Issue Areas

ACNM's Issue areas

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 practitioner.

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.

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 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.
 

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 Tax Watch, 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 practice).

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 outcomes.

State Practice Environment for Certified Nurse-Midwives – Updated June 2023 – CNM Map This map displays practice environments for CNMs. Whether a CNM is able to practice midwifery independently, is required to have a collaborative agreement, or is only allowed to practice under supervision. Some states engage in a hybrid model where a midwife can practice independently but with certain restrictions in place. These restrictions vary state-to-state.
 
State Practice Environment for Certified-Midwives  – Updated 2025 – CM Map This map displays practice environments for CMs. Whether a CM is able to practice midwifery independently, is required to have a collaborative agreement, or is only allowed to practice under supervision. Some states engage in a hybrid model where a midwife can practice independently but with certain restrictions in place. These restrictions vary state-to-state.

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 practitioner.

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.

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. OB-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, licensed independent providers who may collaborate with each other based on the needs of their patients.

Principles for Credentialing and Privileging Certified Nurse-Midwives and Certified Midwives
An overview of the principles that policymakers who develop language regarding credentialing and privileging for CNMs and CMs should consider.

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

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.
 
CNM/CM Medicaid Reimbursement Rates This chart indicates Medicaid Reimbursement Rates for Certified Nurse-Midwives and Certified Midwives.
 

The Certified Midwife (CM) credential was developed in 1994 in order to expand access to midwifery through multiple educational pathways. The first CM was licensed in 1997. The CM pathway includes a graduate degree in midwifery from a program accredited by the Accreditation Commission for Midwifery Education (ACME) and board certification through the American Midwifery Certification Board (AMCB). CMs differ from Certified Nurse-Midwives (CNMs) only in that they are not also licensed as nurses. CMs and CNMs meet the same core competencies, sit for the same board exam, and have identical scopes of practice including prescriptive privileges.

The CM credential is currently recognized in Arkansas, Colorado, Delaware, Hawaii, Maine, Maryland, New Jersey, New York, Oklahoma, Rhode Island, Virginia, and the District of Columbia. Several other states are currently pursuing licensure of CMs.

The Committee of Midwife Advocates for the Certified Midwife (C-MAC) is the ACNM committee that provides support for expanding licensure of CMs. C-MAC coordinates activities within the Division of Advocacy and Affiliate Support and works closely with ACNM’s federal lobbyist and the ACNM Director of Government Affairs. In accordance with ACNM’s 2021-2024 strategic goals, C-MAC develops advocacy strategies to promote equitable national and state recognition of the CM credential to allow CMs to practice to the full extent of their education and training. C-MAC activities include the following:

  • Education about the CM credential to stakeholders
  • Advocacy for state licensure of CMs
  • Lobbying for the CM role in federal and state initiatives related to provision of midwifery care

For more information about licensing CMs or to connect with C-MAC, contact [email protected].

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Position of The College

The American College of Nurse-Midwives is committed to supporting policy solutions that ensure all people have access to a full-range of preventive, reproductive, and sexual health services. The world’s major health and human rights organizations affirm that when individuals have full autonomy over their reproductive health, it elevates level of education and economic growth for themselves and their families, benefitting entire communities.

ACNM is committed to individual patient autonomy across the spectrum of reproductive health, including abortion. This commitment includes advocating to keep abortion access unconditionally safe and legal for all people midwives serve, but especially for vulnerable populations with limited resources and unequal access to quality healthcare.

As we recognize the vital role access to comprehensive reproductive and sexual health plays in reducing health and economic disparities, we will continue to voice our opposition to state and federal legislation and/or regulation that aims to restrict access to the full-range of sexual and reproductive health services, including abortion, or compromise the safety of such care. Below you can access position statements from ACNM reaffirming our stance, clinical guidance, research for evidence-based practice, training opportunities, and legal guidance for midwives and other medical professionals.

