The Certified Nurse-Midwife *

Since 2010, the attention of the world has been particularly focused on women and children’s health through the platform of the U.N. Millennium Development Goal (MDG) and Global Strategy for Women’s and Children’s Health; its aim is to save the lives of 16 million women and children by 2015 (U.N. Millennium Development Goals Report, 2010). Midwifery has emerged as a key human resource to help achieve this goal. Internationally, three new reports, Missing Midwives (Save the Children, 2011), State of the World’s Midwifery: Delivering Health, Saving Lives (U.N. Population Fund, 2011), and Save Lives: Invest in Midwives (Partnership for Maternal, Newborn and Child Health, 2011) have recommended increasing the number of midwives in the world as one of the best ways to reduce maternal and neonatal mortality. They call on the U.N. and world governments to invest in educating and retaining midwives. These important reports come at the same time as newly released International Confederation for Midwives (ICM) documents, which were developed and/or updated to “strengthen midwifery worldwide in order to provide high-quality, evidence-based health services for women, newborn, and childbearing families” (ICM, 2013). Collectively, they are the culmination of 3 years of work by global expert task forces to update essential competencies for basic midwifery practice, education, regulation, and association strengthening. As a result, midwives from around the world have a standard against which they can evaluate their profession. The ICM’s standards, linked with the three reports and outlining the urgent need for more and better prepared midwives, are a call to action and a blueprint for taking the agenda forward (see Chapter 6).

In the United States, the Institute of Medicine (IOM) released its report on The Future of Nursing (IOM, 2011), the impetus of which was the passage of the Patient Protection and Affordable Care Act (PPACA; see Chapter 22). It identified certified nurse-midwives (CNMs) as one of four types of advanced practice registered nurses and called on nurses and midwives to be full partners in redesigning health care in the United States. In a professionally related arena, Childbirth Connections, a national nonprofit organization dedicated to improving maternity care through consumer engagement and health system transformation, sponsored the Transforming Maternity Care Partnership. There was active leadership and participation in this project by CNMs and the professional organization, the American College of Nurse-Midwives (ACNM). The project produced a report, Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System (Angood, Armstrong, Ashton, et al., 2010). Although complex, the blueprint called for expanding access to midwives and reducing barriers to midwifery practice, among other system-critical focus areas for improvement. The project has been experiencing exciting growth, and ACNM and Childbirth Connections are partners with the Centers for Medicare and Medicaid Services (CMS) in an initiative entitled Strong Start, designed to improve maternity care outcomes through evaluating new models of prenatal care, including group prenatal care, birth center care, and woman and family centered maternity care homes (CMS, 2012). Rima Jolivet, Program Director of the Transforming Maternity Care Symposium, described this as “a time of tremendous momentum … a tipping point in maternity care quality improvement” (Jolivet, Corry, & Sakala, 2010, p. S52). Hopefully, these global and domestic initiatives will mobilize and intensify worldwide action aimed at transforming the care that is available to all women and children.

Because midwifery and nurse-midwifery in the United States and globally represents different levels of preparation and meaning, we begin by defining the terms internationally and within the U.S. context. The common denominator for all midwives is being with a woman during pregnancy and birth. The ICM definition of a midwife is “a person who has successfully completed a midwifery education program that is duly recognized in the country where it is located and that is based on ICM Essential Competencies and Global Standards for Education; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and to use the title ‘midwife,’ and who demonstrates competency in the practice of midwifery” (ICM, 2011). In the United States, there are three groups of professionals who meet the ICM definition of a midwife. CNMs are individuals educated in the two disciplines of nursing and midwifery. “They earn a graduate degree, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation CNM” (ACNM, 2012a). Certified midwives (CMs) are individuals educated in the discipline of midwifery. “They earn graduate degrees, meet health and science education requirements, and complete a midwifery education program accredited by ACME. They pass the same national certification examination as CNMs to receive the professional designation CM (ACNM, 2012a).

