This appendix contains a table that documents the detailed calculations used to compute the new professional practice index for CNMs for each of the 50 States plus the District of Columbia.

Legal Status (Maximum = 35)

Title protection indicates acceptance and acknowledgement of the skills required to practice as a professional. Legal protection provides a safeguard for both the public and the practicing professional.

CNMs are licensed, certified, or approved in all fifty States and the District of Columbia. Licensure as a nurse midwife provides recognition of the status of the profession. CNMs are frequently regulated as a category of Advanced Practice Nurse (APN). They are sometimes addressed as a separate category within the statutes and regulations which speak to professional practice, licensure requirements, and prescriptive authority. In some States, Midwives or CNMs are considered independently from other nurses and are regulated as a separate profession from APNs.

Regulation by the Board of Nursing is the most common structure when CNMs are considered to be APNs. Separate regulation by a Board of Midwifery is considered ideal since a separate board can best represent the interests and the orientation of midwives. When midwives are regulated by a separate entity, non-nurse midwives may be included in the rules.

Gynecological care in statute or regulation suggests that midwives are viewed as practicing in an expanded role. Limiting midwives to care in pregnancy and at birth does not fully use their professional competencies.

The nature of midwifery practice demands a relationship with a physician. Complicated pregnancies and deliveries require the availability of specialty physicians with the skills to provide needed patient care. Practice as a self-employed (autonomous) midwife is an option in several States, but the need for a collaborating physician is universal. Practice agreements and review of records that are left to the discretion of the midwife and the physician acknowledge the competency and skill of each profession and the ability of both to safely meet patient need.

Temporary permits allow nurse midwives awaiting the results of the certification examination to practice.

Inactive or retired status allows non-practicing CNMs to use their title.

The profession of Midwifery philosophically supports non-nurse midwives who are properly trained and regulated. The roots of midwifery practice are in the care of women during pregnancy and childbirth in communities where other medical resources are limited. Requiring a masters degree, although elevating to a profession, limits the ability of non-nurse midwives (also referred to as direct entry or lay midwives) to provide care. Rather, professional midwifery associations support adequate skill and competency in midwifery and have opened their certification examinations to these midwives.

Hospital privileges permit a nurse midwife to admit a patient without a supervising physician and provide autonomy to the professional. Signing birth certificates and the ability to directly refer indicate recognition of the professional ability of the midwife.

Reimbursement (Maximum = 35)

In 1997, the Balanced Budget Act, expanded the locations at which CNM could be reimbursed for services. Since this was a progression in reimbursement from 1992, a score was awarded to every State for direct Medicare payment.

State reimbursement policy for payment of services rendered to Medicaid-eligible patients varies considerably by State and by profession.

The legal right to be reimbursed for services provided is critical to the autonomy of CNMs. Although services may be provided totally by the CNM, the inability to bill third parties for payment as an identified provider can be a barrier to the provision of care.

Direct access legislation allows women to choose well care services from a nurse midwife. Legislation enabling that independent choice acknowledges the skill of the CNM and suggests the roles that CNMs can play in healthcare delivery.

Prescriptive Authority (Maximum = 30)

When prescriptive authority is granted as part of the licensure process for nurse midwives, it is recognition of confidence in the education and skill of the CNM. The necessity of a separate application for prescriptive privilege suggests special requirements for the authority not fundamental to the didactic and clinical preparation of the midwife.

Although DEA numbers are a requirement for prescribing controlled substances, a separate score was allotted to emphasize the importance of the privilege of writing scripts for scheduled drugs.

Definition of the prescriptive privilege in law rather than by individual physicians suggests full recognition of the capability of the professional. Dependence for prescriptive authority on physician delegation limits the nurse midwife by creating barriers to efficient practice. Review with another health professional of patient needs and ordering of appropriate medications is a necessary part of practice. However, the circumstances under which that consultation occurs may best be determined by the midwife and may not need to be detailed in law or in a cooperative agreement.

The ability to receive and distribute sample medications, to independently sign a prescription and to prescribe medical devices are suggestive of recognition of the expertise of nurse midwives.

Continuing education requirements maintain the skill of the professional and update competencies.

The actual point allocations for the 50 States are presented below.