CHAPTER 33 – MIDWIFERY JOINT COMMITTEE

SECTION .0100 – MIDWIFERY JOINT COMMITTEE

21 NCAC 33 .0101 ADMINISTRATIVE BODY AND DEFINITIONS

(a) The responsibility for administering the provisions of G.S. 90, Article 10A, shall be assumed by an administrative body, the Midwifery Joint Committee, hereinafter referred to as the "Committee." The certified nurse midwife shall hereinafter be referred to as "CNM."

(b) In addition to the definitions set forth in G.S. 90-178.2, the following shall apply to the Rules in this Chapter:

(1) "American Midwifery Certification Board (AMCB)" means the national certifying body for candidates in nurse-midwifery and midwifery who have received their graduate level education in programs accredited by the Accreditation Commission for Midwifery Education.

(2) "Accreditation Commission for Midwifery Education (ACME)" means an accreditation agency established to advance and promote midwifery education.

(3) "American College of Nurse-Midwives (ACNM)" means the professional association that represents CNMs and certified midwives (CMs) in the United States. ACNM sets the standard for midwifery education and practice in the United States.

(4) "American College of Obstetricians and Gynecologists (ACOG)" means the professional membership organization for obstetrician-gynecologists that produces practice guidelines for health care professionals and educational materials for patients, provides practice management and career support, facilitates program and initiatives to improve women's health, and advocates for members and patients.

(5) "Obstetrics" means a branch of medical science that deals with birth, its antecedents, and sequels, including prenatal, intrapartum, postpartum, newborn or gynecology, and otherwise unspecified primary health services for women.

History Note: Authority G.S. 90‑178.4;

Eff. February 1, 1984;

Amended Eff. July 1, 2000; October 1, 1988;

Readopted Eff. November 1, 2018;

Amended Eff. April 1, 2020;

Temporary Amendment Eff. October 1, 2023.

21 NCAC 33 .0102 FEES

(a) The fee for a new application and initial approval shall be one hundred dollars ($100.00).

(b) The fee for annual renewal shall be fifty dollars ($50.00).

History Note: Authority G.S. 90‑178.4(b);

Eff. February 1, 1984;

Amended Eff. July 1, 2000;

Readopted Eff. November 1, 2018;

Amended Eff. April 1, 2020.

21 NCAC 33 .0103 eligibility and APPLICATION

(a) To be eligible for an approval to practice independently as a CNM, an applicant shall:

(1) submit a completed application for an approval to practice, attesting under oath or affirmation that the information on the application is true and complete, and authorizing the release to the Committee of all information pertaining to the application.

(2) submit the approval to practice application fee as established in 90-178.4(b)(1) and Rule .0102 of this Section;

(3) have an unencumbered RN license or privilege to practice in all jurisdictions in which a license is or has ever been held.

(4) hold an active, unencumbered North Carolina RN license or privilege to practice;

(5) hold an unencumbered CNM license or an approval to practice in all jurisdictions in which a license or an approval to practice is or has ever been held;

(6) provide an official copy of the educational transcript and certificate from American Midwifery Certification Board and the full address of the practice location where the applicant intends to practice midwifery;

(7) submit an attestation of completion of at least 24 months experience and 4,000 practice hours as a CNM. Documentation of successful completion of this requirement shall be provided to the Committee upon request; and

(8) have no pending court conditions as a result of any misdemeanor or felony conviction(s). Applicant shall provide a written explanation and any investigative report or court documents evidencing the circumstances of the crime(s) if requested by the Committee. The Committee may use these documents when determining if an approval to practice should be denied pursuant to G.S. 90-178.6.

(b) An applicant seeking an approval to practice with less than 24 months experience and 4,000 hours of practice as a CNM shall:

(1) submit an application for an approval to practice, attesting under oath or affirmation that the information on the application is true and complete, and authorizing the release to the Committee of all information pertaining to the application.

