Virginia Certified Nurse Midwives have been safely practicing for the last 6 years without supervision by other professions. With the new law and these regulations we are no longer in a collaborative practice which restricts our ability to practice by our current standards. The American College of Nurse Midwives, our national organization, provides the Standards for our practice which the State of Virginia should follow. Our Standards allow for independent practice with consultation, colloaboration and referral to our obstetrical colleagues as needed.

These current rules increase the burden of regulation on Nurse Midwives unecessarily, hampering our ability to practice and increasing costs of care while decreasing accessibility to our services for women in the State of Virginia.

Please remove the Certified Nurse Midwife from this bill.

Virginia Legislators,

I am a certified nurse midwife caring for the uninsured and underinsured population of pregnant women in Prince William County. My practice setting is a Federally Qualified Health Center. It is a CNM practice and we collaborate and consult with  physicians in obstetric hospitalist groups at 2 local hospitals. Our practice has been directly responsible for a dramatic decrease in the drop in with no prenatal care delivery rate at our  local hospitals during the 3 years we have been in existence.

Virginia CNMs have been safely practicing for the last 6 years without supervision by other professions. With the new law and these regulations we are under a team leader physician which is not a collaborative practice. This leads to limitations in practice, difficulty in opening midwifery owned and midwifery run practices and restricts hospital admitting privileges. These rules increase the regulatory burden on certified nurse midwives, increase cost of care, and decrease access to care while providing no benefit to the public.Nurse -midwifery practice in Virginia should follow the Standards of the American College of Nurse Midwives which allows for independent practice.

Respectfully,

Lisa Wiener, CNM, Prenatal Director GPWCHC

Please reconsider new changes about practice agreements for these following reasons:

**All the national Advanced Practice Nursing Organizations oppose practice agreements and promote independent practice.

**Virginia CNMs have been safely practicing for the last 6 years without supervision by other professions. With the new law and these regulations we are under a team leader physician which is not collaborative practice. This leads to limitations in practice, difficulty in opening midwifery owned and midwifery run practices and restricts hospital admitting privileges.

**Nurse-midwifery practice in Virginia should follow the Standards of the American College of Nurse-Midwives which allows for independent practice.

**These rules increase the regulatory burdens on certified nurse midwives, increase cost of care, and decrease access to care while providing no benefit to the public.

               Thank you,

               Jennifer Cheney, CNM in Norfolk, VA

Virginia CNMs have been safely practicing for the last 6 years without supervision by other professions. With the new law and these regulations we are under a team leader physician which is not a collaborative practice. This leads to limitations in practice, difficulty in opening midwifery owned and midwifery run practices and restricts hospital admitting privileges. These rules increase the regulatory burden on certified nurse midwives, increase cost of care, and decrease access to care while providing no benefit to the public.Nurse -midwifery practice in Virginia should follow the Standards of the American College of Nurse Midwives which allows for independent practice.

PLEASE take this into consideration!

Respectfully,

Mary E. Kwiecinski, CNM

Jan 14, 2013

I have been practicing as a WHNP for 21 years now serving women of all ages.  I am currently in a CNM program at Shenandoah University with plans to graduate in August of this year.  My goal is to open a free-standing birth center in the Williamsburg area as this option is not available for the women living there.  I have spent the past few months visiting birth centers, am in contact with local child bearing aged women, and am registered to attend the American Association of Birth Center’s conference in Raleigh North Carolina this month on establishing a birth center.

What I have seen is that birth centers provide a cost effective, safe, family supportive option for low risk births and women’s health care.  They offer many services that help transition families such as lending libraries, parent support groups, exercise and other wellness classes in a comfortable environment.  I have also heard from the women who have their babies at birth centers, and they LOVE the experience!

I am worried that the current legislative actions that are being considered will greatly impact my ability to open a birth center and ultimately do away with an option that many women are seeking.   The new laws and regulations which would place CNMs under a physician leader are not only unnecessary as CNMs have been safely practicing in the Commonwealth of Virginia for the last 6 years, but they will also severely limit our practice.  For example:  if the physicians in a given community are threatened by the competition of a birth center, it would become impossible for me to practice.  Many physicians and midwives work beautifully together, and I hope that the future leads to even more successful partnerships; but this is not always the case and therefore families who would like to choose this model of care should not be penalized. 

