The American Public Health Association (APHA) takes a position in support of the expansion of midwifery as a key strategy to improving access to care for childbearing families for the purpose of increasing their health care options and thereby to the subsequent improvement of birth outcomes.
II. Statement of the Problem
The United States spends more per capita on health care than any other country, and yet substantial gaps in maternal and child health care access remain.1,2 Although a large majority of the nearly 4 million children born annually in the U.S. result from an uncomplicated vaginal delivery, childbirth is increasingly viewed as a medical event, with over 90% of all births attended by a physician trained to focus on the pathologic potential of pregnancy and birth. Childbirth is one of most common reasons to seek health care and the single most common cause for hospitaliza-tion. Even with advances in prenatal care tech-nology, low birth weight and preterm birth rates fall short of the Healthy People 2010 goals.3 The APHA has publicly supported the use of innovative strategies to improve birth outcomes and decrease maternal and newborn morbidity and mortality.4-13 These documents do not, however, address access to midwifery services.
In summary, the World Health Organization (WHO) defines a midwife as a competent care giver in midwifery graduated from an education program recognized by the government that licenses the midwife to practice. As the standard of care for uncomplicated pregnancies throughout much of the world,14 midwives are the main providers of care in 75% of all European births.15 Conversely, in the U.S. midwives participate in fewer than 10% of all births.16 In terms of quali-ty, satisfaction, and costs, the midwifery model for pregnancy and maternity care has been found to be beneficial to women and families, resulting in good outcomes and cost savings.17 A collaborative approach between midwife and physician utilizes the expertise of both professions, which is key to ensuring optimal outcomes for women and infants. With its focus on pregnancy as a normal life event and health promotion for women of all ages, the midwifery model of care is an appropriate alternative or complement to the medical approach to childbirth.18
In exploring the use of interrelated health providers within managed care and other staffing con-figurations, the Health Services Resource Administration (HRSA), Bureau of Health Professions’ project, Use and Impact of Alternative or Complementary Providers, is developing methods designed to forecast the need for alternative and/or complementary providers and document their impact on physician supply and demand.19 For example, the project examines the integrated use of obstetrician/gynecologists with certified nurse-mid-wives, anesthesiologists with nurse-anesthetists, and the use of non-traditional providers in managed care. Through the project, the National Center for Health Workforce Information & Analysis will develop recommendations for health professions’ training that will reflect current and projected “real world” use of alternative and complementary providers to increase access to health care.20
III. The Status of Midwifery in the United States;
Women comprise 52% of our nation’s population and 46% of the workforce. In general, women live longer than men, suffer more from chronic illnesses, are more frequent users of health ser-vices, and account for nearly two of every three health care dollars spent. Additionally, women make three out of four of all household health care decisions.19 It is well documented that midwives contribute substantially to the health care services of diverse populations of women and their babies. In particular, studies have demonstrated that 7 of 10 visits to certified nurse-midwives (CNMs) were by women vulnerable to poor outcomes.21 CNMs attended 7% of the approximately 4 million births in 1997 and “other” midwives attended 0.4%.22 However, during 1995 and 1996 respectively, in the U.S. only 6.7% of CNMs and 6% of homebirth midwives in the U.S. were non-white, indicating that the racial and ethnic diversity of midwives does not reflect that of the nation’s population.23 Nationally, the midwifery profession has demonstrated an increased commitment for diversity within its ranks, especially given midwives’ historic commitment to the care of vulnerable women, children, and families.24,25
Midwives in the United States with national certification generally fall into three categories: certified nurse-midwives (CNMs), who number over 7,0003 and who meet the educational criteria of the American College of Nurse Midwives (ACNM), and are certified by the American College of Nurse-Midwives Certification Council (ACC); certified midwives (CMs), who number fewer than 20,2 a relatively new category of ‘direct-entry’ midwives who are non-nurses educated within ACNM accredited educational programs and certified by the ACC; and certified professional midwives (CPMs), another category of direct-entry midwife who number approximately 1,000 and are certified by the North American Registry of Midwives (NARM).26 (Note: direct-entry midwifery, which included CPMs and CMs, is a term used to refer to midwives whose education did not require a nursing back-ground). It should be noted that there is small number of other midwives who have not attained these credentials. Most though not all recognized midwifery educational pathways are accredited by agencies recognized by the U.S. Department of Education, which assures the quality and content of midwifery education programs.