(2) submit the approval to practice application fee as established in 90-178.4(b) and Rule .0102 of this Chapter;

(3) hold an unencumbered license or privilege to practice in all jurisdictions in which a license is or has ever been held;

(4) hold an active, unencumbered North Carolina RN license or privilege to practice;

(5) hold an unencumbered CNM license or an approval to practice in all jurisdictions in which a license or an approval to practice is or has ever been held;

(7) submit information identifying the collaborating provider with whom the applicant will collaborate;

(c) When a CNM seeks independent practice, the CNM shall submit a new application for an approval to practice independently, attesting under oath or affirmation that the information on the application is true and complete, and authorizing the release to the Committee of all information pertaining to the application and required fee.

(d) Applications are posted on the Board of Nursing's website at www.ncbon.com. The following information shall appear on the application:

(1) the applicant's name, telephone number and email address;

(2) the applicant's primary address of residence;

(3) the educational degrees obtained by the applicant with the program name and completion date;

(4) the number and expiration date of the applicant's national certification from the AMCB;

(5) other professional or occupational licenses with the license number and jurisdiction in which the license was issued, if applicable;

(6) the name, license number, telephone number, email address, and practice location of the collaborating provider, if applicable; and

(7) the approval to practice number shall be provided on the application if the application is for the renewal or reinstatement of an existing approval to practice.

(e) All educational transcripts and certification shall be submitted directly to the Board from the primary source.

(f) In the event that any information required in accordance with this Rule should indicate a discrepancy in the application, an applicant may be required to appear in person for an interview with the Committee if the Committee determines in its discretion that more information is needed to evaluate the application.

History Note: Authority G.S. 90-171.48; 90‑178.4(b); 90‑178.5;

Eff. February 1, 1984;

Amended Eff. March 1, 2017; January 1, 1989;

Readopted Eff. November 1, 2018;

Amended Eff. April 1, 2020;

Temporary Amendment Eff. October 1, 2023.

21 NCAC 33 .0104 Provider collaboration required

(a) A CNM who has practiced fewer than 24 months and 4,000 hours of practice as a CNM shall practice in consultation with a collaborating provider in accordance with a collaborative provider agreement in compliance with Rule .0116 of this Chapter.

(b) The approval to practice of the CNM practicing under the supervision of a collaborative provider agreement is terminated when the CNM discontinues working within the approved collaborative provider agreement or experiences an interruption in their RN licensure status. The CNM shall notify the Committee in writing within five days of the termination of the collaborative provider agreement.

(c) The CNM shall have 90 days to submit a newly-executed collaborative provider agreement with a collaborative provider to the Committee. During this 90-day period, the CNM may continue to practice midwifery in accordance with the Midwifery Practice Act and this Chapter. Should the 90-day period expire without a newly-executed collaborative provider agreement being submitted to the Committee, the approval to practice is rendered inactive and the CNM shall be required to submit an application for reinstatement of the approval to practice consistent with Rule .0103 and Rule .0115 of this Chapter. The Committee will notify the CNM when the application has been approved and the approval to practice is reinstated.

(d) To be eligible a collaborative provider shall:

(1) hold an active, unencumbered approval to practice as a CNM and have a minimum of 4 years and 8,000 hours of practice as a CNM; or

(2) hold an active, unencumbered license to practice medicine in North Carolina and be actively engaged in the practice of obstetrics.

(e) A CNM who has practiced over 24 months and has 4,000 hours of practice as a CNM may be issued an approval to practice midwifery independently and shall consult and collaborate with and refer patients to such other health care providers as may be appropriate for the care of the patient.

History Note: Authority G.S. 90-178.3; 90‑178.4(b);

Eff. February 1, 1984;

Amended Eff. July 1, 2000; October 1, 1988; April 1, 1985;

Readopted Eff. November 1, 2018;

Temporary Amendment Eff. October 1, 2023.

21 ncac 33 .0105 DISCIPLINARY ACTION

(a) The CNM is subject to G.S. 90-171.37; 90-171.48 and 21 NCAC 36 .0217 by virtue of the license to practice as a RN.