Why are we looking at ways in which we reduce access to care for our population and not working together on ways to increase access to care?  This type of legislation goes directly against national health care goals!  The model of midwifery care in other countries with far less money than America is placing them in better status with regard to infant mortality rates and other measurable areas of public health.  Let’s do the right thing for our state.

Sincerely,

Cheryl L. Sharp, MSN, WHNP-C

Midwifery Candidate Shenandoah University-2013

I am currently a Certified Nurse Midwife in the state of Virginia and I left private practice approximately 13 years ago because of the lack of a midwifery friendly environment in the state of Virginia.  I went to work for the federal government as a Certified Nurse Midwife and was granted credentials as an independent  provider of care.  As such I am able to admit and discharge my patients, prescribe medications,  and  generally work well in a collaborative environment with my physician colleagues . 

After the law was changed and midwifery care was granted the privilege to practice with a collaborative/consultative relationship with physicians; I was contemplating going to one of the underserved area to establish a midwifery practice. 

With the change in law - that is no longer a feasible option for me.  I am asking that you remove this restriction for the nurse midwives in the state of Virginia.  With the safety of midwifery care well established; it keeps the state of Virginia from recruiting well qualified providers that could set up practices in the underserved areas and render quality women's health care to thousands of women. 

Midwives are trained to be independent providers of care and do not need a "physician team leader" in order to render competent, compassionate care to our population.  Collaborative/Consultative environments without all the paperwork - practice agreements - are more conducive to midwifery care.

Karen R. Brayboy, MSN, CNM

The law passed by the General Assembly in 2012 regarding the practice of CNMs and the regulations stemming from it is a backword step for CNMs when it comes to requiring CNMs to work in "teams" under a physician leader.   This decreases our ability to provide care in areas where physicians refuse to work in teams with us due to concerns about liability or competition.  The requirements including the requirement for practice agreements increase the costs for midwifery and decrease access to midwifery care.  Nurse -midwifery practice in Virginia should follow the Standards of the American College of Nurse-Midwives (ACNM).  ACNM standards do not require practice agreements with physicians, supervision by physicians, or medical teams.  In fact the law/regulations are at odds with itself because they state that the practice should be according to the standards of the ACNM then deviate from the standard by requiring practice agreements and teams.  There is no valid safety reason for the requirement to have a practice agreement with physicians.  Both the ACNM and the American College of OB/GYNs have a joint statement against practice agreements.

In order to meet the need for chart reviews, it will increase the cost for access to electronic medical records.  It increases the time our birth center medical director must spend reviewing charts.  It increases the costs to those CNMs who must pay physicians by the hour to review charts and be "leader of the team".  These costs are passed on to clients and insurance companies and Medicaid.  

The requirements put midwives at unfair disadvantage in the marketplace and are a restraint of trade, in direct opposition to the Constitution of Virginia.  I hope that the General Assembly, Governor, and Joint Boards will rectify this situation soon to allow freedom in the provision of health care in our state. 

Physicians are not educated in Midwifery and Midwives are not educated in Medicine.  We are separate, though overlapping in some areas, disciplines.  We work together through collaboration and consultation as needed for our clients.  We don't need the state requiring agreements.  LESS REGULATION AND MORE FREEDOM will allow CNMs to follow ACNM standards, equal better care and access to care, and more consumer control of the health care market.

It is my concern that these provisions will make it harder to practice as a CNM in the Commonwealth of Virginia. By making it harder for CNMs to practice, this legislation threatens the available choices women in the state have for their maternity care. Evidence has shown that midwife-attended births are safe and an important option for pregnant mothers and their families. Please protect women's access to CNMs in Virginia, and don't make it harder for them to practice the skills they are well-trained to apply.

