Gynecologic and contraceptive services provided by certified nurse-midwives in North Carolina

Gynecologic care by midwives has been little represented in the peer-reviewed literature despite the fact that the majority of midwives provide these services. Offering patients a variety of contraceptive options is important for informed choice and consent and for reducing the unintended pregnancy rate, which is nearly 50% in the United States. This study describes the volume of gynecologic care and the contraceptive methods provided by certified nurse-midwives (CNMs) in North Carolina. The study was conducted using a cross-sectional, confidential, self-administered mail questionnaire completed by 133 CNMs in clinical practice in North Carolina. The majority of the CNMs worked in private practice settings (67%), in urban areas (60%), and had 10 or fewer years of experience (62%). The median number of women seen weekly for gynecologic care was 15 (range 0-80), and 30% of CNMs provided gynecologic care to more than 25 women each week. The contraceptive methods discussed and provided by the CNMs were comprehensive. The high percentage of midwives providing gynecologic care merits further study of the content and quality of this care.     

Serving women in need: nurse-midwifery practice in the United States

OBJECTIVE: Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention. METHODOLOGY: A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed. RESULTS: Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics. CONCLUSION: Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.     

National Survey of Factors Contributing to and Hindering the Successful Practice of Nurse-Midwifery: Summary of the American College of Nurse-Midwives Foundation Study

A survey was conducted in 1985 to identify and quantify specific factors that influence whether or not a nurse-midwifery practice will be successful. The results of the study show that most nurse-midwives perceive themselves as quite successful. None of the individual characteristics measured in the study was associated with level of success. The nurse-midwives surveyed rate their practices highest in regard to staff skills and lowest in financial success. Nurse-midwives who owned or were financial partners in their practices tended to give their practices lower financial ratings, whereas practices without direct physician involvement were least able to attract an adequate number of clients. Regardless of their own level of success, the nurse-midwives identified suitable physician collaboration and a good relationship between certified nurse-midwives (CNMs) and physicians as the most important factor for nurse-midwifery success. Opposition from physicians, public ignorance about nurse-midwifery, and confusion between nurse-midwives and lay midwives were identified as the most important problems.     

PROFESSIONAL AUTONOMY FOR MIDWIVES: An Essential Component of Collaborative Practice

Although full admission privileges are considered the hallmark of full practice autonomy, the majority of certified nurse-midwives (CNMs) are denied the right to autonomously admit and discharge patients or have access to privileges only through the authority of a physician. This practice jeopardizes the independence of certified nurse-midwives and identifies them as adjuncts to the attending medical staff. The situation can only become more complicated now that the American College of Nurse-Midwives certifies nonnurses (CMs). Midwifery has a unique and a once autonomous history that is separate in philosophy from medicine. Midwives require physician services for consultation, referral, and collaborative management, but not for authority to practice midwifery. State legislation is not consistent nationwide concerning the definition and governing of nurse-midwifery practice. The Joint Commission on the Accreditation of Health Care Organizations does not regulate admission privileges but provides standards for hospitals. These standards do provide an avenue for admission privileges. Recognizing the CNM/CM as competitive in the health care market is essential. Denial of privileges can be interpreted as a restraint of trade. Without professional autonomy, unfavorable economics may limit the professional practice of midwifery.     

Nurse-midwives’ use of and attitudes toward epidural analgesia

The use of epidural analgesia for labor and birth has risen dramatically in the United States, and nurse-midwives are caring for increasingly greater numbers of women who deliver under epidural analgesia. The authors of this investigation undertook a national survey by mailed questionnaire to explore the use of and attitudes toward epidural analgesia among certified nurse-midwives. A stratified, random sample of one-half of American College of Nurse-Midwives members was polled, and 1,605 (60.7%) questionnaires were returned. A slight majority of certified nurse-midwives (CNMs) (53%) reported a negative attitude toward the increased use of epidurals in CNM practice, and 64% reported concern over the increased number of their clients who desire epidural anesthesia. CNMs were almost evenly split on the issue of whether nurse-midwives should discourage the use of epidurals in nurse-midwifery practice. For those CNMs with epidural analgesia available at their primary birth site (87% of the sample), the mean CNM epidural rate was 26%. Various reasons for the increased use of epidural analgesia in CNM practice are explored, as are the possible implications of such increased use in contemporary nurse-midwifery practice. Suggestions for further research are offered.     

