of their education, training, and scope of practice.
Every State has designated specific practice environments for CNMs/CMs. Some States allow CNMs and APRN’s (advanced practice registered nurses) to practice with full autonomy, or independently. Other States require some level of physician oversight or supervision. Certain States require signed, written collaborative agreements with physicians in order to practice and acquire prescriptive authority.
Currently, 27 States allow full autonomy in practice, including prescriptive authority. 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.
One State, Virginia, has a hybrid model which requires that CNMs are not fully independent and must provide evidence of a “consultation agreement” with a physician. Six States, Texas, Oklahoma, Michigan, Kentucky, Nebraska and Georgia require a collaborative agreement for prescriptive authority, only. Twelve States require only a collaborative agreement: Kansas, Wisconsin, Missouri, Arkansas, Louisiana, Mississippi, Alabama, Indiana, Ohio, Pennsylvania, South Carolina, and Georgia. Georgia has a bewildering hybrid model that requires supervision in 13 State jurisdictions and a collaborating agreement everywhere else. 1
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ACNMand Full Practice Authority
The American College of Nurse-Midwives maintains that safe, quality care is best achieved when CNMs/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, due to clinical situations in which prudent practitioners would seek the assistance of other qualified practitioners.2
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Is Collaboration Necessary? Convincing the Legislators
Collaboration is the process whereby health care professionals jointly manage a patient’s care. The goal of collaboration is to share authority while providing quality care within each provider’s particular scope of practice.
Again, policy makers are urged to develop laws and regulations that allow CNMs/CMs to provide independent maternity care within their scope of practice. This process fosters responsible consultation, effective collaborative management, and seamless transfer of care if this becomes necessary.3
Joint Agreement: ACNM and ACOG
Language provided by the American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists offers a mechanism for consultation, collaboration, and referral when nurse-midwifery patients experience changes in their condition which 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 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 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
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Can CNMs/CMs Overcome Regulatory Barriers to Practice?
Regulatory barriers present a significant challenge to midwifery 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 2 States prohibit CNMs from attending home deliveries.
Three significantly challenging regulatory requirements for CNM/CM practice are: (1) the requirement for physician supervision or a written collaborative agreement, (2) the requirement for physician supervision of prescriptive authority even in otherwise independent CNM practices, (3) legislation governing midwives and out-of-hospital birth. In particular, collaborative agreements interfere with access to midwifery care in a variety of ways.
Hospital credentialing and/or admitting privileges may be denied if the CNM/CM is not able to find a physician willing to co-sign a collaborative contract. Third party reimbursement may also be denied without a physician contractual agreement, even if the services provided are clearly within the CNM’s scope of practice. Insurance companies will deny CNM/CMs 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
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 Gynecologist and Certified Nurse-Midwives
5. Walker, D., et.al. (May 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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