CNMs are educated in the fields of nursing and midwifery. CMs are educated in midwifery alongside CNMs, and thus have comparable competencies and skills although they are not nurses. This training differs from the professional preparation of CPMs certified by NARM focuses on competent entry-level midwives who will practice in predominantly out-of-hospital settings.23 CNMs, CMs, and CPMs must pass a national certification examination to use their respective titles. These categories of midwives are not inter-changeable, and important differences exist in education and certification mechanisms, scope of practice authority, and practice settings.2,27,28;
State laws and national certification regulate the practice of midwifery and legislation differs from state to state relative to credentialing and scope of practice. Nurse-midwifery practice has been legal in all states for over 20 years.23
As of January 2000, 17 states regulated non-nurse midwifery practice and in 14 states, non-nurse midwifery is legal but unregulated. In nine states nonnurse midwifery practice is legally prohibited and in six states the practice is effectively prohibited, as there is no legal way to gain legal authority to practice. Regulatory provisions are unclear in five states. Of those states regulating non-nurse midwifery practice, 14 states have widely varying regulatory mechanisms regarding the scope, qual-ifications, and requirements for supervision, consultation, and referral.2,26Whichever professional entry is chosen, the common connection for all midwives is their philosophical adherence to the midwifery model of care.23
With the exception of birth registration which captures only a portion of midwifery practice and excludes ambulatory care entirely,29 there is no current national or state process for collecting data on services provided by midwives.23 Thus, documentation of the practice of midwifery in the U.S. is incomplete and varies widely between CNMs and direct-entry midwives. Since 1928, more than 20 peer-reviewed journals have reported outcome studies of care by CNM’s.30 To date, nine peer-reviewed studies have been published addressing outcomes of care by direct-entry mid-wives. These studies have primarily reported homebirth outcomes with homebirth being the predominant site of birth for direct-entry mid-wives.30 While a number of publications and reports exist about process and outcomes for all categories of midwives, this literature is difficult to compare to studies about other women’s health providers (especially direct-entry midwives). This is due in part to the lack of inclusion of midwives in systematic national data collection.23,25,30
In 1998 the University of California at San Francisco Center for Health Professions charged a National Taskforce on Midwifery with examining the current status of midwifery in the United States. Participants of the Taskforce, who represented all levels of entry into the midwifery profession in terms of education, training, and prac-tice, generated a comprehensive report which is the most current description of midwifery in the United States. As charged, the Taskforce also made specific recommendations for practice, reg-ulation, credentialing, education, research, and policy.23,25 The Taskforce on Midwifery report, endorsed by the PEW Health Professions Com-mission, presents a multifaceted approach to improving access to health care for women, chil-dren, and their families as well as increasing the diversity of the health care work force. These recommendations provide for a grounded approach to examining the field of midwifery and increasing an accountable provider pool with quality, high standards and sensitivity to the cultural needs of the clientele (Appendix).
IV. Actions Desired and Methods
The APHA should:
- Communicate in writing with the major professional organizations whose members provide health care to women encouraging them to recognize nationally certified midwives as independent and collaborative practitioners
- Recommend through correspondence to and meetings with members of the health care systems that enrollees be assured access to midwives and the midwifery model of care.
- Urge all state legislatures to legalize the practice of midwifery and promulgate regula-tions, including specification of minimal educational standards and assurance to access to appropriate liability insurance in order to assure the safety of the public’s health as it relates to midwifery practice.
- Recommend that states consider in their regulations regarding midwives that the basis for entry-to-practice standards should include: successful completion of a recognized midwifery education process, and successful completion of the appropriate national midwifery certifying examination.
- Recommend that federal and state agencies broaden systematic data collection in birth cer-tificates, death certificates, out patient data sets, the National Ambulatory Medical Care Survey, and other data collection activities that include visits or contacts made by midwives for the care of women or newborns, to include midwifery and midwives.
- Recommend that the Bureau of Health Professions strengthen federal grants and traineeships to minority midwifery students.
- Encourage entities including the Institute of Medicine, National Institutes of Health, Centers for Disease Control and Prevention, and the Health Resources and Services Administration to develop a research agenda addressing midwifery practice, outcomes and cost-effectiveness.
- Anderson GF, Hurst J, Hussey PS, JeeHughes M. Health Spending and Outcomes: Trends in OECD Countries, 1960-1998. Health Affairs. 2000; 19(3).