(b) After notice and hearing in accordance with provisions of G.S. 150B, Article 3A, the Committee may take disciplinary action if it finds one or more of the following:

(1) practicing without a valid approval to practice as a CNM;

(2) presenting false information to the Committee in procuring or attempting to procure an approval to practice as a CNM;

(3) the CNM is adjudicated mentally incompetent by a court of competent jurisdiction or the CNM's mental or physical condition renders the CNM unable to safely function as a CNM;

(4) unprofessional conduct by reason of deliberate or negligent acts or omissions and contrary to the prevailing standards for CNMs as set forth by ACNM;

(5) conviction of a criminal offense where the CNM has deceived or defrauded the public;

(6) soliciting or attempting to solicit payments for the CNM practice with false representations;

(7) failure to maintain professional competence as a CNM such that the CNM would no longer be eligible for certification by the ACMB or the ACNM;

(8) exploiting the patient, including the promotion of the sale of services, appliances, or drugs, for the financial gain of the CNM or of a third party;

(9) failure to respond to inquiries of the Committee for investigation and discipline;

(10) the CNM has engaged or attempted to engage in the performance of midwifery acts other than according to the collaborative provider agreement or without being approved by the Committee to practice independently;

(11) failure to obtain a written, informed consent agreement from a patient;

(12) practiced or offered to practice beyond the scope of CNM practice as defined in Rule .0112 of this Chapter;

(13) failure to comply with any order of the Committee;

(14) violating any term of probation, condition, or limitation imposed on the CNM by the Committee; or

(15) any violation within this Chapter.

(1) dismiss the case;

(2) issue a private letter of concern;

(3) enter into negotiation for a Consent Order; or

(4) a disciplinary hearing in accordance with G.S. 150B, Article 3A.

(d) Upon a finding of a violation of Chapter 90, Article 10A of the North Carolina General Statutes and the rules of this Subchapter, the Committee may utilize the range of disciplinary options as enumerated in G.S. 90-178.6 and 90-178.7.

History Note: Authority G.S. 90-178.6; 90-178.7;

Eff. February 1, 1985;

Amended Eff. August 1, 2002; October 1, 1988;

Readopted Eff. November 1, 2018;

Amended Eff. April 1, 2020;

Temporary Amendment Eff. October 1, 2023.

21 NCAC 33 .0106 NURSE MIDWIFE APPLICANT STATUS (repealed)

History Note: Authority G.S. 90‑178.2; 90‑178.5;

Eff. March 1, 1991;

RRC Objection Eff. May 18, 2000 due to lack of statutory authority;

RRC returned rule to agency on June 19, 2000;

Codifier of Rules removed rule from the NCAC Eff. June 19, 2000.

21 ncac 33 .0107 NURSE MIDWIFE APPLICANT STATUS

History Note: Authority G.S. 90-178.2; 90-178.3; 90-178.5; 90-171.83;

Eff. April 1, 2001;

Repealed Eff. March 1, 2017.

21 NCAC 33 .0108 SUSPENSION OF AUTHORITY TO EXPEND FUNDS

In the event the Midwifery Joint Committee's authority to expend funds is suspended pursuant to G.S. 93B-2(d), the Committee shall continue to issue and renew licenses and all fees tendered shall be placed in an escrow account maintained by the Committee for this purpose. Once the Committee's authority is restored, the funds shall be moved from the escrow account into the general operating account.

History Note: Authority G.S. 93B-2;

Eff. May 1, 2011;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.

21 NCAC 33 .0109 Termination of Approval to Practice

History Note: Authority G.S. 90-178.2; 90-178.3; 90-178.4; 90-178.5;

Emergency Adoption Eff. June 18, 2012;

Emergency Adoption expired August 31, 2012.

21 NCAC 33 .0110 REPORTING CRITERIA

(a) The Department of Health and Human Services ("Department") may report to the Committee information regarding the prescribing practices of those midwives ("prescribers") whose prescribing:

(1) falls within the top two percent of those prescribing 100 morphine milligram equivalents ("MME") per patient per day; or

(2) falls within the top two of those prescribing 100 MMEs per patient per day in combination with any benzodiazepine and who are within the top one percent of all controlled substance prescribers by volume.

(b) The Department may report to the Committee information regarding midwives who have had two or more patient deaths in the preceding 12 months due to opioid poisoning where the prescribers authorized more than 30 tablets of an opioid to the decedent and the prescriptions were written within 60 days of the patient deaths.

