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Full Practice Authority

“Full practice authority” refers to the ability of CNMs and CMs to autonomously practice to the full extent of their education, clinical training and certification. Increasing the number of states with autonomous regulatory frameworks for midwifery practice as conducted by CNMs and CMs can be one way to expand access to care for women in the United States. Currently, 27 states and the District of Columbia license and regulate CNMs to practice to full extent of their education, clinical training and certification. Three states still require physician supervision of CNM practice and the remaining 20 states require a signed collaborative practice agreement with a supervising physician as a condition of licensure for a subset of nurse-midwifery services (e.g., the intrapartum period or for prescriptive authority).

Sample full practice authority bill language:

From Maryland

.01 Definitions.

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

      (1) “ACME” means the Accreditation Commission for Midwifery Education.

      (2) “ACNM” means the American College of Nurse Midwives.   

      (3) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as:
        (a) A certified nurse midwife (CNM);

        (b) A certified registered nurse anesthetist (CRNA);

        (c) A certified nurse practitioner (CRNP); or

        (d) A clinical nurse specialist (CNS). 

      (4) “AMCB” means the American Midwifery Certification Board.

      (5) "Board" means the Board of Nursing.

      (6) “Certification” means the permission to practice nurse midwifery granted by the Board to a registered nurse who has:
        (a) Met all the specified requirements of a national certifying body recognized by the Board; and

        (b) Complied with the requirements of this chapter.

      (7) “Certified nurse midwife” means an advanced practice registered nurse who is certified by the Board to practice nurse midwifery in this State.

      (8) “Clinical practice guidelines” means written standards using guidelines established by:
        (a) The ACNM in Standards for the Practice of Midwifery, as amended or supplemented, and available from ACNM, 8403 Colesville Road, Suite 1550, Silver Spring, MD 20910; or

        (b) Any other national certifying body recognized by the Board.

      (9) “Delegated medical functions” means those functions that come within the definition of “practice medicine” in the Health Occupations Article, §14-101, Annotated Code of Maryland, that have been delegated to a certified nurse midwife to perform.

      (10) “Multistate licensure privilege” has the meaning set forth in COMAR

      (11) "Newborn" means an infant in the first 48 hours of life.

      (12) "Nurse midwifery" means the health care management of newborns and clients throughout their reproductive life cycle.

      (13) “Physician” means an individual licensed to practice medicine in this State.

      (14) “Registered nurse (RN)” means an individual who:
        (a) Is licensed by the Board to practice registered nursing; or

        (b) Has a multistate licensure privilege to practice registered nursing.

.06 Scope of Practice.

A. A certified nurse midwife who meets the requirements of Regulation .02 of this chapter may perform the following functions:

      (1) Independent management of clients appropriate to the skill and educational preparation of the certified nurse midwife and the nurse midwife's clinical practice guidelines;

      (2) Consult or collaborate with a physician or other health care provider as needed; and

      (3) Refer clients with complications beyond the scope of practice of the certified nurse midwife to a licensed physician.

B. A certified nurse midwife shall keep a record of all cases attended.

C. A certified nurse midwife has the right and obligation to refuse to perform any delegated medical act, oral or written, if, in the certified nurse midwife’s judgment, it is unsafe or an invalidly prescribed medical act or beyond the competence of the certified nurse midwife, in which case the nurse midwife shall notify the delegating physician at once.

.07 Nurse Midwife Peer Review Advisory Committee.

The Board shall appoint at least four certified nurse midwives from names submitted for consideration to act as its Advisory Committee in accordance with Health Occupations Article, §8-503, Annotated Code of Maryland.

.11 Prescribing of Substances by a Certified Nurse Midwife.

Pursuant to Health Occupations Article, §8-601, Annotated Code of Maryland, a certified nurse midwife may prescribe:

A. Substances commonly used in the practice of nurse midwifery; and

B. Controlled substances on Schedules II-V under Criminal Law Article, §§5-403—5-406, Annotated Code of Maryland, commonly used in the practice of nurse midwifery; and

C. Dispense substances prescribed in accordance with §§A and B of this regulation in the course of treating a client at a:

      (1) Nonprofit medical facility or clinic;

      (2) Health center operating on the campus of an institution of higher learning;

      (3) Public health facility;

      (4) Medical facility under contract with a State or local health department; or

      (5) Facility funded with public funds.


Accreditation Commission for Midwifery Education, American College of Nurse-Midwives,
        American Midwifery Certification Board, Midwives Alliance of North America,
        Midwifery Education Accreditation Council, National Association of Certified
        Professional Midwives, & North American Registry of Midwives. (2015). Principles for
        model U.S. midwifery legislation & regulation.