Please remove the Certified Nurse Midwives from this portion of the regulation.  We have been practicing safely and with excellent relationships with our collaborative physicians and practices without this restrictive language for 6 years now. 

This language is restrictive for the nature of our practice.  We do not function in the same roles as WHNP and other NP's by definition.  This regulation will unnecessarily hamper our ability to care for indigent and underserved populations in rural areas; the very areas that are already underserved by the medical community.

Please remove the Certified Nurse Midwives from this bill.

Please remove Certified Nurse Midwives from this regulation.  Certified Nurse Midwives have practiced independently without direct physician oversight everywhere for many years, including in Virginia.    There is good scientific evidence supporting the safety of independent Certified Nurse-Midwife care.  By requiring direct physician oversight of their practices, many Virginia CNMs would be unable to practice, and this would restrict access for Virginia mothers to the care provider of their choice.  In this way, this regulation would restrict Virginia mothers' reproductive choice.  Furthermore, this requirement would unecessarily burden the ability of CNMs to practice their profession without any increase in public safety.  Reducing access to trained and qualified birth attendants for Virginia mothers actually decreases public safety overall.  

These rules will increase the regulatory burdens on certified nurse midwives, increase cost of care, and decrease access to care while providing no benefit to the public. Midwives are trained to be independent providers of care and do not need a "physician team leader" in order to render competent, compassionate care to our population. Collaborative/Consultative environments without all the paperwork - practice agreements - are more conducive to midwifery care. Virginia CNMs have been safely practicing for the last six years without supervision by other professions. With the new law and these regulations we are under a team leader physician, which is not collaborative practice. This leads to limitations in practice, difficulty in opening midwifery-owned and midwifery-run practices and restricts hospital admitting privileges. All the national Advanced Practice Nursing Organizations oppose practice agreements and promote independent practice. As a woman who has benefited from midwifery care in VA I personally wouldn't have it any other way. Also, as an aspiring midwife it saddens me to see all of the regulations that are being put on midwives who do the same thing if not more than OB's to care for women. We need to protect midwives and the patients right to choose with whom and where they deliver as well. 

CNMs have a history of safe practice in Virginia. They do not need to be under the authority of a physician when collaborative care works safely and well. Please remove CNMs from this proposal.

Requiring CNMs to practice within obstetrician-led "patient care teams" increases regulation, reduces women's access to midwifery care (not all CNMs are able to find OBs to team with in their geographic areas), and increases the cost of midwifery care, with no added benefit for women in Virginia.

Evidence shows that for women with low-risk pregnancies, midwifery care leads to better outcomes and fewer interventions than OB care.  Midwives are highly-skilled and well-trained to be independent providers who work collaboratively with obstetricians on an as-needed basis.  Please help make midwifery care more widely available to the women of Virginia.  For low-risk women, midwifery care produces better health outcomes, reduces health care costs, and is beloved by those who receive it, myself included!

Please allow CNMs to practice independently!

Midwives have been practicing in the state of Virginia without "supervision" for the last 6 years.  Our outcomes for our patients are as equal or better than that of our physician colleagues.  restricting us to have a physician lead team restricts our practice and is an unnecessary administrative burden .   We already follow ACNM requirements regarding a collaborative relationship with our physician colleagues.  

As a Certified Nurse-Midwife, I am licensed as an APRN in Virginia. I see women throughout their lives, from adolescence to menopause, and attend births independently in a hospital setting. When I see a patient who has a high-risk condition, I consult with my collaborating physicians or have the patient to transfer care to a physician.

In 2006, the state legislators allowed Virginia nurse-midwives to better serve women, by changing the requirement for physician supervision in the regulations to collaboration and consultation. Prior to and since that time, CNMs have been safely providing excellent care to women and newborns in Virginia and throughout the United States and other countries. Now new legislation, in the form of HB 346, threatens our ability to continue to practice as safe, independent providers in Virginia.

When the new law is implemented, with a requirement that nurse-midwives function as a member of a physician-led team, new regulations could have a negative effect, by limiting patient access to much needed maternity services. Change in the regulations could limit the nurse-midwife's ability to open and own a practice, admit patients to the hospital for births, or be reimbursed by insurance companies for the care provided.