- Reed A, Roberts J. State Regulation of Midwives: Issues and Options. J Nurse-Midwif-ery. 2000; 45(2):130-149.
- Williams DR. Preserving Midwifery Practice in a Managed Care Environment. J Nurse-Midwifery. 1999; 44(4):375-383.
- US. Department of Health and Human Services, Washington, DC. US Public Health Service. Developing Objectives for Healthy People 2010. Washington, DC: September 1997.
- APHA Policy Statement 5818: Grants for Maternal and Child Health Research. APHA Public Policy Statements, 1948 to Present, Cum-ulative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 6615: Perinatal Mortality. APHA Public Policy Statements, 1948 to Present, Cumulative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 6805: Credentials for Health Occupations. APHA Public Policy Statements, 1948 to Present, Cumulative. Wash-ington, DC: American Public Health Association; current volume.
- APHA Policy Statement 7924: Alternatives in Maternity Care. APHA Public Policy Statements, 1948 to Present, Cumulative. Wash-ington, DC: American Public Health Association; current volume.
- APHA Policy Statement 8209: Guidelines for Licensing and Regulating Birth Centers. APHA Public Policy Statements, 1948 to Present, Cumu-lative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 8401: Infant Mortality among the Poor. APHA Public Policy Statements, 1948 to Present, Cumulative. Wash-ington, DC: American Public Health Association; current volume.
- APHA Policy Statement 8529: Preventing Low Birthweight. APHA Public Policy Statements, 1948 to Present, Cumulative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 9615: Supporting National Standards of Accountability for Access and Quality in Managed Health Care. APHA Public Policy Statements, 1948 to Present, Cumulative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 9714: Support for Research on Alternative and Complimentary Practices. APHA Public Policy Statements, 1948 to Present, Cumulative. Washington, DC: American Public Health Association; current volume.
- APHA Policy Statement 9815: Meeting Public Health and Epidemiologic Data Needs in a Managed Care Environment. APHA Public Policy Statements, 1948 to Present, Cumulative. Washington, DC: American Public Health Associa-tion; current volume.
- Care in Normal Birth Report of Technical Working Group. WHO Maternal Health and Safe Motherhood Program 1996.
- Hafner-Eaton C, Pierce LK. Birth choices, the law, and medicine: Balancing individual freedoms and protection of the public’s health. J Health Polit Pol Law. 1994; 19:813-835.
- Ventura SF, Martin JA, Curtin SC, Mathews TJ. Report of the final natality statis-tics, 1996. Monthly vital statistics report: 46(11 s). Hyattsville, MD: National Center for Health Statistics, 1998.
- Rooks JP. The midwifery model of care. J Nurse-Midwifery. 1999; 44(4): 370-374.
- US Department of Health and Human Services, Health Resources and Services Ad-ministration. Fact Sheet: Women’s Health: A LifeSpan Issue. Washington, DC. Department of Health and Human Services, May 1993.
- US Department of Health and Human Services, Health Resources and Services Admin-istration. Agenda for Women’s Health. Wash-ington, DC. Department of Health and Human Services, February 1999.
- Paine LL, Lang JM, Strobino DM, Johnson TRB, DeJoseph JF, Declercq ER, et al. Characteristics of nurse-midwife patients and visits, 1991. Am J Public Health. 1999; 89(6): 906-909.
- Curtin SC. Recent changes in birth atten-dant, place of birth, and the use of obstetric inter-ventions, United States, 1989-1997. J Nurse-Midwifery. 1999; 44(4): 349-354.
- Dower CM, Miller JE, O’Neil EH and the Taskforce on Midwifery. Charting A Course for the 21st Century: The Future of Midwifery. San Francisco, CA: Pew Health Professions Commission and the UCSF Center for the Health Profes-sions, April 1999.
- Rooks JP. Midwifery and Childbirth in America. Philadelphia, PA: Temple University Press, 1997.
- Paine LL, Dower CM, O’Neil EH. Midwifery in the 21st century: Recommendations from the Pew Health Commission/ UCSF Center for the Health Professions 1998 Task Force on Midwifery. J Nurse-Midwifery. 1999; 44(4): 341-348.
- Myers-Cieko JA. Evolution and current status of direct-entry midwifery education, regu-lation, and practice in the United States, with examples from Washington state. J Nurse-Mid-wifery. 1999; 44(4): 384-393.