This direct entry route was developed by ACNM in the mid-1990s in an effort to assert and uphold an equivalent standard among midwives in education, certification, and practice (Fullerton, Schuiling, & Sipe, 2005). A certified professional midwife (CPM) is an individual who is a knowledgeable, skilled, and professional independent midwifery practitioner and who has met the standards of certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care. A CPM is certified via an examination administered by NARM. In addition to CNMs, CMs, and CPMs, there are also direct entry midwives (DEMs), lay midwives (also known as granny midwives, traditional midwives, traditional birth attendants, empirical midwives, and independent midwives), and licensed midwives (Midwives Alliance of North America [MANA], 2012). Some of these practitioners are legally recognized, some have had formal training, and some have had apprenticeship training. In this chapter, we focus only on CNMs who, in 42 states, are practicing in an advanced practice nursing role (Osborne, 2011). We focus on CNMs who are practicing in an advanced nursing role. For the purposes of this text, the terms midwife and CNM may be used interchangeably and, when issues related to non-nurse midwives are addressed, an attempt is made to clarify that.

Nurse-midwifery in the United States has its roots in nursing and has made many contributions that have paved the way for advanced practice nursing to flourish. By 1970, ACNM had developed functions, qualifications, and midwifery standards of practice; within the next several years, they had also established criteria for the accreditation of midwifery education programs and a national certifying examination. Nurse-midwifery activities have been instrumental in securing prescriptive authority and direct reimbursement by insurers for CNMs. These activities have also had a favorable direct or indirect impact on all advanced practice nurses (APNs). The pioneering efforts of CNMs have helped cultivate a clinical and political climate of acceptance, not only for themselves but also for clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and nurse practitioners (NPs) as legitimate and visible providers of care across all settings. The purpose of this chapter is to describe nurse-midwifery practice in the United States so that the reader can appreciate why it can be seen as an advanced practice nursing role and why there are concerns within midwifery if it is seen only as an advanced practice nursing role. As authors, we offer our own perspectives on the issues that prevent full integration of nurse-midwifery into advanced practice nursing. Nurses and CNMs alike have a stake in issues related to this level of professional practice. The reflections presented in this chapter are meant to foster dialogue and understanding as nurses and CNMs work to accomplish their goals related to practice. It is our hope that professional nursing will continue to work productively and collaboratively in activities that promote advanced practice nursing.

Historical Perspective

Midwifery predates nursing and medicine. Throughout time, and in all cultures, the midwife has played an important and respected role. In Biblical times, the midwife assisted a woman in labor, helped birth the baby, and provided for aftercare of the mother and infant. Novice midwives acquired knowledge and skill by apprenticing with experienced midwives and through their own observations and experiences.

In colonial times, midwives were an integral part of community life and were highly respected members of society. In the early 1900s, a number of developments in the United States considerably diminished that respect and led to an ebb in the practice of midwifery. The immigrant population was served by European immigrant midwives and African American women from the South were cared for by traditional African American midwives. These midwives lacked a national organization, methods of communication, access to the health care system, and legal recognition (Burst, 2005). An active campaign to discredit midwives was waged by public health reformers and obstetricians seeking to develop their specialty, even though data demonstrated good care outcomes for these providers (Dawley, 2003). During this same time frame, physicians took over the role of birth attendant and birth moved into the hospital setting. The medicalization of birth did much to eliminate midwifery and continues to influence and regulate the practice of nurse-midwifery.

Although midwifery remained part of mainstream health care in many European, Asian, and African countries, the renaissance of midwifery in the United States did not occur until the 1940s and 1950s. Strong nursing leaders and the childbirth education movement largely shaped the reappearance of midwifery as a nursing role (Dawley, 2003). Like other forms of advanced practice nursing that emerged later, the resurgence of midwifery and the evolution of nurse-midwifery occurred in response to the need for care of the underserved. By the late 1960s, the contributions of nurse-midwives were accepted and recognized. Demand for nurse-midwifery services increased and the profession responded by opening more education programs and more midwifery practices (see Chapter 1).