Our professional organization, the American College of Nurse-Midwives, has nationally recoginzed standards of practice, which should be the model used by Virginia. These standards allow for independent practice but include appropriate consultation, collaboration, and referral to physicians for women who risk out of nurse-midwifery care, giving women the very best each of our professions can offer. This reflects how nurse-midwives currently practice and allows more women to access our services--and results in better health for women and babies in Virginia.

Thank you for the opportunity to comment,
Kris Conrad, DNP, APRN, CNM
Blacksburg, VA

CNMs have extensive education and experience, much like an OB. The government should have no hand in RESTRICTING my choice in what type of prenatal care and delivery I prefer. I see no reason why my CNM should not be able to oversee my pregnancy and deliver my baby. This is a family decision!

The proposed creation of "patient care teams" INCREASES regulation, rather than reducing it, as the Governor’s Regulatory Reform Project intends. Requiring CNMs to practice as part of such teams would have the effect of reducing access to (while increasing the cost of) midwifery care with no added benefit for women in Virginia. The existing collaborative/consultative model without all the paperwork that practice agreements entail is more conducive to effective, accessible midwifery care.

Re:  18VAC90-30 Regulations Governing the Licensure of Nurse Practitioners

As certified nurse-midwives (CNMs), our practice includes consultation and collaboration with physicians. This positive step forward in nurse-midwifery practice in Virginia occured when the regulations governing the licensure of nurse practitioners were changed to remove the supervisory language and instead called for collaboration and consultation between physicians and nurse-midwives. We have continued to demonstrate safe practice Virginia--without supervision by other professions, but instead in collaboration with others--to provide optimal care to the families of Virginia.  

In collaborative relationships, each provider practices to the full extent of his or her education while best serving the needs of the patient. Introducing requirements for membership in care teams can restrict patient choice and access to care and raise costs to consumers. When placed as subordinates on a team, CNMs are likely to have difficulty obtaining hospital privileges, staffing birth centers, and securing insurance reimbursement, all things which decrease patient access to midwifery care.  

Nurse-midwifery practice in Virginia should follow the Standards of The American College of Nurse-Midwives (ACNM), which allows for independent practice. The Standards of the ACNM allow for practice which includes consultation, collaboration, and referral, and any regulations which prevent nurse-midwives from practicing to the full scope of their education and training will ultimately be detrimental to the health of women and families in Virginia.

Respectfully, The Virginia Affiliate of the American College of Nurse-Midwives Executive Board

Kristin H. Conrad, DNP, CNM--President

Risa Rispoli, CNM--Vice-President

Deborah Meslar-Little, NP, CNM--Treasurer  

Phyllis Turk, MSN, CNM--Secretary

Karen King, MS, CNM--Legislative Chair

I am a Certified Nurse Midwife working at a busy midwife owned and operated health care practice in Manassas, Virginia.  We are 4 CNMs and several support staff caring primarily for women who lack health care insurance or who receive Medicaid.  We have a sliding scale fee for our services, for women who are non-insured.  We were the first maternity practice in Prince William County to offer Centering Pregnancy model of group prenatal care, a model demonstrated to reduce preterm births and NICU admissions for newborn babies.  in 3.5 years since opening for business, we have provided prenatal care for more than 450 pregnant women, most of whom have given birth in the local community hospital across the street from our office.  We are midwife-owned and operated!  Our founder started Manassas Midwifery because there was such a need for affordable and accessible prenatal care services.  Legislation to requre us to be supervised by a physicians at the head of our "team" could put us out of business.  We currently work quite satisfactorily with obstetricians in a collaborative manner; we do not work for physicians.  In fact, no physicians have been intersted in joining forces with us in a business partnership to provide comprehensive maternity care that would include obstetric care for high risk clients as well as midwifery care to low risk clients.  The current system of collaboration has worked quite well for more than 6 years and has enabled practices like Manassas Midwifery to start up, to meet unmet needs in the community.  Please don't mess with success!!