- American College of NurseMidwives (ACNM), Division of Accreditation. Education Programs Accredited by the ACNM Division of Accreditation. Washington, DC: ACNM Division of Accreditation, July 1998.
- Midwifery Education Accreditation Council (MEAC). Accredited and Pre-Accredited Midwifery Programs. Flagstaff, AZ: MEAC, 1998.
- Paine LL, Johnson TRB, Lang JM, Gagnon D, Declercq ER, DeJoseph J, et al. A comparison of visits and practices of nursemidwives and obstetrician-gynecologists in ambulatory care settings. J Nurse-Midwifery. 2000; 45(1): 37-44.
- Summers L, Reed A. Quality and Safety of Direct-Entry Midwifery Practice in the US ACNM Resources and Bibliography. Washing-ton, DC: American College of Nurse Midwives, February 16, 2000.
Appendix: Recommendations for
“The Future of Midwifery”
Midwives should be recognized as independent and collaborative practitioners with the rights and responsibilities regarding scope of practice authority and accountability that all independent professionals share.
Every health care system should integrate midwifery services into the continuum of care for women by contracting with or employing midwives and informing women of their options.
When integrating midwifery services, health care organizations should use productivity standards based on the midwifery model of care and measure the overall financial benefits of such care.
Midwives and physicians should ensure that their systems of consultation, collaboration and referral provide integrated and uninterrupted care to women. This requires active engagement and participation by members of both professions.&
Regulation and Credentialing
State legislatures should enact laws that base entry-to-practice standards on successful completion of accredited education programs, or the equivalent, and national certification; do not require midwives to be directed or supervised by other health care practitioners; and allow midwives to own or co-own health care practices. Hospitals, health systems, and public pro-grams, including Medicare and Medicaid, should ensure that enrollees have access to midwives and the midwifery model of care by eliminating barriers to access and inequitable reimbursement rates that discriminate against midwives. Health care systems should develop hospital privileging and credentialing mechanisms for midwives that are consistent with the profession’s stan-dards, recognize midwifery as distinct from other professions, and recognize established processes that permit midwives to build upon their entrylevel competencies within their statutory scope of practice.
Education programs should provide opportunities for inter-professional education and training experiences and allow for multiple points at which midwifery education can be entered. This requires proactive intra- and interprofessional collaboration between colleges, universities and education programs to develop affiliations and complementary curriculum pathways.
Midwifery education programs should include training in practice management and the impact of health care policy on midwifery practice, with special attention to managed care.
The profession should recognize and acknowledge the benefits of teaching the midwifery model of care in a variety of education programs and affirm the value of competency-based education in all midwifery programs.
The midwifery profession should identify, develop and implement mechanisms to recruit student populations that more closely reflect the US population and include cultural competence concepts in basic and continuing education pro-grams.
Midwifery research should be strengthened and funded in the following areas:
- Demand for maternity care, demand for midwifery care, and numbers and distribution of midwives;
- Analyses of how midwives complement and broaden the woman’s choice of provider, set-ting, and model of care;
- Cost benefit, cost-effectiveness, and costutility analyses, including the relationship between knowledge of economic/cost analyses and provider practices;
- Midwifery practice and benchmarking data (among midwives) with a goal of developing appropriate productivity standards;
- Descriptions and outcome analyses of midwifery methods and processes;
- Analysis of midwifery practice outcomes, from pre-conception through infancy, using an evidence-based perspective;
- Normal pregnancy, normal labor and birth, healthy parent-infant relationships, and breastfeeding; and
- Satisfaction with maternity and midwifery care.
Federal and state agencies should broaden systematic data collection, which has traditionally focused on medicine and physicians, to include midwifery and midwives.
A research and policy body, such as the Institute of Medicine, should be requested to study and offer guidance on significant aspects of the midwifery profession including:
- Workforce supply and demand;
- Coordination of regulation by the states;
- Funding of research, education and training; and
- Coordination among the federal agencies whose policies affect affect the practice of midwifery.
Source: Dower CM, Miller JE, O’Neil EH and the Taskforce on Midwifery. Charting A Course for the 21st Century: The Future of Midwifery. San Francisco, CA: Pew Health Professions Commission and the UCSF Center for the Health Pro-fessions; April 1999.
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