(c) The Department may report to the Committee information regarding prescribers who meet three or more of the following criteria, if there are a minimum of five patients for each criterion:

(1) at least 25 percent of the prescriber's patients receiving opioids reside 100 miles or greater from the prescriber's practice location;

(2) the prescriber had more than 25 percent of patients receiving the same opioids and benzodiazepine combination;

(3) the prescriber had 75 percent of patients receiving opioids self-pay for the prescriptions;

(4) the prescriber had 90 percent or more of patients in a three-month period that received an opioid prescription that overlapped with another opioid prescription for at least one week;

(5) more than 50 percent of the prescriber's patients received opioid doses of 100 MME or greater per day excluding office based treatment medications;

(6) the prescriber had at least 25 percent of patients who used three or more pharmacies within a three-month period to obtain opioids regardless of the prescriber.

(d) The Department may submit these reports to the Committee upon request and may include the information described in G.S. 90-113.73(b).

(e) The reports and communications between the Department and the Committee shall remain confidential pursuant to G.S. 90-113.74.

History Note: Authority G.S. 90-113.74; 90-178.4;

Eff. May 1, 2016;

Amended Eff. December 1, 2017;

Readopted Eff. November 1, 2018;

Amended Eff. April 1, 2020.

21 NCAC 33 .0111 CONTINUING EDUCATION (CE)

(a) In order to maintain an approval to practice midwifery, a CNM shall meet the requirements of the Certificate Maintenance Program of the American Midwifery Certifying Board, including continuing education requirements. These requirements are hereby incorporated by reference, including subsequent amendments or editions, and may be accessed at no cost at: https://www.amcbmidwife.org/certificate-maintenance-program/purpose-objectives.

(b) Prior to prescribing Controlled Substances (Schedules II, IIN, III, IIIN, IV, V) defined by the State and Federal Controlled Substances Act, CNMs shall have completed a minimum of one CE hour within the preceding 12 months on one or more of the following topics:

(1) Controlled substances prescription practices;

(2) Prescribing controlled substances for chronic pain management;

(3) Recognizing signs of controlled substance abuse or misuse; or

(4) Non-opioid treatment options as an alternative to controlled substances.

(c) The CNM shall maintain documentation of all CE completed within the previous five years and make available to the Committee upon request.

History Note: Authority G.S. 90-178.3; 90-178.5(a)(2); S.L. 2015-241, s. 12F .16(b);

Eff. March 1, 2017;

Readopted Eff. November 1, 2018;

Temporary Amendment Eff. October 1, 2023.

21 NCAC 33 .0112 SCOPE OF PRACTICE

The CNM's scope of practice is defined by academic educational preparation and national certification and maintained competence. Scope of practice is set by the ACNM at https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000266/Definition%20Midwifery%20Scope%20of%20Practice_2021.pdf, is available at no cost, and is hereby incorporated by reference, including subsequent amendments and editions. Scope of practice includes:

(1) diagnosing, treating, and managing a full range of primary health care services to the patient throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and care of the newborn;

(2) treating patients and their partners for sexually transmitted diseases and reproductive health;

(3) providing care in diverse settings such as home, hospital, birth center, and a variety of ambulatory care settings including private offices and community and public health clinics;

(4) prescribing, administering, and dispensing therapeutic measures, tests, procedures, and drugs;

(5) planning for situations beyond the CNM's scope of practice and expertise by collaborating, consulting with, and referring to other health care providers as appropriate; and

(6) evaluating health outcomes.

History Note: Authority G.S. 90-18.8; 90-178.3;

Temporary Adoption Eff. October 1, 2023.

21 NCAC 33 .0113 COVID-19 DRUG PRESERVATION RULE

History Note: Authority G.S. 90-5.1; 90-8.2; 90-12.5; 90-171.23; 90-171.49;

Emergency Adoption Eff. April 21, 2020;

Emergency Adoption Expired on June 18, 2020 pursuant to G.S. 150B-21.1A(d)(3).