Statements on Reproductive Health Limitations

ACNM Statement on AL Supreme Court IVF Ruling – February 2024
ACNM Condemns SCOTUS Decision, Dobbs v. Jackson Women’s Health Organization
ACNM Opposes State Legislative Threats to Abortion Care

ACNM Position Statement on Midwives as Abortion Care Providers 
ACNM Position Statement on Access to Sexual and Reproductive Health Care Service

Amicus Briefs Joined by ACNM

ACNM, NPWH, AAPA, and APAOG SCOTUS Amicus Brief Following 5th Circuit Decision – February 2024

ACNM and NPWH Amicus Brief in Support of a “Stay” in the Alliance for Hippocratic Medicine vs. U.S. Food and Drug Administration – May 2023

ACOG et. al. Amicus Brief in Support of the Application for an Administrative Stay in the Alliance for Hippocratic Medicine vs. U.S. Food and Drug Administration – April 2023

Clinical Guidance & Research

Decision Assessment and Counseling in Abortion Care – Alissa Perrucci, PhD
This book is a manual for conducting pregnancy decision making counseling for all types of providers.

Alissa Perrucci is the Counseling and Administrative Manager at the UCSF Women’s Options Center. Under her vision and leadership, the Women’s Options Center has become a national model for skilled, compassionate abortion counseling. It is also an invaluable resource for clinical researchers and family planning trainees. Additionally, she is the recipient of the National Abortion Federation’s C. Lalor Burdick Award, which honors “unsung heroes whose daily commitment to excellence exemplifies the ideals of NAF’s members.”

Access Delivered: A Toolkit for Providers Offering Medication Abortion

This Provider Toolkit offers a step-by-step guide for initiating a modern medication abortion service within your primary care practice. It provides information on setting up the service, patient-centered standards of care, and resources for understanding federal and state regulations on abortion services. This toolkit it provided through the partnership of the University of Washington’s School of Medicine and Plan C, an information campaign that seeks to transform access to abortion in the US by normalizing the self-directed option of abortion pills by mail.

Telehealth Equity & Medication Abortion Care: Overview & Advocacy Guide
 | EMAA
Download the “Telehealth Equity & Medication Abortion Care: Overview & Advocacy Guide,” part of the EMAA (Expanding Medication Abortion Access) Project’s efforts to expand access to medication abortion care using telehealth and strengthen collaboration across communities to advocate for policies which improve equitable access to telehealth.

2022 Clinical Policy Guidelines | NAF
The National Abortion Federation (NAF) is the professional association of abortion providers. The mission of the National Abortion Federation is to unite, represent, serve, and support abortion providers in delivering patient-centered, evidence-based care. The Clinical Policy Guidelines are offered in English, Spanish, and French. 

Maximizing Skills in GYN Office Procedures
Provided through the University of California San Francisco

Pain with Office Gyn Procedures: Tips, Tricks and Evidence
 | Karen R. Meckstroth, MD, MPH
Dr. Karen R. Meckstroth is director of the UCSF Center for Pregnancy Options. She is also a generalist obstetrician and gynecologist in the UCSF faculty division at Zuckerberg San Francisco General Hospital and Trauma Center, and she serves as consulting medical director for the Women’s Community Clinic in San Francisco. Meckstroth is a fellow of the American College of Obstetricians and Gynecologists. She is a member of the Society of Family Planning and serves on a regional advisory panel for Physicians for Reproductive Health.

EXPLAINED: So-called “Abortion Reversal”

Dr. Monica McLemore, of the University of California San Francisco, explains what everyone needs to know about so-called “abortion reversal”.

Facts are Important: Medication Abortion “Reversal” Is Not Supported by Science
 | ACOG
The American College of Obstetricians and Gynecologists is a professional association of physicians specializing in obstetrics and gynecology. ACOG produces practice guidelines for health care professionals and educational materials for patients, provides practice management and career support, facilitates programs and initiatives to improve women’s health, and advocates for members and patients.

The Safety and Quality of Abortion Care in the United States from the National Academies of Sciences, Engineering, and Medicine
The National Academy of Sciences, The National Academy of Engineering, and The National Academy of Medicine work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

The Turnaway Study
 | ANSIRH at UCSF
Advancing New Standards in Reproductive Health (ANSIRH), based at the University of California San Francisco (UCSF), is a leading research program that informs the most pressing debates on reproductive health, rights, and access. The Turnaway Study is ANSIRH’s prospective longitudinal study examining the effects of unwanted pregnancy on women’s lives. The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term.