NURSE-MIDWIVES' USE OF AND ATTITUDES TOWARD EPIDURAL ANALGESIA

The use of epidural analgesia for labor and birth has risen dramatically in the United States, and nurse-midwives are caring for increasingly greater numbers of women who deliver under epidural analgesia. The authors of this investigation undertook a national survey by mailed questionnaire to explore the use of and attitudes toward epidural analgesia among certified nurse-midwives. A stratified, random sample of one-half of American College of Nurse-Midwives members was polled, and 1,605 (60.7%) questionnaires were returned. A slight majority of certified nurse-midwives (CNMs) (53%) reported a negative attitude toward the increased use of epidurals in CNM practice, and 64% reported concern over the increased number of their clients who desire epidural anesthesia. CNMs were almost evenly split on the issue of whether nurse-midwives should discourage the use of epidurals in nurse-midwifery practice. For those CNMs with epidural analgesia available at their primary birth site (87% of the sample), the mean CNM epidural rate was 26%. Various reasons for the increased use of epidural analgesia in CNM practice are explored, as are the possible implications of such increased use in contemporary nurse-midwifery practice. Suggestions for further research are offered. © 1998 by the American College of Nurse-Midwives.     

Malpractice liability burden in midwifery: a survey of Michigan certified nurse-midwives

A statewide survey was conducted among 282 nurse-midwives in Michigan to examine the extent of their current medical liability burden. Two hundred ten responses were received for an adjusted response rate of 76.9%. Data from 145 certified nurse-midwives (CNMs) who were currently engaged in clinical practice in Michigan were used for this analysis. Sixty-nine percent of CNMs reported that liability concerns had a negative impact on their clinical decision making. Most CNMs (88.1%) acquired malpractice insurance coverage through an employer, whereas 4.9% were practicing "bare" due to difficulty in obtaining coverage. Thirty-five percent of the respondents had been named in a malpractice claim at least once in their career, and 15.5% had at least one malpractice payment of $30,000 or more made on their behalf. CNMs who purchased malpractice insurance coverage themselves or were going bare were significantly less likely to include obstetrics in their practice than their counterparts covered through an employer (70.6% versus 87.2%; P = .04). These findings among Michigan CNMs call for further investigation into the consequences of the current malpractice situation surrounding nurse-midwifery practice and its influence on obstetric care, particularly among women from disadvantaged populations.     

STRATEGIES FOR DISSEMINATION OF POLICY RESEARCH

Although there is evidence of high-quality care and cost-effective practice by certified nurse-midwives, CNMs still face many barriers to practice. Outcomes must be documented and disseminated more widely so that policy makers will be convinced that restrictions to CNM practice must be removed. The author identifies three obstacles to policy-related research dissemination: lack of cumulative data, lack of relevance to specific issues, and lack of power. To overcome these obstacles, five strategies are proposed to promote a wider dissemination of policy-related research results. CNMs must use these strategies to promote nurse-midwifery to the general public, government officials, interest groups, and policy makers.     

Findings of the 1990 Annual American College of Nurse-Midwives Membership Survey.