21 NCAC 33 .0114 ANNUAL RENEWAL

(a) The CNM shall renew the approval to practice annually no later than the last day of the applicant's birth month by:

(1) maintaining an active, unencumbered North Carolina RN license or privilege to practice;

(2) submitting a completed application as outlined in Rule .0103 of this Chapter for renewal, attesting under oath or affirmation that the information on the application is true and complete, and authorizing the release to the Committee of all information pertaining to the application;

(3) attesting to having completed the requirements of the Certificate Maintenance Program of the American Midwifery Certification Board or its successor, including continuing education requirements, and submit evidence of completion if requested by the Committee as specified in Rule .0111 of this Chapter; and

(4) submitting the approval to practice renewal fee as established in G.S. 90-178.4(b)(2) and this Chapter.

(b) It shall be the duty of the CNM to keep the Committee informed of a current mailing address, telephone number, and email address.

(c) If the CNM has not renewed by end of his or her birth month and submitted the annual fee, the approval to practice shall expire.

History Note: Authority G.S. 90-178.4(b); 90-178.5;

Temporary Adoption Eff. October 1, 2023.

21 NCAC 33 .0115 INACTIVE STATUS

(a) Any CNM who wishes to place their approval to practice on an inactive status shall notify the Committee in writing.

(b) A CNM with an inactive approval to practice status shall not practice as a CNM.

(c) A CNM with an inactive approval to practice status who reapplies for an approval to practice shall meet the qualifications for an approval to practice in Rule .0103 of this Chapter and shall not resume practicing until notification is received that the Committee has granted the application.

(d) A CNM who has not practiced as a CNM in more than two years shall complete a midwifery refresher course approved by the Commission. The refresher course shall be based on the American College of Nurse-Midwives' reentry to midwifery practice guidelines, which are hereby incorporated by reference, including subsequent amendments or editions and are available at no cost at: http://www.midwife.org/Re-entry-Guidelines-for-CNMs/CMs. The refresher course shall be directly related to the CNM's area of academic education and national certification. A midwifery refresher course participant shall be granted an approval to practice that is limited to clinical activities required by the refresher course.

History Note: Authority G.S. 90-178.3; 90-178.5;

Temporary Adoption Eff. October 1, 2023.

21 NCAC 33 .0116 COLLABORATIVE PROVIDER AGREEMENT

(a) A CNM with less than 24 months and 4,000 hours of practice as a CNM is required to have a written collaborative provider agreement to practice midwifery. The collaborative provider agreement shall:

(1) be agreed upon, signed, and dated by both the collaborating provider and the CNM, and maintained in each provider site;

(2) be reviewed at least annually, to ensure that the CNM and collaborating provider continue to practice under the terms of the agreement, and determine whether any changes to the agreement are necessary. This review shall be acknowledged by a dated signature sheet, signed by both the collaborating provider and the CNM, appended to the collaborative provider agreement, and available for inspection by the Committee;

(3) include mutually agreed upon written clinical practice guidelines for the drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed by the CNM; and

(4) include a pre-determined plan for emergency services.

(b) The collaborating provider and the CNM shall be available to each other for consultation by in-person communication or telecommunication.

(c) The CNM shall maintain a copy of the collaborative provider agreement executed within the previous five years and make available to the Committee upon request.

History Note: Authority G.S. 90-18.8; 90-178.3; 90-178.4; 90-178.5;

Temporary Adoption Eff. October 1, 2023.

21 NCAC 33 .0117 PRESCRIBING AUTHORITY

(a) The prescribing stipulations contained in this rule apply to writing prescriptions and ordering the administration of medications by a CNM.

(b) A CNM must possess a valid United States Drug Enforcement Administration ("DEA") registration in order to prescribe controlled substances.

(c) To act as a collaborating provider for a CNM, the DEA registration of the collaborating provider shall include the same schedule or schedules of controlled substances as the CNM practicing under a collaborative provider agreement.

(d) Prescribing and dispensing stipulations for the CNM authorized to practice under a collaborative provider agreement are as follows:

(1) The collaborative provider agreement outlined in Rule .0116 of this Chapter shall include the drugs and devices that the CNM may prescribe.

