HB 758
Department of Legislative Services
Maryland General Assembly
2021 Session
FISCAL AND POLICY NOTE
Enrolled
House Bill 758 (Delegate Bagnall)
Health and Government Operations Education, Health, and Environmental Affairs
Maryland Licensure of Certified Midwives Act
This bill establishes a licensing and regulatory system for a “licensed certified midwife” to
“practice certified midwifery” under the State Board of Nursing (BON). BON must
(1) establish standards for the practice of certified midwifery; (2) maintain a list of all
licensed certified midwives; (3) set applicable fees; and (4) initiate specified disciplinary
action. The BON Safe Practice Committee must evaluate licensed certified midwives who
request participation in the program and report to the board the name and license number
of any licensed certified midwife who is expelled from the program for failure to comply
with the conditions of the program. On request of the board, an employer must report the
name and license number of each employee licensed to practice certified midwifery.
Fiscal Summary
State Effect: Special fund revenues increase, likely beginning in FY 2023, from licensure
fees, as discussed below. BON special fund expenditures increase by at least $20,700 in
FY 2022 and $18,900 in FY 2023 for contractual staff. Future years reflect elimination of
the contractual position.
(in dollars) FY 2022 FY 2023 FY 2024 FY 2025 FY 2026
SF Revenue $0 - - - -
SF Expenditure $20,700 $18,900 - - -
Net Effect ($20,700) ($18,900) $0 $0 $0
Note:() = decrease; GF = general funds; FF = federal funds; SF = special funds; - = indeterminate increase; (-) = indeterminate decrease
Local Effect: None.
Small Business Effect: Minimal.
Analysis
Bill Summary:
Definitions
“Licensed certified midwife” means an individual who has been issued a license by BON
to practice certified midwifery. Licensed certified midwife does not include a licensed
direct-entry midwife or a licensed nurse certified as a nurse-midwife.
“Practice certified midwifery” means the management and care of essentially normal
newborns and of essentially normal women antepartally, intrapartally, and postpartally.
Practice certified midwifery includes (1) family planning and well woman reproductive
care; (2) the prescribing of substances commonly used in the practice of midwifery; (3) the
prescribing of Schedules II through V controlled dangerous substances (CDS) commonly
used in the practice of midwifery; and (4) dispensing of the substances prescribed in the
course of treating a patient at a specified medical facility or clinic.
“ACME” means the Accreditation Commission for Midwifery Education, or a successor
organization that is an accrediting agency for midwifery education programs and
institutions and is approved by the U.S. Department of Education.
“AMCB” means the American Midwifery Certification Board, or a successor organization
that is a certifying agency for midwifery education programs and is approved by the
National Commission for Certifying Agencies.
Certified Midwife Licensure
To qualify for a certified midwife license, an applicant must (1) be of good moral character;
(2) submit to a criminal history records check (CHRC); (3) hold a current, valid
certification as a certified midwife from AMCB; (4) have graduated from a graduate-level
accredited program for midwifery education approved by ACME; (5) have completed
coursework in health and sciences, as specified; and (6) have passed the AMCB
examination. An applicant must submit an application and pay the required fee.
The bill specifies procedures BON must follow with respect to criminal history records
information of an applicant for licensure as a certified midwife and prohibits BON from
issuing a license if such information has not been received.
The board must issue a certified midwife license to any applicant who meets specified
requirements. BON must electronically record each license in the board’s database and on
the board’s website. A license expires on a date set by the board, unless the license is
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renewed for an additional term. A license may not be renewed for a term longer than
two years.
At least three months before a license expires, the board must send the licensee a renewal
notice that states (1) the date on which the current license expires; (2) the date by which
the renewal application must be received by the board; and (3) the amount of the renewal
fee. Before a license expires, the licensee must submit a renewal application and
satisfactory evidence of current certification as a certified midwife by AMCB. If a licensee
requires a CHRC prior to renewal, the board must send information regarding how the
licensee may complete the required CHRC. BON may grant a 30-day extension beyond a
license’s expiration date so that the licensee may renew the license prior to expiration.
A licensee must notify the board of any change in the licensee’s name or address within
60 days after the change occurred. Otherwise, the board may impose an administrative
penalty of $100.
Reinstatement
If a license was suspended or revoked for more than one year, or if more than one year has
passed since a license was surrendered, the board may reinstate the license if the licensee
(1) applies for reinstatement; (2) meets renewal requirements; and (3) submits to a CHRC.
The board must reinstate the license, reinstate the license with specified terms and
conditions, or deny reinstatement of the license.
Application and Renewal Fees
BON must set reasonable fees for the issuance and renewal of licenses and other services
provided to licensed certified midwives. The fees charged must be set to produce funds to
approximate the cost of maintaining the licensing program and other services provided to
licensed certified midwives. The collected fees must be used exclusively to cover the actual
documented direct and indirect costs of fulfilling the statutory and regulatory duties of the
board to regulate certified midwives.