The 1990 Annual ACNM Membership Survey was conducted by the Division of Research for the purpose of obtaining current information about certified nurse-midwives (CNMs) who were members of ACNM. Of the 2,899 surveys sent, 1,992 surveys were returned from 1,877 CNMs and 115 student nurse-midwives (a response rate of 68.7%). The mean age of the CNMs was 41.8 years. Most were female (97.9%) and white (95.3%); 85.1% were active members and 6% were life members of ACNM. The CNMs had been employed in nurse-midwifery-related employment a mean of 8.5 years. The greatest proportion were in clinical nurse-midwifery practice attending births (64.2%). An additional 10.0% were in clinical nurse-midwifery practice not attending births. Experienced nurse-midwives employed full-time reported a mean annual income of $45,229 and being on-call 71.4 hours per week. New nurse-midwives employed full-time reported a mean annual income of $40,504 and being on-call 59.6 hours per week. Most nurse-midwives employed full-time were salaried (57.4%), whereas most CNMs working part-time were paid based on the number of hours worked (49.7%).     

PROCESSES OF CARE: Comparisons of Certified Nurse-Midwives and Obstetricians

Prenatal and intrapartum care provided to 1,181 women, all meeting risk requirements for nurse-midwifery care, by certified nurse-midwives (n = 471) and obstetricians (n = 710) are compared using indicators of physical and of educational/psychosocial components of maternity care. Data are from clinical records and questionnaires completed by the women. Bivariate analyses show that the two provider groups differ on some, but not all, processes of care. When the woman's evolving health status, personal characteristics, and preferences are controlled, there are significant differences that confirm two models of care. The nurse-midwifery approach emphasizes educational/ psychosocial care and restrained, individualized use of technology. The obstetrics approach emphasizes more routine use of state-of-the-art technology. This study contributes new information to substantiate different models but also shows that both provider groups use elements of both. The difference in emphasis should encourage collaborative practice, given the shared basis for maternity care, whether it is provided by certified nurse-midwives or obstetricians.     

Processes of care Comparisons of certified nurse-midwives and obstetricians

Prenatal and intrapartum care provided to 1,181 women, all meeting risk requirements for nurse-midwifery care, by certified nurse-midwives (n = 471) and obstetricians (n = 710) are compared using indicators of physical and of educational/psychosocial components of maternity care. Data are from clinical records and questionnaires completed by the women. Bivariate analyses show that the two provider groups differ on some, but not all, processes of care. When the woman's evolving health status, personal characteristics, and preferences are controlled, there are significant differences that confirm two models of care. The nurse-midwifery approach emphasizes educational/psychosocial care and restrained, individualized use of technology. The obstetrics approach emphasizes more routine use of state-of-the-art technology. This study contributes new information to substantiate different models but also shows that both provider groups use elements of both. The difference in emphasis should encourage collaborative practice, given the shared basis for maternity care, whether it is provided by certified nurse-midwives or obstetricians.     

FINDINGS OF THE 1990 ANNUAL AMERICAN COLLEGE OF NURSE-MIDWIVES MEMBERSHIP SURVEY

The 1990 Annual ACNM Membership Survey was conducted by the Division of Research for the purpose of obtaining current information about certified nurse-midwives (CNMs) who were members of ACNM. Of the 2,899 surveys sent, 1,992 surveys were returned from 1,877 CNMs and 115 student nurse-midwives (a response rate of 68.7%). The mean age of the CNMs was 41.8 years. Most were female (97.9%) and white (95.3%); 85.1% were active members and 6% were life members of ACNM. The CNMs had been employed in nurse-midwifery-related employment a mean of 8.5 years. The greatest proportion were in clinical nurse-midwifery practice attending births (64.2%). An additional 10.0% were in clinical nurse-midwifery practice not attending births. Experienced nurse-midwives employed full-time reported a mean annual Income of $45,229 and being on-call 71.4 hours per week. New nurse-midwives employed full-time reported a mean annual income of $40,504 and being on-call 59.6 hours per week. Most nurse-midwives employed full-time were salaried (57.4%), whereas most CNMs working part-time were paid based on the number of hours worked (49.7%)     