Training & Education

Early Abortion Training Curriculum | TEACH
Training in Early Abortion for Comprehensive Healthcare (TEACH) trains clinicians in reproductive health, enables them to provide abortion care, and cultivates the next generation of reproductive health champions to ensure everyone has access to comprehensive healthcare. The newly revised 6th edition of the TEACH Early Abortion Training Curriculum is an all-inclusive interactive curriculum with tools to train new reproductive health providers to competence.

Ultrasound in Abortion Care, Ultrasound Training Workbook from the Affiliates Risk Management Services, Inc.(ARMS) & the Planned Parenthood Consortium of Abortion Providers (CAPS) 

Clinical Abortion Staffing Solutions
 | NAF
CASS was founded with one goal in mind: to support the people and places that make safe, timely, compassionate abortion care possible. We seek to promote equitable abortion access by connecting abortion providing sites to committed healthcare professionals, offering targeted technical assistance to both sites and abortion care job seekers, and supporting abortion providing sites in creating fulfilling and equitable work environments.

Individual Clinical Training
 | Midwest Access Project
Midwest Access Project (MAP) seek to improve access to comprehensive reproductive health care by training providers in abortion, miscarriage care, contraception, and pregnancy options counseling. To meet MAP’s mission to expand access to high quality reproductive health training and services, the clinical training program’s strategic direction is to train a diverse array of anti-racist health care professionals who are highly motivated to provide comprehensive reproductive health care in their future practice to under-served patient populations, but who lack access to the clinical training to do so.

The Abortion Course & ANSIRH Simulation Videos| Innovating Education in Reproductive Health
Innovating Education in Reproductive Health is a project of the Bixby Center for Global Reproductive Health. The mission of the project is to generate, curate, and disseminate free curricula and learning tools about sexual and reproductive health, including abortion, in order to transform health professions education.

Abortion Pill CME
 | TEACH
TEACH has developed a video-based online training about the use of mifepristone for early abortion or miscarriage management. This CME training is in collaboration with UC Davis, Brown University, Bixby Center for Reproductive Health, & the Society of Family Planning (SFP).

How to Order Mifepristone & Helpful Fact Sheets | RHAP
The Reproductive Health Access Project (RHAP) trains, supports, and mobilizes primary care clinicians to ensure equitable access to sexual and reproductive health care, including abortion. By centering communities most impacted by barriers to care, RHAP fills critical gaps in clinical education and care delivery.

Want to offer medication abortion? Email Christie Pitney at [email protected]
 
Legal Guidance

An Overview of Abortion Laws | The Guttmacher Institute
The Guttmacher Institute is a leading research and policy organization committed to advancing sexual and reproductive health and rights (SRHR) worldwide. The Guttmacher Institute envisions a future in which all people can realize their rights and access the resources they need to achieve sexual and reproductive health. This vision is aligned with a progressive and evidence-based definition of SRHR, grounded in human rights, which holds that sexual and reproductive health is not merely the absence of disease, dysfunction or infirmity but a state of physical, emotional, mental and social well-being in all aspects of sexuality and reproduction.

Medication Abortion by Telehealth: Legal Issues for Providers| RAAP
Regulatory Assistance for Abortion Providers (RAAP), provides free legal compliance advice to eligible abortion providers in all U.S. states and territories. Experts can help with questions about establishing or expanding services, complying with abortion-specific state laws, preparing for or responding to facility inspections, offering medication abortion by telehealth, staff and practitioner scope-of-practice, and more. You can contact RAAP via [email protected].

Moonlighting: Employment Contract Toolkit
 | National Women’s Law Center
The National Women’s Law Center fights for gender justice—in the courts, in public policy, and in our society—working across the issues that are central to the lives of women and girls. We use the law in all its forms to change culture and drive solutions to the gender inequity that shapes our society and to break down the barriers that harm all of us—especially women of color, LGBTQ people, and low-income women and families. For nearly 50 years, we have been on the leading edge of every major legal and policy victory for women.

Repro Legal Helpline
: Legal support for patients/people self-managing, and minors trying to access abortion
Repro Legal Helpline is run by If/When/How: Lawyering for Reproductive Justice, a non-profit organization made up of advocates, organizers, and lawyers helping to build a future where everyone is free to make their own decisions about their bodies and reproductive lives. The Repro Legal Helpline is a free, confidential helpline where you can get legal information or advice about self-managed abortion, young people’s access to abortion or judicial bypass, and referrals to local resources.

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