The Nurse-Midwifery Profession in the United States Today

As of 2012, 12,025 nurse-midwives have been recognized as CNMs by the ACNM and AMCB, and 73 have been recognized as CMs (Smith, 2012). In addition, there are 6,500 active and student members of the ACNM (Hamilton, 2012). Of that number, approximately 6,200 are in clinical practice. In 2009, the most current year for which data are available, CNMs attended 313,516 births, which constituted 11.3% of all vaginal births in the United States (Declercq, 2012). Also, as of 2012, there were 39 ACNM-accredited nurse-midwifery graduate programs in the United States. Thirty-four are located in schools of nursing, one in a school of public health, three in allied health graduate programs, and one is a freestanding institution of higher education Although this is an evolving picture, currently five ACNM accredited programs offer Master of Science (MS) and Doctor of Nursing Practice (DNP) options, and an additional three offer the DNP only (ACNM, 2012e). Based on findings from an analysis of ACNM membership surveys from 2006 to 2008, 82% of CNMs and CMs hold master’s degrees and 7% have doctorates.

Approximately 1.4% of CNMs and CMs indicated that they were male (Schuiling, Sipe, & Fullerton, 2010). Nurse-midwifery practice is legal in all 50 states and nurse-midwives have prescriptive authority in 50 states and the District of Columbia (ACNM, 2011e). As with all APRNs, prescriptive authority is regulated by individual state agencies and regulatory boards. As of 2012, 21 states, plus the District of Columbia, had no supervision or contractual agreement required for overall practice, seven states had requirements for prescriptive authority agreements only, and 15 states required various levels of contractual practice agreements for overall practice (ACNM, 2012f). CNMs are also defined as primary care providers under federal law (ACNM, 2012c).

Regulation, Reimbursement, and Credentialing

CNMs are regulated on a state by state basis and there are numerous regulatory and reimbursement barriers at the local, state and federal levels regarding the full deployment of all APNs. These barriers are discussed in Chapter 21. Therefore, this chapter will highlight the regulatory, reimbursement, and credentialing considerations that may be distinct to nurse- midwifery. In regard to regulation, currently, CNMs are regulated by boards of nursing in 38 states and recognized as APRNs in 42 states. In the remaining eight states, CNMs are regulated by boards of medicine, health, commerce, and regents (Osborne, 2011).

The Consensus Model for APRN Regulation (APRN Consensus Work Group, 2008) was endorsed by ACNM, which also published recommendations regarding implementation of the Consensus Model specifically related to midwifery practice (ACNM, 2011c). The first recommendation strongly supports the foundational principle that APRNs be licensed as independent practitioners with no regulatory requirements for collaboration, direction, or supervision. The ACNM has given an official statement on independent nurse-midwifery practice (ACNM, 2012d, presented in Box 17-1). Also, the 2011 ACNM–American College of Obstetricians and Gynecologists (ACOG) report, Joint Statement of Practice Relations Between Obstetricians and Gynecologists and Certified Nurse-Midwives/Certified Midwives, is seen as a model document that recognizes each group as licensed independent providers who may collaborate based on the needs of their patients (ACNM, 2011f; Box 17-2). ACNM advocates that nursing boards support separate boards of midwifery or boards of nurse-midwifery. They also recommend that the consensus document clarify that a graduate nursing degree is not required to take the certifying examination, which is an effort to support nurse-midwifery programs accredited and located in other non-nursing departments or separate institutions of higher learning (e.g., public health or allied health programs).

Box 17-1

Independent Midwifery Practice

The following represents the position of the American College of Nurse-Midwives (ACNM):

• Midwifery practice is the independent management of women’s health care, focusing particularly on common primary care issues, family planning and gynecologic needs of women, pregnancy, childbirth, the postpartum period, and care of the newborn.

• The practice occurs within a health care system that provides for consultation collaborative management and for referral, as indicated by the health status of the woman or newborn.