Disciplinary Action
Subject to hearing provisions, the board may deny a license or grant a license, including a
license subject to a reprimand, probation, or suspension, to any applicant, reprimand any
licensee, place any licensee on probation, or suspend or revoke any license if the licensee
violates specified disciplinary grounds.
After a hearing, if the board finds that there are grounds to suspend or revoke a license to
practice certified midwifery, to reprimand a licensee, or to place a licensee on probation,
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the board may impose a penalty of up to $5,000 and/or suspend or revoke the license,
reprimand the licensee, or place the licensee on probation. The board may also require a
licensee to comply with specified terms and conditions.
Any person aggrieved by a final decision of the board in a contested case may petition for
judicial review as allowed by the Administrative Procedure Act. An individual may not
appeal to the Secretary of Health but may take a direct judicial appeal. A board decision
may not be stayed while judicial review is pending.
Examination by a Health Care Provider
The bill requires BON, in specified circumstances, to require an applicant for license as a
certified midwife or a licensed certified nurse midwife to submit to an appropriate
examination by a health care provider.
Prohibited Actions
Unless authorized to practice certified midwifery, an individual may not represent to the
public by title, description of service, method, procedure, or otherwise, that the individual
is authorized to practice certified midwifery in the State. A licensee may not advertise in a
manner that is unreasonable, misleading, or fraudulent. An individual may not practice,
attempt to practice, or offer to practice as a licensed certified midwife unless licensed by
BON to practice as a licensed certified midwife. An individual may not use the abbreviation
“CM” or use the designation “Certified Midwife” with the intent to represent that the
individual practices certified midwifery in the State. An individual may not use the
designation “Midwife” unless they are authorized to practice certified midwifery or they
are a licensed certified nurse-midwife or a licensed direct-entry midwife.
Current Law: In general, an individual must be licensed as a certified nurse-midwife to
practice nurse midwifery in the State or licensed as a direct-entry midwife in order to
practice direct-entry midwifery in the State.
Certified Nurse-midwife
BON provides advanced practice registered nurse certification to nurse-midwives who
must also be a licensed RN. “Practice nurse midwifery” means the management of care of
essentially normal newborns and essentially normal women antepartally, intrapartally, and
postpartally. Practice nurse midwifery includes (1) family planning and well woman
reproductive care; (2) the prescribing of substances commonly used in the practice of
midwifery; (3) the prescribing of Schedule II through V CDS commonly used in the
practice of midwifery; and (4) dispensing of the substances prescribed in the course of
treating a patient at a specified medical facility or clinic.
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Under BON regulations, an applicant for certification as a nurse-midwife must hold a
current RN license and complete a program in a clinical nurse specialty area accredited by
a national certifying body that is specified or recognized by the board. Certified
nurse-midwives are considered independent practitioners.
An applicant for an advance practice certification must (1) be a licensed RN or have a
privilege to practice under the Nurse Licensure Compact; (2) complete an education
program approved by BON; (3) submit a completed application for each area in which
certification is sought; and (4) submit documentation that the applicant has graduated from
a graduate-level accredited program for advanced practice registered nursing and of
certification as an advanced practice RN by a national certifying body recognized by BON.
Direct-entry Midwife
Direct-entry midwifery refers to an educational path that does not require prior nursing
training to enter the profession. “Practice direct-entry midwifery” means providing
maternity care that is consistent with a midwife’s training, education, and experience as
well as identifying and referring patients who require medical care to an appropriate health
care provider. “Practice direct-entry midwifery” includes (1) providing the necessary
supervision, care, and advice to a patient during a low-risk pregnancy, labor, delivery, and
postpartum period and (2) newborn care that is consistent with national
direct-entry midwifery standards and based on the acquisition of clinical skills necessary
for the care of pregnant women and newborns, including antepartum, intrapartum, and
postpartum care.
The practice of direct-entry midwifery does not include (1) induction or augmentation of
labor with pharmaceuticals or artificial rupture of membranes prior to the onset of labor;
(2) surgical delivery or any surgery except an emergency episiotomy; (3) use of forceps or
vacuum extractor; (4) administration of an anesthetic, other than a local anesthetic;
(5) administration of any kind of narcotic pain reliever; or (6) administration of any
prescription medication, as specified.
An applicant for licensure as a direct-entry midwife must:
be age 21 or older and of good moral character;
be a high school graduate or have completed equivalent education;
submit to a CHRC;
be certified to perform cardiopulmonary resuscitation;
have completed, in the past two years, the American Academy of
Pediatrics/American Heart Association neonatal resuscitation program;
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hold a valid Certified Professional Midwife credential granted by the
North American Registry of Midwives; and
have completed a midwifery education program accredited by the Midwifery
Education and Accreditation Council or ACME.
