Position Statement

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

It is the position of American College of Nurse Midwives (ACNM) that safe, quality health care can best be provided to women and their infants when policy makers develop laws and regulations that permit Certified Nurse Midwives (CNMs) and Certified Midwives (CMs) to provide independent midwifery care within their scope of practice while fostering consultation, collaborative management, or seamless referral and transfer of care when indicated. ACNM affirms the following:

  • Requirements for a signed collaborative agreement do not guarantee the effective communication between midwives and physicians that is so critical to successful collaboration:
    • They do not assure physician availability when needed
    • There is no evidence that they increase the safety or quality of patient care
    • In certain circumstances, such as the aftermath of a natural or declared disaster, such requirements have hampered the ability of CNMs/CMs to provide critically necessary emergency relief services
  • Collaborative agreements signed by individual physicians wrongly imply that CNMs/CMs need the supervision of those individuals in all situations. Based on this misconception:
    • Professional liability companies have used signed agreements with their implied requirements for supervision as the rationale for raising physician premiums citing increased risk related to such unneeded supervision
    • CNMs/CMs may be restricted from exercising their full scope of practice or from receiving hospital credentials, clinical privileges, or third party reimbursement for services that fall within the scope of their training and licensure
  • Requirements for signed collaborative agreements can create an unfair economic disadvantage for CNMs/CMs:
    • They have been used to limit the number of midwives who can practice collaboratively with any one physician, effectively barring CNMs/CMs from practice in some cases or restricting the ratio of CNMs/CMs to physicians
    • They allow potential economic competitors to dictate whether or not midwives can practice in a community
    • They restrict access to care and choice of provider for women. This is of particular concern in underserved areas.

Background
The American College of Nurse-Midwives (ACNM) strongly supports the principle of collaboration in the delivery of healthcare services, as evidenced by the Standards for the Practice of Midwifery, the ACNM Position Statement on Collaborative Management in Midwifery Practice, and the Joint Statement of Practice Relations between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives. However, the ACNM opposes requirements for signed collaborative agreements between physicians and certified nurse-midwives (CNMs) or certified midwives (CMs) as a condition for licensure, reimbursement, clinical privileging and hospital credentialing, or prescriptive authority as such requirements, in practice, interfere with effective coordination of care.

The Standards for the Practice of Midwifery state that midwifery care is based upon knowledge, skills, and judgment which are reflected in written practice guidelines that are mutually agreed upon, and specifically mandates that those guidelines define the parameters for consultation, collaboration, and referral. The Standards do not require signed collaborative agreements with physicians. Policies that create confusion about the designation of responsibility are to be avoided, especially given the current malpractice climate. It is critical that laws and regulations facilitate effective relationships between health care professionals, creating systems whereby midwives and physicians can communicate openly and practice collaboratively while continuing to provide quality care that falls within each individual's professional scope of practice.



* Certified nurse-midwives are registered nurses who have graduated from a midwifery education program accredited by the ACNM Division of Accreditation and have passed a national certification examination administered by the American Midwifery Certification Board, Inc. (AMCB), formerly the American College of Nurse-Midwives Certification Council, Inc. (ACC).
* Certified midwives are graduates of an ACNM Division of Accreditation accredited, university affiliated midwifery education program, have successfully completed the same science requirements and AMCB national certification examination as certified nurse-midwives and adhere to the same professional standards as certified nurse-midwives.

Source: ACNM Board of Directors
Date: March, 2006
Revised and approved by the ACNM Board of Directors: December 4, 2009
Reviewed and approved by the ACNM Board of Directors, Dec. 2011