Adams, E. K., & Markowitz, S. (2018). Improving efficiency in the health-care system:
        Removing anticompetitive barriers for Advanced Practice Registered Nurses and
        Physician Assistants.
The Hamilton Project.
American College of Nurse-Midwives. (2011). Position statement: Collaborative agreement
        between physicians and Certified Nurse-Midwives and Certified Midwives.

American College of Nurse-Midwives. (2012). Definition of midwifery and scope of practice of
        Certified Nurse-Midwives and Certified Midwives.

American College of Nurse-Midwives. (2012). Position statement: Independent midwifery

American College of Nurse-Midwives. (2014). Position statement: Principles for licensing and
        regulating midwives in the United States in accordance with the Global Standards of the
        International Confederation of Midwives.

American College of Nurse-Midwives. (2018). Quick reference: Practice environments for
        Certified Nurse-Midwives as of June 2018 [Map]
American College of Nurse-Midwives & American College of Obstetricians and Gynecologists.
        (2018). Joint statement of practice relations between Obstetrician-Gynecologists and
        Certified Nurse-Midwives/Certified Midwives.

American College of Obstetricians and Gynecologists. (2016). Collaboration in practice:
        Implementing team-based care
American Nurses Association. (2015). Words matter - guide to discussing APRN practice.
American Nurses Association. (2020). ANA’s principles for Advanced Practice Registered Nurse
        (APRN) full practice authority
Bryan, D. N. (2019). Promoting maternal health in rural and underserved areas. Mercatus
        Center, George Mason University.
Frogner, B. K., Fraher, E. P., Spetz, J., Pittman, P., Moore, J., Beck, A. J., Armstrong, D., &
        Buerhaus, P. I. (2020). Modernizing Scope-of-Practice regulations - time to prioritize
        patients. New England Journal of Medicine, 382(7), 591-593.
Jefferson, K., Bouchard, M. E., & Summers, L. (2021). The regulation of professional midwifery
        in the United States. Journal of Nursing Regulation, 11(4), 26-38.
Katebi, C. (2019). The Nurse Practitioner Solution. Americans for Prosperity.
Koslov, T. I., Jin, G., & Feinstein, D. (2016, 25 July). Letter from the Office of Policy Planning,
        Bureau of Competition, and Bureau of Economics of the Federal Trade Commission to
        the Department of Veterans Affairs, Advanced Practice Registered Nurses
, July 25, 2016
March of Dimes. (2019). March of Dimes position statement: Midwifery care and birth outcomes in the United States.
Martin, B., & Reneau, K. (2020). How collaborative practice agreements impede the
        administration of vital women’s health services. Journal of Midwifery & Women’s Health, 65(4),      
        487-495. https://doi.org/10.1111/jmwh.13088          
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Model legislation - Full Practice Authority - From Maryland.
North Carolina Institute of Medicine, Division of Public Health, & North Carolina
        Department of Health and Human Services. (2020). Healthy moms, healthy babies:
        Building a risk-appropriate perinatal system of care for North Carolina
Petek, G. (2020). Analysis of California’s Physician-Supervision Requirement for Certified Nurse
. Legislative Analyst’s Office.
Phillips, S. J. (2020). 32nd annual APRN legislative update: Improving access to high-quality,
       safe, and effective healthcare. The Nurse Practitioner, 45(1), 28-55.
Ranchoff, B. L., & Declercq, E. R. (2019). The scope of midwifery practice regulations and the
        availability of the Certified Nurse-Midwifery and Certified Midwifery workforce,
        2012-2016. Journal of Midwifery & Women’s Health, 65(1), 119-130.
Souter, V., Nethery, E., Kopas, M. L., Wurz, H., Sitcov, K., & Caughey, A. B. (2019).
       Comparison of midwifery and obstetric care in low-risk hospital births. Obstetrics & Gynecology, 134(5),
       1056-1065. https://doi.org/10.1097/AOG.0000000000003521.
Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, R., Cheyney, M., Fisher, T., Butt,
        E., Yang, Y. T., & Kennedy, H. P. (2018). Mapping integration of midwives across the
        United States: Impact on access, equity, and outcomes. PLoS ONE, 13(2).
Yang, Y. T., & Kozhimannil, K. B. (2015). Making a case to reduce legal impediments to
        midwifery practice in the United States. Women’s Health Issues, 25(4), 314-317.
Yang, Y. T., Attanasio, L. B., & K. B. Kozhimannil. (2016). State scope of practice laws,
        nurse-midwifery workforce, and childbirth procedures and outcomes. Women’s Health
, 26(3), 262-267. https://doi.org/10.1016/j.whi....

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