(2) The CNM has an assigned DEA number that is entered on each prescription for a controlled substance.

(3) Refills may be issued consistent with Controlled Substances (Schedules II, IIN, III, IIIN, IV, V) defined by the State and Federal Controlled Substances Act.

(4) The collaborative provider shall possess a schedule(s) of controlled substances equal to or greater than the CNM's DEA registration.

(5) The CNM may prescribe a drug or device not included in the collaborative provider agreement only as follows:

(A) Upon a specific written or verbal order obtained from the collaborating provider before the prescription or order is issued by the CNM; and

(B) The written or verbal order as described in Part (c)(3)(A) of this rule shall be entered into the patient record with a notation that it is issued on the specific order of a collaborating provider and signed by the CNM and the collaborating provider.

(e) All prescribing requirements shall be written in the patient's chart and shall include the medication and dosage, the amount prescribed, the directions for use, the number of refills, and the signature of the CNM.

(f) The prescriptions issued by the CNM shall contain:

(1) the name of the patient;

(2) the CNM's name, approval to practice number issued by the Committee, and telephone number; and

(3) the CNM's assigned DEA number shall be written on the prescription form when a controlled substance is prescribed.

(g) A CNM shall not prescribe controlled substances for the CNM's own use, the use of the CNM's collaborating provider, the use of the CNM's immediate family, the use of any other person living in the same residence as the CNM, or the use of any person with whom the CNM is having a sexual relationship. As used in this Paragraph, "immediate family" means a spouse, parent, child, sibling, parent-in-law, son-in-law or daughter-in-law, brother-in-law or sister-in-law, step-parent, step-child, or step-sibling.

History Note: Authority G.S. 90-18.8; 90-178.3;

Temporary Adoption Eff. October 1, 2023.

21 NCAC 33 .0118 BIRTH OUTSIDE HOSPITAL SETTING

(a) Prior to initiating care for a patient planning a birth outside of a hospital setting, the CNM shall be required to:

(1) obtain a signed, written informed consent agreement with the patient that details:

(A) identifying information of the patient to include name, date of birth, address, phone number, and email address if available;

(B) identifying information of the CNM to include the name, RN license number, approval to practice number, practice name, if applicable, and email address;

(D) an acknowledgment and understanding of the clear assumption of these risks by the patient;

(E) when and if deemed necessary by the CNM, an acknowledgment by the patient to consent to transfer to a health care facility licensed under Chapter 122C or Chapter 131E of the General Statutes that has at least one operating room; and

(F) a disclosure that the CNM is not covered under a policy of liability insurance, if applicable.

(2) The CNM shall provide a detailed, written plan of care consistent with G.S. 90-178.4(a2).

(3) After a decision of non-emergent transfer care has been made, the CNM shall:

(A) call the relevant receiving health care facility to notify them of transfer;

(B) provide a copy of the patient's medical record to the receiving health care facility; and

(C) provide a verbal summary of the care provided by the CNM to the patient and newborn, if applicable, to the receiving health care facility.

(4) In an emergent situation, the CNM shall initiate emergency care as indicated by the situation and immediately transfer care by making a reasonable effort, dependent upon the circumstances and nature of the emergency, to contact the health care professional or facility to whom the patient or patients will be transferred and to follow the health care professional's instructions; remain with the patient(s) until transfer of care is completed; and continue emergency care as needed while:

(A) transporting the patient(s) by private vehicle; or

(B) calling 911 and reporting the need for immediate transfer.

(b) Copies of the informed consent agreement and emergent and non-emergent transfer of care plans shall be maintained in the patient's record and provided to the Committee upon request.

(c) A CNM approved to practice may attend and provide midwifery services for a planned home birth outside of a hospital setting for a pregnancy deemed low-risk by the American College of Obstetricians and Gynecologists (ACOG). No CNM shall attend or provide midwifery services to a patient for a planned home birth outside of a hospital setting for known situations contraindicated by ACOG specifically fetal malpresentation, multiple gestation, and prior cesarean.

History Note: Authority G.S. 90-18.8; 90-178.3; 90-178.4;

Temporary Adoption Eff. October 1, 2023.