ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Alabama

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1 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Alabama The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 46 Number of CNM/CM Attended Births, 2013: 969 Percent of CNM/CM Attended Births, 2013: 1.67% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 0 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

2 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The practice of midwifery in Alabama is defined as "care for the mother during pregnancy and labor providing continuous physical and emotional support and continuous evaluation of progress throughout labor and delivery" [Ala. Code ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Alabama requires a collaborative agreement as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 80% of the physician rate. Regulatory Board: Joint Committee of the Board of Nursing and Board of Medical Examiners Recognized Midwifery Credentials: CNM Midwifery Education Programs: None Currently

3 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Alaska The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 83 Number of CNM/CM Attended Births, 2013: 3,063 Percent of CNM/CM Attended Births, 2013: 26.80% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 9 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

4 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The Alaska Board of Nursing, through its regulations, recognizes the scope of practice statements of national certification bodies recognized by the Board. CNM scope of practice in Alaska is therefore defined by the American College of Nurse- Midwives (ACNM) Standards for the Practice of Nurse- Midwifery [Alaska Admin. Code tit. 12, ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Alaska is an independent practice state, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries.the fee- for- service Medicaid reimbursement rate for midwives is currently 85% of the physician rate. Regulatory Board: Board of Nursing Recognized Midwifery Credentials: CNM, CPM Midwifery Education Programs: None Currently

5 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Arizona The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 190 Number of CNM/CM Attended Births, 2013: 5,568 Percent of CNM/CM Attended Births, 2013: 6.51% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 6 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

6 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: Certified nurse- midwives (CNM) in Arizona are regulated as a category of registered nurse practitioner (RNP) by the Board of Nursing. CNMs are noted to have an expanded scope of practice within a specialty area that includes: (i) Assessing clients, synthesizing and analyzing data and understanding and applying principles of health care at an advanced level. (ii) Managing the physical and psychosocial health status of clients. (iii) Analyzing multiple sources of data, identifying alternative possibilities as to the nature of a health care problem and selecting, implementing and evaluating appropriate treatment. (iv) Making independent decisions in solving complex client care problems. (v) Diagnosing, performing diagnostic and therapeutic procedures, and prescribing, administering and dispensing therapeutic measures, including legend drugs, medical devices and controlled substances within the scope of registered nurse practitioner practice on meeting the requirements established by the board. (vi) Recognizing the limits of the nurse's knowledge and experience and planning for situations beyond the nurse's knowledge, educational preparation and expertise by consulting with or referring clients to other health care providers when appropriate. (vii) Delegating to a medical assistant pursuant to (viii) Performing additional acts that require education and training as prescribed by the board and that are recognized by the nursing profession as proper to be performed by a nurse practitioner [Ariz.Rev. Stat. Ann ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Arizona is an independent practice state, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 90% of the physician rate. Regulatory Board: Board of Nursing Recognized Midwifery Credentials: CNM, CPM

7 Midwifery Education Programs: None Currently

8 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Arkansas The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 34 Number of CNM/CM Attended Births, 2013: 210 Percent of CNM/CM Attended Births, 2013: 0.56% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 1 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

9 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The practice of nurse- midwifery in Arkansas is defined as "the performance for compensation of nursing skills relevant to the management of women's health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, family planning, and gynecological needs of women, within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client" [Ark. Code Ann ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Arkansas requires a collaborative agreement as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries.the fee- for- service Medicaid reimbursement rate for midwives is currently 80% of the physician rate. Regulatory Board: Board of Nursing Recognized Midwifery Credentials: CNM, CPM Midwifery Education Programs: None Currently

10 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: California The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 1026 Number of CNM/CM Attended Births, 2013: 43,126 Percent of CNM/CM Attended Births, 2013: 8.72% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 24 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

11 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The statute defines the scope of practice of nurse- midwifery as the furthering or undertaking...to assist a woman in childbirth so long as progress meets criteria accepted as normal. This scope of pract ice specifically excludes the assisting of childbirth by any artificial, forcible, or mechanical means and the performance of any v Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): California requires a supervisory relationship with a physician as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 100% of the physician rate. Regulatory Board: Board of Registered Nurses Recognized Midwifery Credentials: CNM, CPM Midwifery Education Programs: California State University - Fullerton; San Diego State University; University of California - San Francisco