• Independent midwifery enables CNMs and CMs to use their knowledge, skills, judgment, and authority in the provision of primary health service for women while maintaining accountability for the management of health care in accordance with the ACNM Standards for the Practice of Midwifery.

Background

Independent practice is not defined by the place of employment, the employee-employer relationship, requirements for a physician’s co-signature, or the method of reimbursement for services. Further, independent practice should not be interpreted to be alone, because there are clinical situations in which any prudent practitioner would seek the assistance of another qualified practitioner.

Collaboration is the process whereby health care professionals jointly manage care. The goal of collaboration is to share authority while providing quality care within each individual’s professional scope of practice. Successful collaboration is a way of thinking—a relationship that requires knowledge, open communication, mutual respect, a commitment to providing quality care, trust, and the ability to share responsibility.

From the American College of Nurse-Midwives. (2012). Position statement: Independent midwifery practice. Silver Spring, MD: Author.

Box 17-2

College Statement of Policy

Joint Statement of Practice Relations Between Obstetrician-Gynecologists, Certified Nurse-Midwives, and Certified Midwives

The American College of Obstetricians and Gynecologists (the College) and the American College of Nurse-Midwives (ACNM) affirm our shared goal of safe women’s health care in the United States through the promotion of evidence-based models provided by obstetrician-gynecologists (OB-GYNs), CNMs, and CMs. The College and ACNM believe that health care is most effective when it occurs in a system that facilitates communication across care settings and among providers. OB-GYNs, CNMs, and CMs are experts in their respective fields of practice and are educated, trained, and licensed independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.

Recognizing the high level of responsibility that OB-GYNs, CNMs, and CMs assume when providing care to women, the College and ACNM affirm their commitment to promote the highest standards for education, national professional certification, and recertification of their respective members and to support evidence-based practice. Accredited education and professional certification preceding licensure are essential to ensure skilled providers at all levels of care across the United States.

The College and ACNM recognize the importance of the options and preferences of women in their health care. OB-GYNs, CNMs, and CMs work in a variety of settings, including private practice, community health care facilities, clinics, hospital, and accredited birth centers. The College and ACNM hold different positions on home birth. Establishing sustaining viable practices that can provide broad services to women requires that OB-GYNs, CNMs, and CMs have access to affordable professional liability insurance coverage, hospital privileges, equivalent reimbursement from private payers and under government programs, and support services, including but not limited to laboratory testing, obstetric imaging, and anesthesia. To provide highest quality and seamless care, OB-GYNs, CNMs, and CMs should have access to a system of care that fosters collaboration among licensed, independent providers.

Adapted from the American College of Nurse-Midwives and American College of Obstetricians and Gynecologists. (2011). Joint statement of practice relations between obstetrician-gynecologists and certified nurse-midwives/certified midwives. Washington, DC: Authors.

CNMs achieved equitable reimbursement for their services under Medicare, effective January 2011. Their reimbursement rate increased from 65% of the physician’s fee to 100% of the Medicare Part B physician fee schedule. This long-awaited provision was part of the PPACA (see Chapter 22). CNMs have not yet been included in the wellness examination provision of the PPACA, but have been working to change this (ACNM, 2012g). Medicaid mandates reimbursement for nurse-midwives in all 50 states; the level of reimbursement ranges from 65% to 100% of physician reimbursement rates (ACNM, 2011e). Thirty-three states mandate private insurance reimbursement for nurse-midwife services and there is the same type of variability in the level of reimbursement as there is for Medicaid (Fulea, 2012).

The effect that this variation in state law and regulation has on nurse-midwifery practice was examined by Declercq and colleagues (1998). They found that when compared with states with low regulatory support for nurse-midwifery practice, states with high regulatory support had a nurse-midwifery workforce three times larger than that in other states, with three times the number of CNM-attended births and twice as many CNM-patient contacts. Similar variation has been observed for APNs, meaning that those states with high regulatory support have higher numbers of APNs, thus exacerbating the current maldistribution of providers (Lugo, O’Grady, Hodnicki, et al., 2007). Some states are regulated by midwifery boards only, but practices in those states are not necessarily more independent for CNMs. For example, Utah’s separate midwifery board is more restrictive than New Mexico’s regulatory board, which is governed by the Department of Health.