State regulation of midwives: issues and options

In the United States, state governments play a central role in determining the extent to which midwives can provide care to women and babies. State laws and regulations establish midwives' scope of practice, set licensure requirements, and frequently determine their ability to get paid and obtain access to health care facilities. For certified nurse-midwives (CNMs), state regulation has evolved from a haphazard patchwork of highly variable regulatory models into a fairly uniform set of rules and requirements from one state to the next. For direct entry midwives (DEMs), there is much less uniformity, with some states outlawing practice by any midwife who is not a CNM, whereas other states have established rigorous standards and requirements for the licensure of DEMs. This article provides a broad overview of these state regulatory variables for both CNMs and DEMs, and explores issues and options that both state regulators and midwives should consider when developing or amending state laws and regulations governing their practice. In particular, the role of the state in regulating the practice of the certified midwife (CM) is examined in the context of existing regulatory frameworks for CNMs and DEMs.     

The effects of malpractice insurance on certified nurse-midwives. The case of rural Arizona

This study of CNMs in rural Arizona indicated malpractice insurance has had a negative effect on the practice of nurse-midwifery. In 1987 a telephone survey was conducted to assess the effects on the practice patterns of Arizona's 21 rural CNMs, four of whom had had previous experience as licensed midwives. Results indicated 24% had been refused medical back-up by a physician. Although 10% were personally responsible for paying malpractice insurance premiums, they were not able to afford the cost and were going "bare." Nearly 30% had changed their employment status from private practitioner to salaried employee, suffering a decrease in professional autonomy, flexibility of hours, quality of lifestyle, benefits, and income. Unless there are changes that result in lower malpractice insurance premiums or greater compensation and benefits, there likely will be a diminishing number of entries into an increasingly stressed profession.     

THE EFFECTS OF MALPRACTICE INSURANCE ON CERTIFIED NURSE-MIDWIVES: The Case of Rural Arizona

This study of CNMs in rural Arizona indicated malpractice insurance has had a negative effect on the practice of nurse-midwifery. In 1987 a telephone survey was conducted to assess the effects on the practice patterns of Arizona's 21 rural CNMs, four of whom had had previous experience as licensed midwives. Results indicated 24% had been refused medical back-up by a physician. Although 10% were personally responsible for paying malpractice insurance premiums, they were not able to afford the cost and were going “bare.” Nearly 30% had changed their employment status from private practitioner to salaried employee, suffering a decrease in professional autonomy, flexibility of hours, quality of lifestyle, benefits, and income. Unless there are changes that result in lower malpractice insurance premiums or greater compensation and benefits, there likely will be a diminishing number of entries into an increasingly stressed profession.     

Effectiveness of certified nurse-midwives. A prospective evaluation study.

A prospective evaluation study of the effectiveness of the services of certified nurse-midwives demonstrated that in a hospital setting the care of low-risk maternity patients provided by nurse-midwives was as effective as the provided by house staff physicians. A total of 438 low-risk maternity patients were studied. Selected outcomes pertaining to the prenatal period, labor and delivery, and early infancy demonstrated, with two exceptions, no significant differences. The two exceptions were: (1) overcompliance with appointment attendance was more common among the nurse-midwifery group of patients; (2) a higher rate of forceps delivery was reported among the house staff group of patients.     

Professional liability issues and practice patterns of obstetric providers in Washington State

OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers' most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington's obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study's results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III.     

A comparison of visits and practices of nurse-midwives and obstetrician-gynecologists in ambulatory care settings

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.     

The genesis of the ACNM 1971 Statement on Abortion.

In 1971, the Board of Directors of the American College of Nurse-Midwives approved a statement that prohibited certified nurse-midwives (CNMs) from performing abortions. In 1990, the statement was superseded by a second "Statement on Abortion," which essentially reworded the 1971 statement with no substantive change. In 1991, 20 years after the first statement was adopted, a resolution was approved at the Annual Meeting recommending that the Board of Directors rescind the statement, thereby allowing individual CNMs to utilize the guidelines for the incorporation of new procedures into nurse-midwifery practice if she/he decides to provide abortions. This article describes the historical basis for the initial 1971 statement in the hope that an understanding of that history will assist nurse-midwives as they reconsider the statement.