12 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Colorado The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 348 Number of CNM/CM Attended Births, 2013: 8,106 Percent of CNM/CM Attended Births, 2013: 12.47% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 2 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

13 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The Board of Nursing recognizes ACNM's "Standards for the Practice of Midwifery" as defining the appropriate scope for nurse- midwifery practice in Colorado. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Colorado is an independent practice state, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries.the fee- for- service Medicaid reimbursement rate for midwives is currently 100% of the physician rate. Regulatory Board: Board of Nursing Recognized Midwifery Credentials: CNM, CPM Midwifery Education Programs: University of Colorado- Denver

14 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Connecticut The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 200 Number of CNM/CM Attended Births, 2013: 3,968 Percent of CNM/CM Attended Births, 2013: 11.01% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 2 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

15 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: Nurse- midwifery is defined as "the management of women's health care needs, focusing particularly on family planning and gynecological needs of women, pregnancy, childbirth, the postpartum period and the care of newborns, occurring within a health care team and in collaboration with qualified obstetrician- gynecologists" [Conn. Gen. Stat a]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Connecticut is an independent practice state, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 90% of the physician rate. Regulatory Board: State Department of Public Health Recognized Midwifery Credentials: CNM Midwifery Education Programs: Yale University

16 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Delaware The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 30 Number of CNM/CM Attended Births, 2013: 949 Percent of CNM/CM Attended Births, 2013: 8.77% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 1 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

17 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The Board of Nursing recognizes ACNM's "Standards for the Practice of Midwifery" as defining the appropriate scope for nurse- midwifery practice in Delaware. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Delaware requires a collaborative agreement as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 100% of the physician rate. Regulatory Board: Board of Nursing dpr.delaware.gov/boards/nursing/ Recognized Midwifery Credentials: CNM, CM Midwifery Education Programs: None Currently

18 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: DC The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 37 Number of CNM/CM Attended Births, 2013: 996 Percent of CNM/CM Attended Births, 2013: 10.73% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 1 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

19 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: CNMs, as APRNs, may (1) Initiate, monitor, and alter drug therapies; (2) Initiate appropriate therapies or treatments; (3) Make referrals for appropriate therapies or treatments; and (4) Perform additional functions within his or her specialty determined in accordance with rules and regulations promulgated by the board [D.C. Code ]. Under the regulations CNMs may perform the following functions: (a) Manage the care of the normal obstetrical patient; (b) Perform minor surgical procedure; (c) Manage the normal obstetrical patient during labor and delivery to include amniotomy, episiotomy, and repair; (d) Initiate and perform local anesthetic procedures and order the necessary anesthetic agents to perform the procedures; (e) Manage care of the newborn; (f) Perform post- partum examination; (g) Provide gynecological care for women; (h) Prescribe appropriate medications; (i) Provide family planning and STD services; (j) Provide primary health care; and (k) Such other functions and services the Board deems appropriate upon review and analysis of professional and association literature which articulates scopes and standards for nurse- midwifery practice [D.C. Mun. Regs. tit. 17, ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Washington DC has independent practice, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries.the fee- for- service Medicaid reimbursement rate for midwives is currently 100% of the physician rate. Regulatory Board: Board of Nursing doh.dc.gov/service/board- nursing Recognized Midwifery Credentials: CNM Midwifery Education Programs: Georgetown University

20

21 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Florida The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 635 Number of CNM/CM Attended Births, 2013: 22,416 Percent of CNM/CM Attended Births, 2013: 10.41% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 29 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

22 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: Certified nurse- midwives in Florida are regulated by the Board of Nursing (BON) as a category of advanced registered nurse practitioner (ARNP). The statute defines advanced or specialized nursing practice as the performance of advanced- level nursing acts... which, by virtue of post- basic specialized education, training, and experience, are proper to be performed by an ARNP. Those acts include nursing diagnosis and nursing treatments as well as acts of medical diagnosis and treatment,prescription, and operation which are identified and approved by a joint committee of representatives from the Boards of Medicine and Nursing [Fla. Stat. Ann ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Florida requires a supervisory relationship with a physician as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 80% of the physician rate. Regulatory Board: Board of Nursing floridasnursing.gov/ Recognized Midwifery Credentials: CNM, CPM Midwifery Education Programs: University of Florida

23 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Georgia The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 441 Number of CNM/CM Attended Births, 2013: 17,958 Percent of CNM/CM Attended Births, 2013: 14.02% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 1 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