In addition to state regulation, hospitals and health plans have established credentialing requirements for health care professionals. These credentialing standards determine who may have hospital admitting privileges be employed by health care systems, and be listed on managed care provider panels. An optimum system would create a mechanism consistent with the profession’s standards, recognizing nurse-midwifery as distinct from other health care professions and recognizing processes that permit CNMs to build on entry-level competencies within their statutory scope of practice. Credentialing is a particularly thorny issue for CNMs, as revealed in a 2011 online survey conducted by ACNM. A total of 1893 responses were received; 80% of the CNM respondents stated that they did not have full voting privileges within the medical staffs of their local facilities, almost 50% reported that employment by a physician practice or the hospital was a requirement of privileging, and 65% stated that they had privileges to practice but limitations or supervisory restrictions on scope of practice (Cooney & Johnson, 2012).

The federal government, through CMS exerts a strong influence over hospitals through its conditions of participation (CoP). These are rules with which hospitals are required to comply to maintain eligibility to participate in Medicare and Medicaid programs. In 2012, CMS issued final revisions related to medical staff participation by clarifying that hospitals may grant privileges to physicians and nonphysicians and that regardless of whether they were granted medical privileges, practitioners in the institution are required to adhere to the bylaws and regulations of the institution. The CoP document urges hospitals to use “nonphysician providers” to help them care for the health of the public and requires that an application for credentialing be reviewed by the medical staff and governing body of the hospital. In all, these regulations send a strong signal about the use of CNMs and other APNs in hospital settings, but fall short of requiring that CNMs be credentialed as members of the medical staff (Cooney & Johnson, 2012).

American College of Nurse-Midwives

During the 1940s, the National Organization of Public Health Nurses (NOPHN) established a section for nurse-midwives. During the reorganization of national nursing organizations, the NOPHN was absorbed into the American Nurses Association (ANA) and National League for Nursing (NLN), but these two organizations did not include a recognizable entity for nurse-midwives. Midwives at the 1954 ANA convention formed the Committee on Organization. This committee approved the definition of a nurse-midwife but the NLN and the ANA could not find a place for the nurse-midwives (for various reasons). Subsequently, at their May 1955 meeting, the Committee on Organization voted to form a separate nurse-midwifery organization—the ACNM (Dawley, 2005; Dawley & Burst, 2005; Varney, Kriebs, & Gegor, 2004).

The growth and development of American nurse-midwifery was fostered by the ACNM, founded in 1955 as the professional organization for certified nurse-midwives. The mission of the ACNM is to promote the health and well-being of women and infants within their families and communities through the development and support of professional midwifery. The organization establishes clinical standards, creates liaisons with state and federal agencies and members of Congress, administers and promotes continuing education programs, supports midwifery-relevant research and practice, and supports the accreditation of education programs.

The ACNM philosophy (ACNM, 2004; Box 17-3), code of ethics (ACNM, 2008a; Box 17-4), and standards for practice of midwifery (2011d; Box 17-5) are the core documents that guide the profession and practitioner. ACNM has also seen the recent focus on nurse-midwifery as strategic to women and children’s health globally, and maternity care nationally, as a mandate to examine and update their mission and values closely. Specifically, the 2012 vision for the organization is to advance the health and well-being of women and newborns by setting the standards for nurse-midwifery excellence. The mission that follows is to work to establish nurse-midwifery as the standard of care for women, leading the profession through education, clinical practice, research, and advocacy (ACNM, 2012b). ACNM is also embarking on a public awareness campaign because a 2008 consumer survey revealed that only 11% of women indicated that they had used a midwife for reproductive health care and 48% said it “never occurred” to them to use a midwife for their reproductive health care. If the goal is to have nurse-midwifery be the standard of care for women in the United States, there needs to be substantial work with the public in that direction (ACNM, 2011a).

Box 17-3