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Full Practice Authority

Issue Summary

Full practice authority refers to the ability of midwives to autonomously practice to the full extent of their education and training.  Some states require midwives to practice under a supervision agreement with a physician or under a collaboration agreement with a physician. Other states require a supervision or collaboration agreement only for a subset of midwifery services, such as the intrapartum period or for purposes of prescriptive authority.

Applicable ACNM Policy Statements and Standard Setting Documents

Code of Ethics
The Code of Ethics of the American College of Nurse-Midwives describe
moral obligations that guide the behaviors of midwives and individuals
representing the profession of midwifery, including members of ACNM.

Collaborative Agreements between Physicians and Certified Nurse-Midwives and Certified Midwives

It is the position of ACNM that safe, quality health care can best be provided when policy makers develop laws and regulations that permit CNMs and CMs to provide independent midwifery care within their scope of practice while fostering consultation, collaborative management, or seamless referral or transfer of care when indicated.

Collaborative Management in Midwifery Practice for Medical, Gynecologic, and Obstetric Conditions
In the context of midwifery care, the midwife may need to consult with
other members of the health care team to provide additional expertise
necessary to meet the health needs of the patient. This document defines
the concepts of consultation, collaboration, and referral.

Core Competencies for Basic Midwifery Practice
The Core Competencies for Basic Midwifery Practice address the
fundamental skills, knowledge, and behaviors expected of a new

Creating a Culture of Safety in Midwifery Care
This statement reviews the principles endorsed by ACNM to promote client
safety and decrease the risk of adverse outcomes for women and infants
during pregnancy, labor, birth, and throughout a woman's lifespan.

Definition of Midwifery and Scope of Practice of Certified Nurse-Midwives and Certified Midwives
An overview of the education and training of CNMs/CMs, including
definition of scope of practice and iteration of practice settings.

Expansion of Midwifery Practice and Skills Beyond Basic Core Competencies
As science and technology advance to create changes in the delivery of
health care, CNMs and CMs may desire to or be required to attain
knowledge and skills beyond the basic level of midwifery practice as
defined by ACNM Core Competencies. This document reviews ACNM's
recommendations for expanding midwifery skills beyond core competencies.

Home Birth

A brief policy statement that synthesizes an array of ACNM positions on
home birth, including selection of birth site, access to home birth, and
reimbursement for home birth services.

Independent Midwifery Practice
Midwifery practice is the independent management of women's health care. Independent practice is not defined by the place of employment, the employer-employee relationship, requirements for physician co-signature, of the method of reimbursement for services.

Joint Statement of Practice Relations between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives
ACOG and ACNM believe health care is most effective when it occurs
within a system that facilitates communication across care settings and
among providers.

Principles for Licensing and Regulating Midwives in the United States in Accordance with the Global Standards of the International Confederation of Midwives
This position statement provides an in-depth explanation of ACNM's position on midwifery licensure in the United States in accordance with the following standards published by the International Confederation of Midwives: International Definition of a Midwife, Essential Competencies for Basic Midwifery Practice, Global Standards for Midwifery Regulation, and Global Standards for Midwifery Education.

Standards for the Practice of Midwifery
CNMs and CMs must practice in accordance with the Standards for the Practice of Midwifery.

Statutory and Regulatory Language Differentiating Scope of Practice/Practice Authority by Practice Setting
This position statement affirms ACNM's opposition to statutory and/or
regulatory language that differentiates allowed scope of practice or
practice authority based on practice setting or site of birth.

Other ACNM Documents of Interest

Midwifery in the United States and the Consensus Model for APRN Regulation
This white paper developed by ACNM, the Accreditation Commission for Midwifery Education (ACME), and the American Midwifery Certification Board (AMCB) describesthe impact of certain recommendations of the Consensus Model on the profession of midwifery and gives a brief overview of the evolution of midwifery in the United States.

North Carolina Board of Dental Examiners v. FTC -- Understanding the Issue
This issue brief examines the primary questions under consideration by the Supreme Court and its implications for midwifery practice.

Map: Regulatory Environment for Certified Nurse-Midwives and Certified Midwives
A simple map that demonstrates which states grant autonomous practice, require a collaborative relationship with a physician (which may be for overall care or for an aspect of midwifery services), or require a supervisory relationship with a physician. The map is accurate as of June 2016.

Other Documents and Resources of Interest

The American College of Obstetricians and Gynecologists. Collaboration in Practice: Implementing Team-based Care.
This document provides a framework for organizations or practices across all specialties to develop
team-based care. The guidance presented is a result of the task force's work
and is based on current evidence and expert consensus. The task force
challenges and welcomes all medical specialties to gather additional
data on how and what types of team-based care best accomplish the
Triple Aim and the Institute of Medicine's expectations of health care.

Future of Nursing Campaign for Action. The Free Market Case for Full Practice Authority.
A number of think tanks that value free markets have voiced support for reducing barriers to care provided by advanced practice registered nurses.  The American Action Forum, American Enterprise Institute, Americans for Prosperity, Cato Institute, Florida TaxWatch, Heritage Foundation, and Pacific Research Institute have advocated that states make this change to reduce unnecessary government regulation and spending, and increase competition.

Kozhimannil, K. B., Henning-Smith, C. and Hung, P. (2016), The Practice
of Midwifery in Rural US Hospitals. Journal of Midwifery & Women's
Health, 61: 411- 418.

CNMs attend births at one-third of rural maternity hospitals in 9 US
states. Significant variability across states appears to be partially
related to autonomous practice regulations: states allowing autonomous
midwifery practice have a greater proportion of rural hospitals with
midwives attending births (34% vs 28% without autonomous midwifery

Markowitz, S., Adams, E.K., Lewitt, M.J., and Dunlop, A. (2016), Competitive Effects of Scope of Practice Restrictions: Public Health or Public Harm-. NBER Working Paper, No. 22780.

In this paper, we examine the controversy surrounding SOP restrictions for
certified nurse midwives (CNMs). We use the variation in SOP laws
governing CNM practice that has occurred over time in a
quasi-experimental design to evaluate the effect of the laws on the
markets for CNMs and their services, and on related maternal and infant


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