24 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: The certified nurse- midwife (CNM) provides independent management of women's health care, focusing particularly on pregnancy,childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women. The certified nurse- midwife practices within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client. The certified nurse- midwife must practice in accordance with the Board- approved American College of Nurse- Midwives' current Standards for the Practice of Nurse- Midwifery [Ga. Comp. R. & Regs ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Georgia requires a collaborative agreement as a condition for practice. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered, and how to get paid for their services to Medicaid beneficiaries.the fee- for- service Medicaid reimbursement rate for midwives is currently 100% of the physician rate. Regulatory Board: Board of Nursing sos.ga.gov/index.php/licensing/plb/45 Recognized Midwifery Credentials: CNM Midwifery Education Programs: Emory University

25 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Hawaii The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 50 Number of CNM/CM Attended Births, 2013: 1,671 Percent of CNM/CM Attended Births, 2013: 8.81% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 0 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

26 admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. State Scope of Practice Statement: CNMs are regulated as a category of advanced practice registered nurse (APRN). the advanced practice registered nurse may perform the following generic acts which include, but are not limited to:(1) Provide direct care by utilizing advanced scientific knowledge, skills, nursing and related theories to assess, plan, and implement appropriate health and nursing care to patients;(2) Provide indirect care. Plan, guide, evaluate and direct the nursing care given by other personnel associated with the health care team;(3) Teach, counsel, or plan care for individuals or group, utilizing a synthesis of advanced skills, theories, and knowledge of biologic, pharmacologic, physical, sociocultural and psychological aspects of care to accomplish desired objectives;(4) Serve as a consultant and resource of advanced clinical knowledge and skills to those involved directly or indirectly in patient care;(5) Participate in joint and periodic evaluation of services rendered including, but not limited to, chart reviews, case reviews, patient evaluations, and outcome of case statistics;(6) Establish collaborative, consultative, and referral networks as appropriate with other health care professionals. Patients who require care beyond the scope of practice of an APRN shall be referred to an appropriate health care provider;(7) Manage the plan of care prescribed for the patient;(8) Initiate and maintain accurate records and authorize appropriate regulatory and other legal documents;(9) Recognize, develop, and implement professional and community educational programs related to health care;(10) Conduct research and analyze the health needs of individuals and populations and design programs which target at- risk groups and cultural and environmental factors which foster health and prevent illness;(11) Participate in policy analysis and development of new policy initiative in the area of practice specialty; and(12) Contribute to the development, maintenance, and change of health care delivery systems to improve quality of health care services and consumer access to services [Haw. Code R ]. Regulatory Environment (Autonomous Practice, Collaborative Requirement, or Supervisory): Hawaii is an independent practice state, meaning any required relationships with a physician or other provider do not rise to the level of a contractual agreement. Medicaid Coverage: Medicaid covers approximately half of all births in the United States, with the percent ranging from 20 to over 60 percent among states. As such, it is a key payer for midwifery services and it is critical that midwives understand when their patients may qualify for Medicaid coverage, what services are covered,

27 and how to get paid for their services to Medicaid beneficiaries. The fee- for- service Medicaid reimbursement rate for midwives is currently 75% of the physician rate. Regulatory Board: Board of Nursing hawaii.gov/dcca/pvl/boards/nursing Recognized Midwifery Credentials: CNM Midwifery Education Programs: None Currently

28 ACNM Department of Advocacy and Government Affairs Grassroots Advocacy Resources State Fact Sheet: Idaho The American College of Nurse- Midwives (ACNM) is the national organization representing the interests of certified nurse- midwives (CNM) and certified midwives (CM) practicing in the United States. CNMs and CMs are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate that they meet ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Midwives are trained to offer a full range of primary health care services for women from adolescence beyond menopause. Number of AMCB Certified Midwives, 2014: 44 Number of CNM/CM Attended Births, 2013: 1,753 Percent of CNM/CM Attended Births, 2013: 7.84% Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.according to the CDC, in 2012 the vast majority of midwifery- attended births occurred in the hospital setting (94.8%). Other birth locations included birth centers (2.6%), home births (2.6%), and approximately 0.1% in a clinic or other setting. Number of Birth Centers in State, 2014: 6 A 2012 meta- analysis of midwifery outcomes when compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages." ACNM considers the scope of midwifery practice to include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods;

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