State Revenues: The bill specifies that initial and renewal fees for a licensed certified
midwife must be set to produce funds to approximate the cost of maintaining the licensing
program and the other services provided to licensed certified midwives. However, BON
advises that initial and renewal license fees will likely be approximately $150.
BON estimates that the initial number of licenses issued under the bill will be minimal.
Additionally, based on information provided by BON on a previous bill, it will likely take
at least nine months to develop regulations for certified midwives, Thus, licenses are not
likely issued before fiscal 2023. For illustrative purposes only, if 10 individuals seek a
certified midwife license under the bill, special fund revenues increase by approximately
$1,500 in fiscal 2023. Special fund revenues increase an additional $1,500 biennially
beginning in fiscal 2025 to account for renewal fees.
Typically, license fee revenues are set to cover the administrative costs incurred by a health
occupations board. However, as the number of certified midwives anticipated to seek
licensure is low, the Department of Legislative Services (DLS) advises that expenditures
incurred by BON to issue certified midwife licenses exceed licensure revenues.
Any impact on special fund revenues from the imposition of existing penalties or fines is
anticipated to be minimal.
State Expenditures: Special fund expenditures increase by at least $20,712 in fiscal 2022,
which accounts for the bill’s October 1, 2021 effective date. BON has determined that
one regular full-time position is needed to implement this bill. However, DLS advises that
the added responsibilities incurred by this legislation are likely not permanent given the
small number of anticipated new licensees and the similarities between the practice of
certified midwifery and nurse midwifery, and, thus, may be performed by a contractual
employee. This estimate reflects the cost of hiring one part-time contractual administrative
specialist to develop regulations in fiscal 2022 and process initial certified midwife license
applications in fiscal 2023. It includes a salary, fringe benefits, one-time start-up costs, and
ongoing operating expenses.
FY 2022 FY 2023
Contractual Position 0.5 0
Salary and Fringe Benefits $15,376 $18,612
Operating Expenses 5,336 328
Total Board of Nursing Expenditures $20,712 $18,940
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Future years reflect elimination of the contractual position at the end of fiscal 2023.
This estimate does not include any health insurance costs that could be incurred for
specified contractual employees under the State’s implementation of the federal Patient
Protection and Affordable Care Act.
To the extent that additional individuals wish to obtain licensure as a certified midwife,
BON special fund expenditures increase to maintain additional staff to oversee the
licensure program. Additionally, once certified midwife licenses are issued, to the extent
complaints are received, special fund expenditures may increase further to hire a
contractual investigator and an assistant attorney general on a part-time basis to investigate
complaints and take disciplinary actions as needed, though these duties may be absorbed
by existing resources within BON. Any such cost has not been factored into this estimate.
Additional Comments: Individuals who have received certification by AMCB may be
licensed as a certified midwife in Delaware. Additionally, legislation has been introduced
in Virginia to allow certified nurse midwives to practice consistent with the Standards for
the Practice of Midwifery set by the American College of Nurse-Midwives.
Additional Information
Prior Introductions: None.
Designated Cross File: SB 684 (Senator Lam) - Education, Health, and Environmental
Affairs.
Information Source(s): Maryland Department of Health; Department of Legislative
Services
Fiscal Note History: First Reader - March 9, 2021
an/jc Third Reader - March 29, 2021
Revised - Amendment(s) - March 29, 2021
Enrolled - May 5, 2021
Analysis by: Amberly Holcomb Direct Inquiries to:
(410) 946-5510
(301) 970-5510
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Statutes affected: Text - First - Maryland Licensure of Certified Midwives Act: 8-317 Health Occupations, 8-205 Health Occupations, 8-208 Health Occupations, 8-316 Health Occupations, 8-317 Health Occupations, 8-504 Health Occupations, 8-317 Health Occupations, 8-701 Health Occupations, 8-708 Health Occupations, 8-710 Health Occupations, 8-703 Health Occupations
Text - Third - Maryland Licensure of Certified Midwives Act: 8-205 Health Occupations, 8-205.1 Health Occupations, 8-208 Health Occupations, 8-316 Health Occupations, 8-317 Health Occupations, 8-504 Health Occupations, 8-317 Health Occupations, 8-701 Health Occupations, 8-708 Health Occupations, 8-710 Health Occupations, 8-703 Health Occupations
Text - Enrolled - Maryland Licensure of Certified Midwives Act: 8-205 Health Occupations, 8-205.1 Health Occupations, 8-208 Health Occupations, 8-316 Health Occupations, 8-317 Health Occupations, 8-504 Health Occupations, 8-317 Health Occupations, 8-701 Health Occupations, 8-708 Heal